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April 22, 2014

Sleep Apnea Increases Risk of Cancer

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Obstructive sleep apnea has been getting accused of causing all sorts of medical problems including hypertension, stroke, heart disease, heart attacks, peripheral vascular disease, etc. We can also add cancer now.

According to Australian researchers, moderate to severe sleep apnea increases the risk of cancer by 2.5 times and death from cancer by 3.4 times. They also reported that sleep apnea increases risk of death (any cause) by 4.2x and stroke by 3.7x.

This conclusion was reached evaluating 397 subjects with obstructive sleep apnea with 20 years follow-up. Of course, further study is needed to confirm these findings.

If sleep apnea is suspected, the first step is to get a sleep study. Surgical options can also be considered which may encompass UPPP, base of tongue reduction, etc.

Source:
Sleep Apnea and 20-Year Follow-Up for All-Cause Mortality, Stroke, and Cancer Incidence and Mortality in the Busselton Health Study Cohort. Journal of Clinical Sleep Medicine 2014;10(4):355-362.

April 18, 2014

FDA Approves Ragwitek... Ragweed Allergy Tablet by Mouth (Instead of Allergy Shots)

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The FDA formally approved Ragwitek, the third new sublingual allergy tablet to be sold in the United States this year that works the same way allergy shots do... but instead is dissolved under the tongue at home instead of a shot in the arm in a medical office. Ragwitek is the first sublingual allergy tablet to treat ragweed. Although Oralair and Grastek are two other sublingual tablets that have already been approved by the FDA, they treat grass allergies rather than ragweed.

Ragwitek is a tablet made by Merck and treats patients aged 18-65 years who are allergic to only short ragweed. Ragwitek has a simple regimen of 1 sublingual tablet daily starting 12 weeks before the ragweed season and continued until the end of the ragweed pollen season. As with Oralair and Grastek, the first dose is given in a medical office to ensure safety with all other doses are taken at home. The tablet dissolves in less than 10 seconds.

Although in next few weeks US physicians should be able to start prescribing Ragwitek, treatment needs to actually begin in early summer thru the fall for full effectiveness.

As with Oralair and Grastek, epipen needs to be available at home due to possible risk of anaphylaxis. As with allergy shots, patients on beta-blockers for high blood pressure are not eligible to undergo this treatment.

Sources:
FDA approves Ragwitek for short ragweed pollen allergies. FDA 4/17/14

April 17, 2014

Dizziness and Imbalance in Kids

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Dizziness is not the easiest thing to figure out in adults. It is even more difficult to figure out in kids who may not have the vocabulary to explain what they feel. Regardless of adult or child, a good history is required to help narrow down possibilities. A flowchart of questions to help come up with a diagnosis can be found here.

Given that, a review article published in 2014 went over the most likely diagnosis of a child who is dizzy.

Based on 724 subjects over 10 studies, benign paroxysmal vertigo of childhood (18.7%) and migraine-associated vertigo (17.6%) were the two main etiologies causing vertigo and dizziness in children. Head trauma (14%) was the third most common cause of vertigo. The mean (95% CI) rate of every vertiginous form was also calculated in relation to the nine studies analyzed with vestibular migraine (27.82%), benign paroxysmal vertigo (15.68%) and vestibular neuritis (9.81%) being the three most common forms.

Benign paroxysmal vertigo of childhood is not clearly understood with some researchers feeling it is a form of adult BPPV (benign paroxysmal positional vertigo) given similar symptoms whereas others feel it is more related to a neurologic vascular basis. With this particular condition, there is no established treatment protocol.

True BPPV occurred in 1.8%. Meniere's disease accounted for only 1.5%. Othostatic hypotension only 1.2%. Middle ear problems surprisingly only occurred in 3% which was felt by the researchers to be highly under-estimated.

Given the top 3 causes of vertigo in children all have a neurologic basis, an evaluation by a good pediatric neurologist is warranted.

Reference:
Prevalence and diagnosis of vestibular disorders in children: A review. Int J Pediatr Otorhinolaryngol. 2014 May;78(5):718-724. doi: 10.1016/j.ijporl.2014.02.009. Epub 2014 Feb 15.

April 16, 2014

FDA Approves Grastek... Grass Allergy Tablet by Mouth (Instead of Allergy Shots)

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Today, the FDA formally approved Grastek, the second new sublingual allergy tablet to be sold in the United States that works the same way allergy shots do... but instead is dissolved under the tongue at home instead of a shot in the arm in a medical office. Although this tablet has been available in Europe for some time, only now has sale/distribution in the United States been allowed under prescription.

Just 2 weeks ago, FDA approved Oralair which also treats grass allergies.

Grastek (aka Grazax in Europe) is a tablet made by ALK-Abello and Merck and treats patients aged 5-65 years who are allergic to only Timothy Grass. Grastek has a simple regimen of 1 sublingual tablet daily starting 12 weeks before and continued until the end of the grass pollen season. As with Oralair, the first dose is given in a medical office to ensure safety with all other doses are taken at home. The tablet dissolves in less than 10 seconds.

Although in next few weeks US physicians should be able to start prescribing Oralair, it really won't do much good for this year's grass allergies because in order for this tablet to be fully effective in the treatment of grass pollen allergies, treatment needs to actually begin in December but no later than January and continue through August. Grass pollen season begins in April/May, so for at least this year, it may be too late.

For both Oralair and Grastek, epipen needs to be available at home due to possible risk of anaphylaxis. As with allergy shots, patients on beta-blockers for high blood pressure are not eligible to undergo this treatment.

Sources:
Merck's grass pollen allergy drug wins U.S. approval. Reuters 4.14.14

April 12, 2014

Esophagoscopy without Sedation [VIDEO]

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Here is a video demonstrating how esophagoscopy can be performed in the office without any sedation. The esophagus is the tube that connects the mouth to the stomach. The exam, called trans-nasal esophagoscopy (TNE), can be performed in any patient as long as the nose is large enough to accommodate the endoscope and lack a severe gag reflex. A very thin disposable sheath (like a condom) is used to protect endoscope and maintain sterility between patient use.


April 07, 2014

Bee Sting Pain Worst on the Nose (Even More Than the Scrotum and Nipple)

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Image by Waugsberg in Wikipedia
A Cornell graduate student took upon himself to figure where a bee sting hurts the most. His conclusion was the nostril... even more than the penis, scrotum, nipple, and 22 other body locations. Each body location was stung 3 times for consistency. [link]

He also determined that the three least painful locations to be the skull, middle toe tip, and upper arm (all scoring a 2.3 out of possible 10). The three most painful locations were the nostril, upper lip, and penis shaft (9.0, 8.7, and 7.3, respectively). Pain was rated on a 1–10 scale relative to an internal standard, the forearm.

The complete list of body locations in rank order can be found here.

Of course, this study was conducted on only one subject (the author) and as such, conclusions may not be entirely valid if done on a larger group of people.

However, I'm not sure how many people would volunteer for this kind of study and it is doubtful IRB would approve of any proposed study that would deliberately sting volunteers to various parts of the body including the genitals.

This may be a "one-of-a-kind" study.

Reference:
Honey bee sting pain index by body location. PeerJ 2:e338 http://dx.doi.org/10.7717/peerj.338
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