Chronic pain in America remains underrecognized, underdiagnosed, and undertreated.

This PainTV educational series is designed to address this significant public health problem by educating clinicians who treat patients with chronic pain through a series of short video commentaries that present clinical pearls and demonstrations on specific topics related to chronic pain management. Collectively, this series aims to raise clinician awareness of the impact of chronic pain; its assessment, treatment, and varied pathophysiologies; and factors that can influence patient functioning and quality of life. http://www.medscape.org/sites/advances/pain-tv?src=cmemp

New Guidelines to Urge Pap Tests Only for Women 20 to 65

From Medscape Medical News > Oncology Janis C. Kelly October 17, 2011 — Screening for cervical cancer is equally effective with conventional Pap testing and liquid-based cytology with human papillomavirus (HPV) testing. So concludes the upcoming update of the 2003 US Preventive Services Task Force (USPSTF) recommendations, based in part on 2 literature reviews published online October 17 in the Annals of Internal Medicine. In addition to concluding that liquid-based cytology HPV testing is generally not superior to conventional Pap tests, the reviewers conclude that routine cervical cancer screening is generally not needed in women younger than 20 years and older than 65 years. Evelyn P. Whitlock, MD, MPH, lead author of the first study, told Medscape Medical News that "cervical cancer screening using conventional cytology (Pap test) or liquid-based cytology would be expected to be equally effective. And, although 1-time testing comparisons show that HPV is more sensitive but less specific for precancerous lesions than cytology, trials comparing HPV-enhanced strategies with cytology have not shown a clear advantage after repeat screening, nor have they compared the impact on false-positive-related burden or harms." Dr. Whitlock, from the Oregon Evidence-Based Practice at Kaiser Permanente Northwest in Portland, also noted that HPV trials currently available are European and do not compare with current American practice for the management of abnormal screening results. The review consisted of 4 fair- to good-quality studies, with a total of 141,566 participants, and compared the evidence on liquid-based cytology and high-risk HPV screening with conventional cytology in population-based screening for cervical cancer. Dr. Whitlock said that "although this review pointed out the need for more complete information on the potential harms and benefits of adding on or substituting HPV testing for cytology, we also found that the research about HPV and cervical cancer is very active and is moving in some very interesting directions. In the future, this research may support using more specific types of HPV testing, along with cytology, screening history, and other information, to individualize screening recommendations, improve screening performance, and safely reduce screening intervals for many low-risk women. At the same time, the emergence of a young cohort of HPV-vaccinated women eligible for cervical cancer screening will raise new, important questions about appropriate approaches." Appropriate Ages The second review focused on the ages at which to appropriately begin and end cervical cancer screening. Lead author Kimberly K. Vesco, MD, MPH, and colleagues presented a "narrative review" of risk factors and other epidemiologic considerations. Dr. Vesco, who is from the Center for Health Research at Kaiser Permanente Northwest, told Medscape Medical News that "the evidence suggests that the potential harms of screening outweigh the benefit of cervical cancer screening for women under 20." Current methods have higher false-positive rates in younger women, because the methods used to diagnosis and treat cervical intraepithelial neoplasia (CIN) have potential adverse effects, and because HPV infections and cytologic abnormalities have relatively high rates of regression in young women, she said. Dr. Vesco said that the data support discontinuing screening for women 65 years and older without a history of CIN or cervical cancer who have had recent negative cervical cancer screening. "The evidence to define adequate prior screening is limited, but the American Cancer Society defines it as 3 or more documented consecutive negative screening tests and no abnormal/positive cytology tests within the last 10 years," Dr. Vesco said. Dr. Whitlock warned against discontinuing cervical cancer screening for older women who do not fit these guidelines, however. "A 65-year-old women who has not been screened regularly or who has a history of abnormal Pap tests, CIN, or cervical cancer would be a candidate for continued screening. Before discontinuing screening, all women should speak with their clinician, particularly women known to be at increased risk due to a weakened immune system (like those with HIV) and women who were exposed to diethylstilbestrol in utero. Women of any age with vaginal bleeding, pain, or other symptoms related to possible cervical cancer should always seek prompt medical attention, regardless of screening history," Dr. Whitlock said. The new draft recommendations on starting and stopping screening, type of test, and intervals will be available for public comment on October 19 on the USPSTF Web site. Ann Intern Med. Published online October 17, 2011. Abstract

Noncommunicable Diseases: More Than a Health Crisis

From Medscape Hematology-Oncology Linda Brookes, MSc; Eduardo L. Cazap, MD, PhD On September 19-20, 2011, the United Nations (UN) General Assembly will hold a High Level Summit on Noncommunicable Diseases (NCDs) in New York to address the global threat posed by NCDs. The Summit is only the second UN meeting of its kind to focus on a global disease issue, the first being the special session on HIV/AIDS in 2001. This Summit will focus on the 4 most prominent NCDs: cancers, cardiovascular diseases, chronic respiratory diseases, and diabetes. The World Health Organization (WHO) has estimated that by 2030, NCDs will be the most common causes of death worldwide. Cancer, long considered a health threat in high-income countries, is now recognized as being an increasingly important cause of morbidity and mortality worldwide. In 2008, 7.6 million or 21% of NCD deaths were caused by cancer, and this number is projected to increase by 4 million over the next 20 years. By 2030, two thirds of all cancer diagnoses will occur in low- and middle-income countries. An Epidemic With Global Economic Impact The impending global epidemic of cancer will have far-reaching impact. "If action is not taken very soon," said Eduardo L. Cazap, MD, PhD, president of the Union for International Cancer Control (UICC), "a financial crisis like that of Lehman Brothers will be peanuts in comparison with a collapse of healthcare systems." http://www.medscape.com/viewarticle/748954?src=ptalk

Vitamin Supplements Associated With Increased Risk for Death

From Medscape Medical News Emma Hitt, PhD October 10, 2011 — In women aged 55 to 69 years, several widely used dietary vitamin and mineral supplements, especially supplemental iron, may be associated with increased risk for death, according to new findings from the Iowa Women's Health Study. Although many vitamin supplements did not appear to be associated with a higher risk for total mortality, several were, including multivitamins, vitamins B6, and folic acid, as well as minerals iron, magnesium, zinc, and copper. Jaakko Mursu, PhD, from the Department of Health Sciences, Institute of Public Health and Clinical Nutrition at the University of Eastern Finland in Kuopio, Finland, and colleagues reported their findings in the October 10 issue of the Archives of Internal Medicine. "Supplements are widely used, and further studies regarding their health effects are needed," Dr. Mursu and colleagues write. "Also, little is known about the long-term effects of multivitamin use and less commonly used supplements, such as iron and other minerals." The current study sought to evaluate the link between supplement use and total mortality rate, using data from the Iowa Women's Health Study. A total of 38,772 older women were included in the analysis. Women were aged between 55 to 69 years, with an average of 61.6 years at the beginning of the study in 1986. Self-reported data on vitamin supplement use were collected in 1986, 1997, and 2004. A total of 15,594 deaths were reported through December 31, 2008, representing about 40% of the initial participants. The use of multivitamins overall was associated with 2.4% increased absolute risk for death (hazard ratio, 1.06; 95% confidence interval, 1.02 - 1.10). Self-reported use of dietary supplements increased substantially between 1986 and 2004. In addition, supplement users had a higher educational level, were more physically active, and were more likely to use estrogen replacement therapy. Vitamin B6, folic acid, iron, magnesium, and zinc were associated with about a 3% to 6% increased risk for death, whereas copper was associated with an 18.0% increased risk for total mortality when compared with corresponding nonuse. In contrast, use of calcium was inversely related to risk for death (hazard ratio, 0.91; 95% confidence interval, 0.88 - 0.94; absolute risk reduction, 3.8%). The researchers assessed the findings for iron and calcium in more detailed analyses conducted during shorter periods (10-year, 6-year, and 4-year follow-up) and found results similar to those for the analyses conducted during the entire time. "In agreement with our hypothesis, most of the supplements studied were not associated with a reduced total mortality rate in older women," Dr. Mursu and colleagues conclude. "In contrast, we found that several commonly used dietary vitamin and mineral supplements, including multivitamins, vitamins B6, and folic acid, as well as minerals iron, magnesium, zinc, and copper, were associated with a higher risk of total mortality." "Although we cannot rule out benefits of supplements, such as improved quality of life, our study raises a concern regarding their long-term safety," the authors add. In a related editorial, Goran Bjelakovic, MD, DMSc, and Christian Gluud, MD, DMSc, from the Centre for Clinical Intervention Research, Cochrane Hepato-Biliary Group, Rigshospitalet, Copenhagen University Hospital, Denmark, note that the current study adds "to the growing evidence demonstrating that certain antioxidant supplements, such as vitamin E, vitamin A, and beta-carotene, can be harmful." "We cannot recommend the use of vitamin and mineral supplements as a preventive measure, at least not in a well-nourished population," they add. "Those supplements do not replace or add to the benefits of eating fruits and vegetables and may cause unwanted health consequences." This study was partially supported by the National Cancer Institute and the Academy of Finland, the Finnish Cultural Foundation, and the Fulbright program’s Research Grant for a Junior Scholar. One study author is an unpaid member of the Scientific Advisory Board of the California Walnut Commission. The other authors and editorialists have disclosed no relevant financial relationships. Arch Intern Med. 2011;171:1625-1634.

Managing the Adverse Effects of Nonsteroidal Anti-inflammatory Drugs

From Expert Review of Clinical Pharmacology Paola Patrignani; Stefania Tacconelli; Annalisa Bruno; Carlos Sostres; Angel Lanas Posted: 09/28/2011; Expert Rev Clin Pharmacol. 2011;4(5):605-621. © 2011 Expert Reviews Ltd. Abstract and Introduction Mechanism of Action of Nonsteroidal Anti-inflammatory Drugs GI Toxicity of NSAIDs CV Effects of NSAIDs COX-inhibiting NO Donators Managing GI Toxicity Management of GI Risk With Asprin Management of Patients With Peptic Ulcers or Dyspepsia Associated With NSAID Use NSAIDs & Lower GI Damage Managing CV Toxicity Expert Commentary Five-year View Abstract Conventional medical treatment for rheumatoid arthritis and osteoarthritis includes the use of NSAIDs (traditional and selective inhibitors of cyclooxygenase [COX]-2), because they provide unmistakable and significant health benefits in the treatment of pain and inflammation. However, they are associated with an increased risk of serious gastrointestinal (GI) and cardiovascular (CV) adverse events. Both beneficial and adverse effects are due to the same mechanism of action, which is inhibition of COX-dependent prostanoids. Since CV and GI risk are related to drug exposure, a reduction in the administered dose is recommended. However, this strategy will not eliminate the hazard owing to a possible contribution of individual genetic background. Further studies will be necessary to develop genetic and/or biochemical markers predictive of the CV and GI risk of NSAIDs. http://www.medscape.com/viewarticle/750226?src=mp&spon=27

Anti-Infective Agents in Periodontal Treatment

From Medscape Dentistry & Oral Health Jorgen Slots, DDS, DMD, PhD, MBA Posted: 09/15/2011 Periodontitis is a polymicrobial infectious disease associated with specific bacterial species[1] (Table 1) and herpesviruses.[2] The primary goal of periodontal therapy is to achieve a periodontal environment free of infectious pathogens. Anti-infective periodontal treatment includes mechanical pocket debridement (scaling and root planing) to remove dental calculus, periodontal pocket irrigation with potent antiseptics, systemic antibiotics for advanced disease, and proper patient self-care. Pharmacotherapeutics targeting subgingival microorganisms can significantly enhance treatment outcomes. However, because porous subgingival calculus comprises a protective reservoir for bacterial survival during anti-infective therapy, meticulous scaling and root planing must precede antiseptic and antibiotic periodontal treatment. The antimicrobials recommended here are readily available throughout the world, have been used in periodontal therapy for decades, offer significant benefits for individuals with limited financial resources, and are well accepted by most dental professionals and patients. Antiseptic Agents in Periodontal Disease An increase in antibiotic-resistant bacteria has created interest in using inexpensive, safe, and highly bactericidal/virucidal antiseptics in periodontal therapy. Antiseptics attack multiple components of infectious agents, practically eliminating the risk for development of resistance, and do not interact with prescription medications. Antiseptics are particularly valuable in the treatment of biofilm infections, which may be unresponsive to even high concentrations of antibiotics. Moreover, because the contents of inflamed periodontal pockets are emptied into the oral cavity every 90 seconds, and relatively small amounts of antimicrobial agents are applied subgingivally, the risk for antiseptics entering the gingival tissue and causing systemic damage is virtually nonexistent. This high degree of safety allows frequent and broad use of antiseptics in periodontal treatment. Povidone-Iodine Aqueous (Lugol's iodine) and tincture (iodine in alcohol) solutions of iodine have been employed as dental antiseptics for more than 150 years, but the early iodine formulations caused surface staining and irritation of mucosa and skin. Iodophors (iodine-releasing agents) developed in the 1950s were solutions of iodine complexed with an organic carrier that largely overcame the negative aspects of iodine treatment. The most common commercial form of povidone-iodine (Betadine® or generic equivalent) is a 10% solution in water, yielding 1% (10,000 ppm) available iodine. Povidone-iodine can give rise to allergic reactions, including itching, burning, and reddening and blistering in the area of application, so a patient's history of allergy to iodine or shellfish must be evaluated. Prolonged iodide intake can inhibit thyroid hormone synthesis and cause goiter, myxedema, or hyperthyroidism; therefore, povidone-iodine should not be used in patients with thyroid dysfunction, pregnant woman, infants, or in routine patient self-care. Povidone-iodine kills in vitro all major periodontopathic bacteria within 15 to 30 seconds and exhibits a wide virucidal spectrum, covering both enveloped (eg, herpesviruses) and non-enveloped viruses. Several studies have shown a measurable improvement in periodontal status after treatment with full-strength povidone-iodine.[4] A study from Sweden[5] showed that patients who received a whole-mouth application of povidone-iodine at the time of initial therapy exhibited less periodontitis for up to 13 years after treatment. Povidone-iodine lavage together with thorough debridement of necrotic tissue has arrested the progression of noma in HIV-infected patients.[6] Of potentially great clinical significance, povidone-iodine can kill the major cariogenic bacterium Streptococcus mutans, and caries-prone children who received a povidone-iodine application to their entire dentition every 2-3 months experienced a marked reduction in new caries lesions compared with control children.[7] Povidone-iodine used in periodontal treatment is applied subgingivally using, for example, a 3-mL endodontic syringe with a 23-gauge cannula that has a blunt end and side ports. The cannula is inserted into the base of the periodontal pocket to ensure maximum drug delivery. A single course of subgingival irrigation of the entire dentition takes about 1.5 minutes and is repeated at least 3 times for a total application time of 5-10 minutes. Sodium Hypochlorite Sodium hypochlorite (NaOCl) is a highly active cytotoxic oxidant recognized to be among the most potent antiseptic and disinfectant agents against bacteria, fungi, and viruses. Sodium hypochlorite occurs naturally in human neutrophils and monocytes/macrophages therefore, it does not evoke allergic reactions; it is not a mutagen, carcinogen or teratogen; and it has a century-long safety record. Dilute sodium hypochlorite has no contraindications. Sodium hypochlorite is available globally at exceptionally low cost as household bleach in concentrations of 5%-6%. Sodium hypochlorite has been used as an antiseptic agent in dentistry for more than a century and remains a widely used root canal irrigant at concentrations ranging from 1.0%-5.25%. Sodium hypochlorite rinsing exerts broad antimicrobial activity against experimental oral biofilms and reduces biofilm by 80-fold compared with water. Dilute sodium hypochlorite rinse (0.5%) has produced a 47% greater reduction in dental plaque mass compared with water rinsing.Low gingivitis scores were maintained around teeth receiving sodium hypochlorite rinse, whereas the gingivitis score increased by 50% in control teeth The American Dental Association Council on Dental Therapeutics has designated dilute sodium hypochlorite a "mild antiseptics mouth rinse" and suggested its use for direct application to mucous membranes.The lowest concentration of sodium hypochlorite solution that reliably inactivates bacteria in vitro is 0.01%. Patients are advised to use an oral irrigator for subgingival application of sodium hypochlorite at a concentration of 0.5%. This is equivalent to 10 mL (2 teaspoonfuls or two thirds of a tablespoon) of 6% household bleach in 125 mL (one half glass) of water. Patients are also advised to rinse orally with 0.2% sodium hypochlorite for 30 seconds, 2 or 3 times per week. This is equivalent to 8 mL (2 reduced teaspoonfuls) of 6% household bleach in 250 mL (a full glass) of water. More frequent rinsing may produce a brown-black extrinsic discoloration of the teeth. Diluted hypochlorite solutions gradually lose strength, so fresh solutions should be prepared for each use. Chlorhexidine Chlorhexidine, a bisbiguanide, has been an important oral antiseptic for more than 40 years, and numerous studies and meta-reviews have confirmed its antiplaque and antigingivitis effects. The ability of chlorhexidine to adhere to the dental pellicle and oral mucosa prolongs its antiplaque effect. Chlorhexidine gluconate is used in dentistry as a 0.12%-0.2% mouthwash applied in a volume of 15 mL for 30 seconds. Low-cost generic chlorhexidine in concentrations of 2% or higher can be diluted in water to the desired concentration for oral use. Chlorhexidine is inactivated by organic serum compounds in the gingival crevice fluid, and subgingival placement produces little change in microbial and clinical variables.As the antimicrobial action of the cationic chlorhexidine is neutralized by anionic compound surfactants in toothpastes, chlorhexidine should not be used in conjunction with toothbrushing. A major disadvantage of chlorhexidine is its propensity to dark stain tooth surfaces. Dark staining gaps along the margin of tooth-colored restorations may reflect into the filling material and necessitate replacement of affected restorations. Antibiotics in Periodontitis Systemic antibiotic therapy for periodontitis aims at reducing or eradicating specific periodontopathic bacteria that are not readily reached by topical therapy, such as pathogens in gingival tissue, in furcation defects, at the base of periodontal pockets, and on the tongue, tonsils and buccal mucosa. The selection of effective and safe antibiotics can be challenging because periodontitis lesions usually harbor a constellation of periodontopathic bacteria that have diverse susceptibility profiles. The tradition in dentistry is to treat empirically (eg, institute antibiotic therapy on the basis of the "best estimate" of the most probable pathogen or pathogens and the usual antibiotic susceptibility pattern of the suspected pathogen or pathogens). Microbiological testing with antimicrobial susceptibility profiling allows dentists to move from a trial and error approach to the more predictable targeted therapy, but susceptibility testing depends on complex and relatively expensive culture methods in a reference laboratory. Antibiotic combination therapy with 2 antibiotics is used to take advantage of different mechanisms of action and to expand the spectrum of antimicrobial activity. Amoxicillin-metronidazole (250 mg amoxicillin-375 mg metronidazole, 3 times daily for 8 days) is the most common antibiotic combination in periodontics. Ciprofloxacin-metronidazole (500 mg of each, twice daily for 8 days) is indicated for periodontitis involving a mixture of enteric gram-negative facultative rods and anaerobic bacteria. Enteric gram-negative facultative rods are particularly prevalent in periodontal sites of older individuals and immunocompromised patients. Ciprofloxacin-metronidazole combination therapy is also a valuable alternative for penicillin-allergic patients. Metronidazole exerts activity against Clostridium difficile and thus reduces the risk for pseudomembranous colitis. Valacyclovir (500 mg, twice daily for 10 days) may be prescribed for patients with severe periodontitis, which is virtually always associated with a herpesvirus infection. The dosing recommendations are for healthy adults with normal weight and must be adjusted for body size to ensure optimal therapeutic effectiveness and safety. Interactions with other medications, toxicity, and hypersensitivity may restrict antibiotic use in individual patients. Tetracycline HCl, doxycycline HCl, and minocycline HCl embedded in various delivery systems have been marketed commercially for direct placement into the periodontal pocket. The usefulness of topical antibiotics in periodontal treatment is questionable.The chief drawbacks of topical antibiotic therapy are an insufficient range of antimicrobial activity for even broad-spectrum antibiotics, a modest and transient clinical effect, possible development of resistant bacteria, adverse host reactions, and high acquisition costs. Topical antibiotic agents are a less desirable choice than the topical use of broad-spectrum, low-cost antiseptic agents with low potential for adverse reactions. Conclusion Mechanical debridement combined with subgingival povidone-iodine application in the dental office and sodium hypochlorite irrigation for patient self-care are valuable antimicrobial treatments in the management of virtually all types of periodontal disease. Systemic antibiotics or periodontal surgery may be required in the treatment of advanced periodontitis.

Peptic Ulcer Disease

Author: BS Anand, MD; Chief Editor: Julian Katz, MD 20th June 2011 Background Gastric and duodenal ulcers usually cannot be differentiated based on history alone, although some findings may be suggestive (see Diagnosis). Epigastric pain is the most common symptom of both gastric and duodenal ulcers. It is characterized by a gnawing or burning sensation and occurs after meals—classically, shortly after meals with gastric ulcer and 2-3 hours afterward with duodenal ulcer. In uncomplicated peptic ulcer disease (PUD), the clinical findings are few and nonspecific. “Alarm features" that warrant prompt gastroenterology referral[1] include bleeding, anemia, early satiety, unexplained weight loss, progressive dysphagia or odynophagia, recurrent vomiting, and family history of GI cancer. Patients with perforated PUD usually present with a sudden onset of severe, sharp abdominal pain. (See Clinical Presentation.) In most patients with uncomplicated PUD, routine laboratory tests usually are not helpful; instead, documentation of PUD depends on radiographic and endoscopic confirmation. Testing for H pylori infection is essential in all patients with peptic ulcers. Rapid urease tests are considered the endoscopic diagnostic test of choice. Of noninvasive tests, fecal antigen testing is more accurate than antibody testing and is less expensive than urea breath tests. A fasting serum gastrin level should be obtained in certain cases to screen for Zollinger-Ellison syndrome. (See Workup.) Upper GI endoscopy is the preferred diagnostic test in the evaluation of patients with suspected PUD. Endoscopy provides an opportunity to visualize the ulcer, to determine the presence and degree of active bleeding, and to attempt hemostasis by direct measures, if required. Perform endoscopy early in patients older than 45-50 years and in patients with associated so-called alarm features. Most patients with PUD are treated successfully with cure of H pylori infection and/or avoidance of nonsteroidal anti-inflammatory drugs (NSAIDs), along with the appropriate use of antisecretory therapy. In the United States, the recommended primary therapy for H pylori infection is proton pump inhibitor (PPI)–based triple therapy.[1] These regimens result in a cure of infection and ulcer healing in approximately 85-90% of cases.[2] Ulcers can recur in the absence of successful H pylori eradication. (See Treatment and Management.) In patients with NSAID-associated peptic ulcers, discontinuation of NSAIDs is paramount, if it is clinically feasible. For patients who must continue with their NSAIDs, proton pump inhibitor (PPI) maintenance is recommended to prevent recurrences even after eradication of H pylori.[3, 4] Prophylactic regimens that have been shown to dramatically reduce the risk of NSAID-induced gastric and duodenal ulcers include the use of a prostaglandin analog or a PPI. Maintenance therapy with antisecretory medications (eg, H2 blockers, PPIs) for 1 year is indicated in high-risk patients. (See Medication.) The indications for urgent surgery include failure to achieve hemostasis endoscopically, recurrent bleeding despite endoscopic attempts at achieving hemostasis (many advocate surgery after 2 failed endoscopic attempts), and perforation. Patients with gastric ulcers are also at risk of developing gastric malignancy. http://emedicine.medscape.com/article/181753-overview