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July 2000

Rashes From Oral Antibiotics in Pediatrics

Rashes occur in approximately 7 per cent of children who are prescribed commonly used oral antibiotics.

Significantly more rashes developed in a Virginia study of 5,923 patient records with the use of cefaclor (Ceclor) than with other oral antibiotics, followed by sulfonamides and penicillins.

Such rashes are likely to be minor and non-life-threatening, the researchers report. But they may cause patient discomfort, parental anxiety and frequent physician visits.

"In addition, these reactions indirectly may impair good therapeutic outcomes and contribute to the problem of antibiotic-resistant strains," the investigators comment.

They documented the frequency and severity of various antibiotic rashes in patients at one five-person, pediatric private practice. Approximately 12,000 children were active patients, making nearly 20,000 outpatient visits, in the practice in 1996.

Approximately 50 per cent of medical records were examined. Of the 5,923 examined, 1,927 (32 per cent) had no record of antibiotic prescription. Rashes were found on 509 records (8.6 per cent) after one or more oral antibiotics were prescribed.

Antibiotic therapy was prescribed most often for acute otitis media, acute pharyngotonsillitis and sinusitis.

Child was defined as birth to 18 years for this study. Rashes were classified as macular and/or papular drug exanthema; hives, urticaria, welts and/or angioedema; erythema multiforms; or, indistinct other rashes.

On a prescription basis, rashes were documented for 4.79 per cent of cefaclor prescriptions, 2.72 per cent of penicillin prescriptions, 3.46 per cent of sulfonamides and 1.04 per cent of other cephalosporins.

Documented frequency of rashes, based on patient numbers for each antibiotic group, were 12.3 per cent for cefaclors, 7.4 per cent for penicillins, 8.5 per cent for sulfonamides and 2.6 per cent for other cephalosporins.

"With many excellent and safe alternatives, physicians considering the use of oral cefaclor need to be aware of its relatively high association with rashes," the researchers concluded.

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Comprehensive Massage Works Best For Low Back Pain

Patients aged 18 - 81 with subacute low-back pain were shown to benefit significantly from comprehensive massage delivered by experienced massage therapists, according to a peer-reviewed report of a randomised, placebo-controlled trial carried out by a Canadian PhD student.  

Patients experienced greatly improved function and much less pain than those given only some components of the comprehensive treatment. This is the first time, the author says, that the effectiveness of massage therapy for low-back pain has been properly documented. 

People with subacute low-back pain lasting between one week and eight months were randomly assigned to four groups - comprehensive massage therapy (n = 25), soft-tissue manipulation only (n = 25), remedial exercise with posture education only (n = 22) or a placebo of sham laser therapy (n = 26). Each subject received six treatments within about one month. 

The most common reasons they could identify for their low-back pain were bending or lifting injuries, work-related mild strains and sports injuries. 

Outcome measures were obtained at baseline, after treatment and at one month follow-up. They consisted of a disability questionnaire, a pain questionnaire, an anxiety index and a test of lumbar range of motion. 

Of the 98 patients who completed post-treatment tests, 91 completed follow-up tests. Statistically significant differences were noted after both treatment and at follow-up. 

The comprehensive massage therapy group had improved function (mean disability score 1.54 versus 2.86 - 6.5, p < 0.001), less intense pain (mean pain score 0.42 versus 1.18 - 1.75, p < 0.001) and a decrease in the quality of pain (mean score 2.29 versus 4.55 - 7.71, p = 0.006) compared with the other groups. Clinical significance was evident for the comprehensive massage therapy group and the soft-tissue manipulation group on the measure of function.

At one month follow-up, 63 per cent of subjects in the comprehensive massage therapy group reported no pain as compared with 27 per cent of the soft-tissue manipulation group, 14 per cent of the remedial exercise group and none of the sham laser therapy placebo group.

"Massage therapy based on physiology and which emphasises the soft-tissue manipulation component of treatment was found to be effective in the nonpharmacological management of subacute low-back pain", the author concludes.

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Older People With Low Back Pain Improve With Exercises

Trunk muscle strengthening exercises for chronic low back pain have been found to be helpful in older as well as younger people.

A study in Japan is the first to look at what trunk strengthening can do for middle-aged sufferers from low back pain. Studies to date have concentrated largely on what it can do for people less than 40 years of age.

This study found that, in people beyond 40 years of age, trunk muscle exercises are useful not only for building muscle strength but also for improving symptoms of chronic low back pain. 

Participants were 52 patients with chronic low back pain and a control group of 60 volunteers. They were investigated and compared for trunk muscle strength and the effect of trunk muscle exercises. 

The low back pain (LBP) group was divided into three subgroups -- group A had only age-related spondylosis. Group B had disk herniation and spondylolisthesis with age-related spondylotic change. Both groups were able to continue the exercises. 

Group C was made up of patients who had abandoned the exercise program. 

Trunk muscle strength and symptoms were assessed in each group. Compared with the control group, both flexion and extension strength were decreased in the LBP group, with reduction in their extension strength being the most marked. 

Muscle strength increased, however, and clinical symptoms improved with the exercises in both groups A and B. In contrast, there were no changes in group C. 

In these older patients with chronic low back pain, reduction of muscle strength was more marked in the spinal extensors than in the spinal flexors.

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Vitamin E Works As Anti-Inflammatory Agent In Type 2 Diabetes
July 10, 2000

A high intake of vitamin E can help reduce heart disease and stroke risk in type 2 diabetics, UT Southwestern researchers have found.  

In a study published in the July 11 issue of Circulation, Drs. Ishwarlal Jialal and Sridevi Devaraj found that increased inflammation caused by white blood cells -- monocytes -- was reduced when diabetics were given 1,200 International Units per day of natural vitamin E (alpha-tocopherol) for three months.  

"This is the first study that shows that vitamin E has anti-inflammatory effects in diabetic patients," said Dr. Jialal, professor of pathology and internal medicine. "It could be a further therapy to prevent vascular complications in diabetes since inflammation seems to be critical as a causative factor in diabetic vascular disease.'' 

The main cause of death and morbidity in type 2 diabetes, also known as non-insulin dependent diabetes mellitus, are vascular complications. Previous studies by Dr. Jialal, the principal investigator in this study and a senior investigator in the Center for Human Nutrition, have shown that vitamin E is a potent antioxidant.

Type 2 diabetics with and without macrovascular disease were compared with nondiabetics. 

Twenty-five participants in each of the three groups were given 1,200 IU of vitamin E daily for three months followed by two-months without the supplement. Blood was taken from all the patients at the beginning of the study, after three months and again after the washout. The effect of the vitamin E was similar in all three groups. 

The study showed that type 2 diabetic patients have increased inflammation, as shown by the activity of a pivotal cell (the circulating monocyte) in plaque formation on artery walls.

The monocyte is a crucial and the most readily accessible cell involved in atherogenesis. 

Study data showed that the diabetic monocyte was more active and promoted more inflammation and more free radicals and cytokines, or messenger molecules. The diabetic monocyte also caused more adhesion to the lining cells of the artery wall.  

"It was very important to elucidate the pivotal role for inflammation in diabetic vascular disease and examine how it could be modulated," said Dr. Devaraj, assistant professor in the clinical biochemistry and human metabolism division in the Department of Pathology.

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Fibromyalgia Care Requires Patient-centered Approach

Adopting a patient-centered approach is important in helping patients cope with fibromyalgia. Ontario researchers suggest that the conventional medical model fails to address the "complex experience" fibromyalgia patients face.

They used qualitative, in-depth interviews with seven patients in one mid-size city to explore the illness experience of people diagnosed with the disease. 

Interviews were audiotaped and transcribed verbatim. Researchers read the transcripts independently. They then compared and combined their analyses. 

Final analysis included an examination of all interviews collectively. This allowed "relationships between and among central themes to emerge," the researchers suggest.

Several themes developed from the interpretive analysis. The analysis shows the patients' journey along a continuum from experiencing symptoms, to seeking a diagnosis, to coping with fibromyalgia.

Researchers found there are four sub-categories in experiencing fibromyalgia symptoms; these included pain, a precipitating event, associated symptoms and modulating factors.   Patients reported feeling frustration and social isolation when seeking a diagnosis. 

Once their diagnosis was confirmed medically, patients said they felt both relief and anxiety about the future. Following diagnosis, patients had to take various steps to learn adaptive coping skills. Again, these were influenced by various medical and social factors.

"Adopting a patient-centered approach is important for helping patients cope with this disease," the researchers concluded. of fibromyalgia

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APA: Bupropion Effective for Hypoactive Sexual Desire Disorder
May 19, 2000

A study presented at this year's American Psychiatric Association annual meeting found that bupropion hydrochloride sustained-release tablets may be an effective treatment for hypoactive sexual desire disorder (HSDD) in females.

HSDD affects at least 20 percent of women in the United States. Psychotherapy has been proven minimally effective in treating this condition and there is no approved drug treatment. 

Researchers reported that almost one-third of the female subjects responded to the treatment, with increases in the number of episodes of sexual arousal, sexual fantasy, and interest in engaging in sexual activity.

The multi-center study included 66 non-depressed women ranging in age from 23 to 65 years who had experienced HSDD for an average of six years. All 66 women received a placebo for four weeks, and 51 then received active treatment for eight weeks. Eleven dropped out of the study during the placebo phase, four dropped out at the beginning of the treatment phase.

Response was seen as early as two weeks during the treatment phase. By the end of the eight-week treatment phase, the response rate indicated a more than two-fold increase in frequency in interest in sexual activity (from an average of 0.9 times at the end of the placebo phase to 2.3 times after treatment), almost double the frequency of sexual arousal (from 1.3 to 2.4 times, on average), and more than twice the number of sexual fantasies (from 0.7 times to 1.8 times, on average following treatment).

Subjects were evaluated during bi-weekly clinic visits.  

"The results of this study are encouraging. One aspect that demonstrated a substantial improvement was that by the end of the treatment phase nearly 40 percent reported being satisfied with their sexual desire, whereas 100 percent were dissatisfied before starting treatment," said lead investigator R. Taylor Segraves, M.D., Ph.D., professor of psychiatry at Case Western Reserve University School of Medicine and chair of the Department of Psychiatry at MetroHealth Medical Center. "Further research is needed on the use of bupropion hydrochloride SR as a treatment for HSDD -- a condition which can cause emotional distress and problems in intimate relationships," Dr. Segraves added.

Of the 51 women who continued into the treatment phase, 15 (29 percent) were considered to be responders, with response seen as early as two weeks after beginning treatment. In addition, bupropion SR was generally well-tolerated.    Dr. Kathleen Segraves believes that further study is warranted and explained, "that we saw anything in that short amount of time is excellent.

HSDD is characterized by a combination of factors including persistently diminished or absent sexual fantasies or desire for sexual activity, and can affect both men and women; a person diagnosed with HSDD can still function sexually.

Bupropion hydrochloride SR was generally well tolerated and no clinically significant changes in vital signs or weight gain were reported during the study. Five percent of subjects reported that insomnia (18 percent), tremor (6 percent) and rash (6 percent) occurred more frequently during the treatment phase than during the placebo phase. Ten percent discontinued the study due to an adverse event such as rash, hives or urticaria.

Bupropion hydrochloride SR is not associated with sexual side effects which are common to selective serotonin reuptake inhibitors (SSRIs). This is likely attributable to its enhancement of certain neurotransmitters -- norepinephrine and dopamine -- that affect sexual desire. Buproprion hydrochloride SR has been shown to reverse or minimize sexual dysfunction associated with SSRIs such as Prozac, Paxil, and Zoloft, when patients either switch to Wellbutrin SR or use it as an add-on to existing antidepressant treatment. Bupropion hydrochloride SR is approved for the treatment of depression and is marketed as Wellbutrin SR by Glaxo Wellcome Inc. 

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Undercooked Meat A Major Toxoplasmosis Risk

Major risk factors for toxoplasmosis among pregnant women are consumption of undercooked lamb, beef, game or cured meats, a study in six European cities has found.

Contact with cats was not a risk factor, add researchers who carried out studies in Brussels, Copenhagen, Luassane, Milan, Naples and Oslo among more than 1,000 pregnant women, both with and without toxoplasma. Subjects were questioned about their occupations, lifestyles and eating habits.

Consumption of undercooked or cured meats was associated with between 30 per cent and 63 per cent of infections, and contact with the soil contributed to 17 per cent of infections. Women who traveled outside Europe, Canada or the United States also had a significant risk of infection.

A weaker association was found among women who tasted raw meat, drank unpasteurised milk or worked with animals.

Researchers point out that in Europe, congenital toxoplasmosis affects between one and 10 neonates per 10 000. One per cent to 2 per cent either die or develop learning difficulties and 4 per cent to 27 per cent develop retinochoroidal lesions leading to permanent unilateral impairment of vision.

Avoidance of infected meat could reduce the risk of infection during pregnancy by between 30 per cent and 60 per cent, researchers speculate.  

Although health information should be regarded as a right, many obstetric units have no policy on advice or information about toxoplasmosis. "Where it is offered, information is often inconsistent, and ignorance, even among women in centres operating prenatal screening, is widespread." 

Health promotion strategies must be based on an understanding of factors affecting women's behaviour. Information given by clinicians within groups, or via the media may be more effective than written material."

Reducing risk of infection strategies could include better labeling of meat, how it was processed, and additional measures to avoid infection among farm animals.  

"Although our study focused on pregnant women, postnatally acquired toxoplasmosis is an important cause of eye disease and can be fatal in immunocompromised patients," researchers conclude. "Health information and health protection strategies may be as relevant to the general public as they are to pregnant women."

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Men's Waistlines, Triglyceride Levels Hint At Heart Story

A man's waist measurement provides one clue to his risk for coronary artery disease, a study in Quebec suggests. 

Measurement and interpretation of waist circumference together with fasting plasma triglyceride concentrations were found in this study to identify men with a metabolic triad of non-traditional risk factors for coronary artery disease. 

This atherogenic metabolic triad of risk factors includes hyperinsulinemia, elevated apolipoprotein [apo] B and small, dense LDL particles.  

Participants in the first and metabolic part of this study were 185 healthy men. A large proportion of them (more than 80 per cent) with waist circumference values greater than 41 inches and with elevated triglyceride levels (over 176 mg/dL) were characterized by the triad of risk factors. 

In the second part of the trial, the results for the metabolic phase were validated via an angiographic study on a sample of 287 men with and without coronary artery disease. In this study, only men with both elevated waist and triglyceride levels were at increased risk of coronary artery disease versus men with low waist and triglyceride levels. 

Authors conclude that simultaneous measurement and interpretation of waist circumference and fasting plasma triglyceride levels could be used as an inexpensive screening tool to identify men characterized by the trio of elevated insulin and apo B and small, dense LDL and at high coronary artery disease risk.

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Alcohol May Boost Serotonergic Levels

Some people may use alcohol to self-medicate low serotonergic function into the normal range. When they are not drinking, such people crave carbohydrates, which also increase serotonin levels. 

North American researchers suggest carbohydrate-craving may even distinguish patients as a distinct subgroup within the alcohol-dependent population.

Three groups of participants were recruited for a study. One group of 10 people was high carbohydrate-craving and dependent on alcohol. A second group of 11 participants was low carbohydrate-craving and dependent on alcohol. A third group of 12 controls was non-addicted.

People in all three groups were put on a high-carbohydrate, low-protein diet for two days. Next, they were given a high-protein, low-carbohydrate diet for two days. 

Researchers measured the effects of the two diets on mood, alcohol craving, stress, and serotonin levels.

At baseline, both alcohol-dependent groups had similar alcohol cravings. Those in the high carbohydrate-craving group craved alcohol significantly more under the stress of the research protocol. Researchers found them "uniquely sensitive to the adverse effects of carbohydrates on mood".

The carbohydrate-craving alcohol-dependent subjects also presented with distinct personality disorders. A protein-high diet increased serotonin activity in these subjects, but reduced it in other study participants. A diet high in sugar made these subjects more depressed than the others.

Lead author Mona Moorhouse said the study was prompted by observing patients at a local alcohol treatment center in Ottawa, Ontario. Approximately 50 per cent of those in alcoholism treatment reported extreme cravings for carbohydrates, particularly sweets, when abstaining from alcohol.

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