November 2007

Medical-Intelligence
A Monthly Review of

Recent Articles of Interest

Table of Contents
Promising Studies of Stroke and Cancer Treatment
Reducing the Risks Following Hip Fracture
The Final Word About Diagnosis and Treatment of Low Back Pain
Brief Notes

Two Promising Treatments Not Yet Ready for Clinical Use
Stroke
Stroke damage is caused by a lack of blood to a small part of the brain but is then made worse by inflammation of the damaged tissues surrounding the stroke. For some unknown reason, minocycline, an antibiotic, has anti-inflammatory effects. An Israeli team randomly gave 151 patients with a stroke caused by a clot either minocycline or placebo within 6 to 24 hours of their stroke then followed them for three months. The minocycline patients had clinically and statistically superior outcomes at 7 days, 30 days, and 90 days. More studies are underway.
Cancer
In some manner, stem cells from bone marrow are attracted to developing tumors. Once there, they produce a molecule that attaches to the tumor cell and greatly increases its metastatic potential. In test tube studies and in mice, drugs that block the molecule from attaching to breast cancer cells block the ability of the cells to metastasize. The next step is to see if these drugs work in humans. This study makes me wonder what kind of evolutionary process might have led to this complex collaboration between tumor and stem cell? It’s hard to think of a way that natural selection could have created it since it’s ultimately lethal to both the tumor and the stem cells.

Reducing the Risks Following a Hip Fracture
Patients who have hip fractures are substantially more likely to have subsequent hip and other fractures. In one study, over a two year period, 15% had a fracture, and 13% died of any cause. In this study, more than 2,000 patients received an IV dose of the osteoporosis drug, zoledronic acid (Reclast), within three months of surgery to repair their hip fractures. The study was halted in two years when it was noted that the treated group had 38% fewer new fractures of any kind and 27% fewer deaths. There were no major adverse effects of the drug.

The Last Word - for Now - About the Diagnosis and Treatment of Low Back Pain
The American College of Physicians and the American Pain Society recently published guidelines for the diagnosis and treatment of low back pain:
1. For patients with nonspecific back pain, carry out no routine imaging or other diagnostic tests.
2. Only for patients with severe or progressive neurological deficits or a possible serious underlying condition are imaging and other diagnostic tests suggested.
3. For evaluation of persistent pain or possible nerve root problems or possible spinal stenosis, imaging (preferably MRI) should be done only when the patient is being considered for surgery or steroid injections.
The not-so-subtle message of the guidelines seems to be: Stop Doing So Many Imaging Exams! Other recommendations are:
Give patients written information about prognosis and self care, encourage activity even in the presence of pain, and treat painful areas with superficial heat.
Use aspirin and anti-inflammatory medication (NSAIDs) as first line medications even though the evidence for their long term efficacy is weak.
For those who don’t improve with self-care alone, try careful spinal manipulation, intensive interdisciplinary rehabilitation, yoga, cognitive therapy, or progressive relaxation. (Why not chicken soup?) Skeletal muscle relaxants may work for acute pain, and tricyclic antidepressants may help with chronic pain.

Brief Notes
Students with allergic rhinitis (runny nose) taking an exam were 40% more likely to drop one grade point than those without rhinitis. Those taking a sedating anti-histamine were even more severely affected, with 70% more likely to drop a grade point. If at all possible, it would be best to arrange for testing of children with allergic rhinitis during symptom-free periods. Good luck.

A study of 8,000 patients suggests that weight loss surgery reduces long term mortality.

A "western" diet was defined as one with high intake of refined grains, red meat, high-fat dairy products, french fries, and desserts. Yum. A "prudent" diet was defined as one with high intake of fruits, vegetables, poultry, and fish. One thousand patients with Stage III (fairly advanced) colon cancer had their cancer and colon removed. Over the next two years, those eating a prudent diet had about 1/3 less chance of suffering recurrence or death than did those eating a Western diet.

A study has shown that the most cost-effective way to remove germs from raw fruit and vegetables is to spray them with a mixture of one part vinegar and three parts water then rinse them in water. In the course of their study, the researchers found this method was actually superior to rubbing the items on your shirt.