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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.

However, evaluation by a good pediatric neurologist is warranted given the most common causes of dizziness in children all have a neurologic basis.

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

April 05, 2014

Mouthwash May Increase Risk of Oral Cancer

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Drinking alcoholic beverages is known to increase risk of oral cancer. It is now suspected that using mouthwash containing alcohol (i.e., original Listerine) may also increase risk for oral cancer.

When it comes to drinking alcoholic beverages like beer, individuals who consume 50 or more grams of alcohol per day (approximately 3.5 or more drinks per day) have at least a two to three times greater risk of developing oral cancer than nondrinkers. Moreover, the risk of cancer is substantially even higher among individuals who consume this amount of alcohol and also use tobacco.

What people may not realize is that some popular over-the-counter mouthwashes ALSO contain alcohol... quite a bit of it with some containing up to 27% of volume. Alcohol is added to provide flavor and "bite." For example, Listerine contains alcohol concentrations of 21.6% in the flavored product and 26.9% in the original gold Listerine Antiseptic.

Whether alcohol is introduced into the mouth via beer or mouthwash, carcinogenic risk is present.

According to one preliminary research, the risk of developing oral cancer from mouthwash containing alcohol is almost 5 times higher than those who do not. Subsequent small studies have not supported this cancer risk, but in 2014, research performed on 3,956 patients did find an independent increased risk of cancer if alcohol-containing mouthwash was used 3 or more times a day.

It is hypothesized that alcohol content in mouthwashes allows for carcinogens to penetrate into the mouth lining increasing cancer risk.

Given the possible increased risk of oral cancer, it may be worthwhile to avoid mouthwashes containing alcohol, especially given there are plenty of alcohol-free mouthwashes commercially sold.




References:
The role of alcohol in oral carcinogenesis with particular reference to alcohol-containing mouthwashes. Aust Dent J. 2008 Dec;53(4):302-5. doi: 10.1111/j.1834-7819.2008.00070.x.

Carcinogenicity of alcoholic beverages Exit Disclaimer. Lancet Oncology 2007;8(4):292-293.

Interaction between tobacco and alcohol use and the risk of head and neck cancer: pooled analysis in the International Head and Neck Cancer Epidemiology Consortium. Cancer Epidemiology, Biomarkers & Prevention 2009;18(2):541-550.

Oral health, dental care and mouthwash associated with upper aerodigestive tract cancer risk in Europe: The ARCAGE study. Oral Oncol. 2014 Mar 26. pii: S1368-8375(14)00065-7. doi: 10.1016/j.oraloncology.2014.03.001

April 02, 2014

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

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Today, the FDA formally approved Oralair, the first 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.

Oralair is made by a French pharmaceutical company Stallergenes (Greer is US distributor partner) and treats patients aged 10-65 years who are allergic to 5 different grasses: Sweet Vernal, Orchard, Perennial Rye, Timothy, and Kentucky Blue Grass. Treatment is composed of a buildup and maintenance phase. Starting 4 months prior to the grass pollen season, a 100 IR tablet is administered under the tongue in a medical office to ensure no significant side effects. At home on day 2, two 100 IR tablets are administered. On day three and daily thereafter, a 300 IR tablet is placed under the tongue until the end of the grass pollen season. The tablets take about 1 minute to dissolve.

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.

Another grass tablet will soon receive FDA approval called Grastek (aka Grazax in Europe). This tablet is made by ALK-Abello and Merck and treats patients aged 5-65 years who are allergic to only Timothy Grass. Grastek has a simpler 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.

For both tablets, 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:
Stallergenes wins U.S. go-ahead for Oralair allergy pill. Reuters 4/2/14

Grastek Recommended by FDA Panel for Timothy Grass Allergy. Medscape 12/12/13
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