What is the efficacy of pharmacologic and non-pharmacologic cough medications?

Response from Jenny A. Van Amburgh, PharmD, CDE, Assistant Dean of Academic Affairs; Associate Clinical Professor, School of Pharmacy, Northeastern University; Director, Clinical Pharmacy Team Director, Residency Program, Harbor Health Services, Inc., Boston, Massachusetts

Most coughs are transient. However, prolonged coughs may warrant cough medicine or nonmedicinal management. The most common pharmacologic agents are centrally acting cough suppressants (eg, dextromethorphan and codeine), peripherally acting cough suppressants (eg, benzonatate), and expectorants (eg, guaifenesin). Popular nonpharmacologic approaches include vapors (eg, menthol) and honey. Although these agents are commonly recommended, information on the efficacy of cough medicines has been drawn from limited small trials with weak methodologies.

Studies involving use of dextromethorphan in children have reported no clinically significant difference in symptoms of cough compared with placebo.This lack of effect is not affected by dose, because studies of higher doses of dextromethorphan have also reported no difference in symptoms. In adult patients with upper respiratory infection, there is no added benefit of using dextromethorphan or codeine. One older study found that dextromethorphan may be a better alternative to codeine.

The efficacy of benzonatate, a cough suppressant that provides symptomatic relief of cough by anesthetizing the respiratory passages, has been shown in case studies only with patients who have cancer. Thus, it is not a reliable option for all patients.

Other cough medications include guaifenesin, an expectorant that decreases the viscosity of sputum to promote a productive cough. Unlike for dextromethorphan, clinically significant evidence exists to support claims that guaifenesin decreases sputum quantity and thickness.

Menthol is a mild anesthetic that provides a cooling sensation when used as a cough drop. Recent studies have focused on patients inhaling vaporized solutions with menthol to help with coughing.These studies show that inhaling menthol can increase the cough threshold and thus reduce sensitivity to cough.Although commonly used, lozenges, ointments, and creams containing menthol have not been studied.

Nonpharmacologic options, such as honey, may soothe coughs. Randomized controlled trials found that honey was significantly better than placebo at reducing symptoms of cough. Currently, the evidence for or against the use of honey for patients with cough is limited. The American Academy of Pediatrics does not recommend honey or any products containing honey in infants younger than 1 year, because there is a higher risk for botulism in this population.^[16]

Data on the efficacy of cough suppressants, vapors, and expectorants for decreasing the frequency or duration of cough are lacking. It is important to inform patients that most coughs will resolve in a couple of weeks. Nonpharmacologic recommendations to help soothe coughs include hydration, nonmedicated lozenges, and cool-mist humidifiers. A cough that involves thick yellow or green phlegm, unintended weight loss, fever > 101.5° F, nighttime sweats, coughing up blood, or underlying diseases (eg, chronic obstructive pulmonary disease, bronchitis, or chronic heart failure), or one that lasts more than or worsens after 7 days of treatment, should be investigated further by a healthcare provider.

Confirmed: New H7N9 Bird Flu Comes From Chickens

Reuters Health Information

Apr 25, 2013By Kate Kelland

LONDON (Reuters) Apr 25 - Chinese scientists have confirmed for the first time that a new strain of bird flu that has killed 23 people in China has been transmitted to humans from chickens.

In a study published online today in the Lancet, the scientists echoed previous statements from the World Health Organization (WHO) and Chinese officials that there is as yet no evidence of human-to-human transmission of this virus.

The H7N9 strain has infected 109 people in China since it was first detected in March. The WHO warned on Wednesday that this strain is "one of the most lethal" flu viruses and is transmitted more easily than the H5N1 strain of bird flu, which has killed hundreds around the world since 2003.

Kwok-Yung Yuen of the University of Hong Kong, who led the study, said its findings that chickens in poultry markets were a source of human infections meant that controlling the disease in these places and in these birds should be a priority.

"Aggressive intervention to block further animal-to-person transmission in live poultry markets, as has previously been done in Hong Kong, should be considered," he said.

He added that temporary closure of live bird markets and comprehensive programs of surveillance, culling, biosecurity and segregation of different poultry species may also be needed "to halt evolution of the virus into a pandemic agent."

"The evidence ... suggests it is a pure poultry-to-human transmission and that controlling (infections in people) will therefore depend on controlling the epidemic in poultry," he said.

Yuen's findings do not mean all cases of human H7N9 infection come from chickens, or from poultry, but they do confirm chickens as one source.

The WHO has said 40% of people infected with H7N9 appear to have had no contact with poultry.

Other types of birds or mammals may be acting as so called "reservoirs" of the flu virus and investigators in China are working hard to try to find out.

CASE STUDIES

Yuen's team conducted detailed case studies on four H7N9 flu patients from Zhejiang, an eastern coastal province south of the commercial hub Shanghai.

All four patients had been exposed to poultry, either through their work or through visiting poultry markets.

To find out whether there was transmission of the virus from poultry to humans, the researchers took swabs from 20 chickens, four quails, five pigeons and 57 ducks, all from six markets likely to have been visited by the patients.

Two of the five pigeons and four of the 20 chickens tested positive for H7N9, but none of the ducks or quails.

After analyzing the genetic makeup of H7N9 virus in a sample isolated from one patient and comparing it to a sample from one of the chickens, the researchers said similarities suggest the virus is being transmitted directly to humans from poultry.

The team also checked more than 300 people who had had close contact with the four patients and found that none showed any symptoms of H7N9 infection within 14 days from the beginning of surveillance. This suggests the virus is not currently able to transmit between people, they said.

But they noted that previous genetic analysis shows H7N9 has already acquired some gene mutations that adapt it specifically to being more able to infect mammals - raising the risk that it could one day spread more easily between people.

"Further adaptation of the virus could lead to infections with less severe symptoms and more efficient person-to-person transmission," the scientists wrote.

SOURCE: http://bit.ly/10Cto3
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Guidelines for Abnormal Pap Smears: Don't Always Treat

Medscape Ob/Gyn > Kaunitz on Women's Health

Andrew M. Kaunitz, MD

Apr 15, 2013

In 2012, several professional groups, including the American Society for Colposcopy and Cervical Pathology (ASCCP), issued updated guidelines on cervical cancer screening.^[1]Now, the ASCCP has updated its 2006 guidance for managing women with abnormal cervical cancer screening tests and cancer precursors, issuing 19 algorithms that address clinical scenarios ranging from women with unsatisfactory cytology to those with various grades of squamous and glandular intraepithelial neoplasia.^[2] Given the growing use of co-testing, which combines cytology with assessment for high-risk human papillomavirus (HPV), this new guidance is timely.

With these new guidelines, certain women with screening results for whom colposcopy with cervical biopsies were previously recommended should now be initially managed without colposcopy. For instance, for women ages 21-24 years with cytology indicating either atypical squamous cells of undetermined significance (ASCUS) or a low-grade squamous intraepithelial lesion (LSIL), the new guidelines do not recommend initial colposcopy. Instead, when HPV reflex testing following ASCUS cytology is negative in such women, they should resume routine screening. If the initial screen reveals ASCUS with positive HPV or LSIL, repeat cytology is recommended at 12 months.

A second algorithm that caught my attention concerns the management of women with LSIL. If LSIL is found in the course of performing co-testing, and the HPV result is negative, repeat co-testing in 1 year is now the preferred management. In contrast, if LSIL is not accompanied by an HPV test, or if such testing is positive, colposcopy is recommended.

The algorithms included in this new guidance are too complicated to memorize, so I plan to keep a copy handy where I see patients. I would like to thank Dr. Karl Smith, Director of Gynecologic Oncology at my institution, for his helpful review of this commentary
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Yearly Mammograms Still Common Despite Guidelines

Apr 23, 2013

Steven Fox

It has been more than 3 years since the US Preventive Services Taskforce (USPSTF) published controversial guidelines recommending less-frequent mammograms for breast cancer screening. The effect of those guidelines on frequency of screening appears to be negligible. At least that is the conclusion of a survey of nearly 28,000 women. The survey results arepublished online April 19 in Cancer.

Previous guidelines issued by the USPSTF had called for routine screening every 1 to 2 years in women older than 40 years. However, when the USPSTF reviewed the guidelines in 2009, they recommended against routine screening for women aged 40 to 49 years and recommended biennial screening for women aged 50 to 74 years.

The revised guidelines ignited considerable controversy, and since their publication, the American Cancer Society and other medical organizations have stuck to their recommendations that women older than 40 years get annual screenings.

To find out what effect the updated USPSTF recommendations, and the ensuing controversy, have had on screening rates, Lydia E. Pace, MD, MPH, from the Division of Women's Health, Department of Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, and colleagues assessed National Health Interview Survey data from 27,829 women.

They focused on how often women chose to be screened, using data collected during 2005, 2008, and 2011 surveys, which provides snapshots of self-reported mammography rates before and after the updated guidelines were issued.

The researchers found that screening rates did not decrease but actually showed a nonsignificant increase.

"The overall unadjusted mammography rates increased over time and were higher in 2011 (54%) than in 2008 (52%; P = .03)," the authors write. However, the difference was not statistically significant after the researchers adjusted for other factors, including race, education, income, immigration status, and insurance level (51.9% in 2008 and 53.6% in 2011; P = .07).

The investigators saw similar results when they divided the study population by age. Among the 40- to 49-year-old women, the adjusted screening rate was 46.1% in 2008 and 47.5% in 2011 (P = .38). Among the women aged 50 to 74 years, the screening rate was 57.2% in 2008 compared with 59.1% in 2011 (P = .09).

"Among all subgroups of women examined, including women who were black, Hispanic, immigrants, less educated, low income, uninsured, or publicly insured, there were no significant decreases in screening for women ages 40 to 49 years or ages 50 to74 years from 2008 to 2011," the authors report.

They add that there may be several reasons why the survey did not show decreased screening. One may be that perhaps it is too early to detect a decline. Another possible explanation is that many providers who refer patients for screening may not agree with the new recommendations, and therefore ignore them. Finally, the researchers note, patients may be continuing to request screenings because they either disagree or do not understand the new recommendations.

Cancer. Published online April 19, 2013. Abstract

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Steven Fox

Apr 23, 2013

 It has been more than 3 years since the US Preventive Services Taskforce (USPSTF) published controversial guidelines recommending less-frequent mammograms for breast cancer screening.

The effect of those guidelines on frequency of screening appears to be negligible. At least that is the conclusion of a survey of nearly 28,000 women. The survey results arepublished online April 19 in Cancer.

Previous guidelines issued by the USPSTF had called for routine screening every 1 to 2 years in women older than 40 years. However, when the USPSTF reviewed the guidelines in 2009, they recommended against routine screening for women aged 40 to 49 years and recommended biennial screening for women aged 50 to 74 years.

The revised guidelines ignited considerable controversy, and since their publication, the American Cancer Society and other medical organizations have stuck to their recommendations that women older than 40 years get annual screenings.

To find out what effect the updated USPSTF recommendations, and the ensuing controversy, have had on screening rates, Lydia E. Pace, MD, MPH, from the Division of Women's Health, Department of Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, and colleagues assessed National Health Interview Survey data from 27,829 women.

They focused on how often women chose to be screened, using data collected during 2005, 2008, and 2011 surveys, which provides snapshots of self-reported mammography rates before and after the updated guidelines were issued.

The researchers found that screening rates did not decrease but actually showed a nonsignificant increase.

"The overall unadjusted mammography rates increased over time and were higher in 2011 (54%) than in 2008 (52%; P = .03)," the authors write. However, the difference was not statistically significant after the researchers adjusted for other factors, including race, education, income, immigration status, and insurance level (51.9% in 2008 and 53.6% in 2011; P = .07).

The investigators saw similar results when they divided the study population by age. Among the 40- to 49-year-old women, the adjusted screening rate was 46.1% in 2008 and 47.5% in 2011 (P = .38). Among the women aged 50 to 74 years, the screening rate was 57.2% in 2008 compared with 59.1% in 2011 (P = .09).

"Among all subgroups of women examined, including women who were black, Hispanic, immigrants, less educated, low income, uninsured, or publicly insured, there were no significant decreases in screening for women ages 40 to 49 years or ages 50 to74 years from 2008 to 2011," the authors report.

They add that there may be several reasons why the survey did not show decreased screening. One may be that perhaps it is too early to detect a decline. Another possible explanation is that many providers who refer patients for screening may not agree with the new recommendations, and therefore ignore them. Finally, the researchers note, patients may be continuing to request screenings because they either disagree or do not understand the new recommendations.

Cancer. Published online April 19, 2013. Abstract

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Are Statins Worth the Diabetes Risk?

Medscape Diabetes & Endocrinology > Viewpoints

Gregory A. Nichols, PhD

Apr 08, 2013

Viewpoint

Recent studies indicating an increased incidence of diabetes associated with statins have raised concerns on 2 fronts. First, some may worry that the hyperglycemic effect of statins may put individuals at risk of developing a serious chronic disease. Indeed, a meta-analysis of previous studies found a 9% increased risk for diabetes associated with statin use. Furthermore, there appears to be a dose response with greater risk for diabetes among patients who are treated intensively with statins compared with placebo or moderate statin doses. However, few would argue that statins provide substantial cardioprotection; therefore, a second concern is that the relatively low risk of developing diabetes might cause some patients to avoid statin therapy despite being at high risk for cardiovascular events.

The current study suggests that the risk of developing diabetes is limited to patients who are already at high risk. The minor increase in blood glucose with statins may be enough to push at-risk patients across the diagnostic threshold. After all, the single strongest predictor of diabetes is hyperglycemia; the higher the glucose, the greater the risk.

 We can now be reasonably comfortable that statins increase diabetes only among people who are probably going to develop it anyway. In addition, although the present study included other important risk factors for diabetes, such as HDL cholesterol and blood pressure, the authors were unclear about whether they were controlled for in the multivariable analyses. If not, it is possible that the residual risk associated with statin therapy would be lower or nonexistent if more extensive models were constructed. In any event, even if diabetes does develop at a somewhat higher rate among high-risk statin users, there is nothing magical about the diagnosis of diabetes. Regardless of whether the patient is at high risk for diabetes or has been diagnosed, one of the primary treatment goals is to reduce the risk for complications, especially cardiovascular disease, which is best achieved with statin therapy to reduce LDL cholesterol.

Scared of Alzheimer Disease? Run From It

Medscape Cardiology 

Henry R. Black, MD

Apr 05, 2013

Hi. I am Dr. Henry Black, Clinical Professor of Internal Medicine at the New York University Langone Medical Center, former President of the American Society of Hypertension, and a member of the Center for the Prevention of Cardiovascular Disease at New York University.

One of the biggest problems we are facing now, and certainly in the future, is dementia and Alzheimer disease. It is estimated that by the time we reach our mid-80s, 15% of Americans will have that diagnosis, and the cost is well over $5 billion and likely to rise.

Everything that has been tried to reduce that risk has pretty much failed. Crossword puzzles do not help, and neither do foods or nutritional supplements. The one thing that seems to make some difference is exercise. This was evaluated very recently in an article in Annals of Internal Medicine from a group at the Cooper Institute in Dallas, Texas.^[1]

This group has been interested in the importance of exercise in cardiovascular disease assessment and prevention since 1970. They have been at it a long time and analyzed long-term effects of exercise in thousands and thousands of individuals, based on Medicare claims data. For this study, they carefully evaluated risk factors and exercise abilities with a standard protocol—how many metabolic equivalents (METs) they achieved and maximal oxygen consumption (VO₂), for example. Then they divided the groups into quintiles. The people in the highest quintile of fitness level were then compared with the people in the lowest quintile to see whether or not they developed Alzheimer disease.

The results are clear: Those in the highest quintile had a lower Alzheimer disease risk than those in the lowest quintile.

One problem with the study is the population they looked at. Almost all had a college education or more, almost all were white, and they were certainly in a higher socioeconomic stratum. How applicable is this to the general population?

Also important, however, is that they looked at midlife fitness -- not when patients were older but during midlife. The average age of the people they evaluated was about 50 years. What they found is clear: If you have a high level of fitness in your 40s, or maybe even earlier than that, your likelihood of developing Alzheimer disease later on is definitely reduced.

What is the take-home message? Don't wait until you have an event (people who had events previously were excluded); get yourself on the treadmill, put your running shoes on, row, whatever it is you want to do, but try to get your fitness level up high when you are in your 30s and 40s, because this is going to prevent you to some degree from having Alzheimer disease when you are in your 70s and 80s, or beyond, hopefully.

Some Infected With H7N9 Had No Contact With Poultry

Reuters Health Information

Apr 17, 2013

 

By Stephanie Nebehay and Sui-Lee Wee

GENEVA/BEIJING (Reuters) Apr 17 - The World Health Organization said on Wednesday that a number of people who have tested positive for a new H7N9 strain of bird flu in China appear to have had no contact with poultry, adding to the mystery about a virus that has killed 17 people to date.

WHO spokesman Gregory Hartl confirmed that "there are people who have no history of contact with poultry", after a top Chinese scientist was quoted as saying this applied to about 40% of those infected.

"This is one of the puzzles still (to) be solved and therefore argues for a wide investigation net," Hartl said in emailed comments.

Hartl an international team of experts going to China soon would include in their investigation the possibility that the virus can be spread between people, although there was "no evidence of sustained human-to-human transmission".

"It might be because of dust at the wet markets, it could be another animal source beside poultry, it could also be human-to-human transmission," he said by telephone.

Wendy Barclay, an influenza expert at Imperial College London, said it could be hard to reveal or rule out exposure to poultry - or to wild birds, which could also be a possible source of infection:

"The incubation time might be quite long, so visiting a market even 14 days before might have resulted in infection."

Hartl said two new suspected cases of possible human-to-human transmission were being investigated.

The first is a couple in Shanghai who tested positive, Hartl said, adding that the wife had died and husband was still sick. A seven-year-old girl in Beijing was the first case in the capital at the weekend and the boy next door has also tested positive, but is not showing symptoms, he said.

NUMBERS TO RISE

The WHO had previously reported two suspected family "clusters", but the first turned out to be a false alarm and the second was inconclusive.

China has warned that the number of infections, 82 so far, could rise. Most of the cases and 11 of the deaths have been in the commercial capital Shanghai.

China reported three new outbreaks to the World Animal Health Organization (OIE) this week, bringing the total number of locations to 11, the OIE said.

Poultry markets remain the focus of investigation by China and the U.N.'s Food and Agriculture Organization.

But Zeng Guang, chief scientist in charge of epidemiology at the China Disease Prevention and Control Center (CDPCC), said about 40 percent of human victims had no clear history of poultry exposure, the Beijing News reported.

The center declined to comment on state media reports saying only 10 of the 77 cases known by Tuesday had had contact with poultry.

A study published last week showed the H7N9 strain was a so-called "triple reassortant" virus with a mixture of genes from three other flu strains found in birds in Asia. One of those three strains is thought to have come from a brambling, a type of small wild bird.

"We can't rule out that this ... has passed through poultry but then been reintroduced to a wild bird population from which some spread to humans might be occurring," Barclay said.