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23 May, 2015

Alcoholic liver disease: Prevalence and Natural History

English: Total recorded alcohol per capita con...
English: Total recorded alcohol per capita consumption (15+), in litres of pure alcohol (Photo credit: Wikipedia)
Alcoholic liver disease (ALD) encompasses a spectrum of injury, ranging from simple steatosis to frank cirrhosis. It may well represent the oldest form of liver injury known to mankind. Evidence suggests that fermented beverages existed at least as early as the Neolithic period (cir. 10,000 BC) (5). Alcohol remains a major cause of liver disease worldwide. It is common for patients with ALD to share the risk factors for simultaneous injury from other liver insults (e.g., co-existing non-alcoholic fatty liver disease, or chronic viral hepatitis). Many of the natural history studies of ALD and even treatment trials were performed before these other liver diseases were recognized, or specific testing was possible. Thus, the individual effect of alcohol in some of these studies may have been confounded by the presence of these additional injuries. Despite this limitation, the data regarding ALD are robust enough to draw conclusions about the pathophysiology of this disease. The possible factors that can affect the development of liver injury include the dose, duration, and type of alcohol consumption, drinking patterns, gender, ethnicity, and associated risk factors, including obesity, iron overload, concomitant infection with viral hepatitis, and genetic factors.
Geographic variability exists in the patterns of alcohol intake throughout the world (6). Approximately two-thirds of the adult Americans drink alcohol (7). The majority drink small or moderate amounts and do so without evidence of clinical disease
(8–10). A subgroup of drinkers, however, drink excessively, develop physical tolerance and withdrawal, and are diagnosed with alcohol dependence (11). A second subset, alcohol abusers and problem drinkers, are those who engage in harmful use of alcohol, which is defined by the development of negative social and health consequences of drinking (e.g., unemployment, loss of family, organ damage, accidental injury, or death) (12). Failure to recognize alcoholism remains a significant problem and impairs efforts at both the prevention and the management of patients with ALD (13,14). Although the exact prevalence is unknown, approximately 7.4% of adult Americans were estimated to meet the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, criteria for the diagnosis of alcohol abuse and/or alcohol dependence in 1994 (15); more recent data suggest 4.65% meet the criteria for alcohol abuse and 3.81% for alcohol dependence (16). In 2003, 44% of all deaths from liver disease were attributed to alcohol (17).
The population-level mortality from ALD is related to the per capita alcohol consumption obtained from national alcoholic beverage sales data. There are conflicting data regarding a possible lower risk of liver injury in wine drinkers (18,19). One epidemiological study has estimated that for every 1 l increase in per capita alcohol consumption (independent of the type of beverage), there was a 14% increase in cirrhosis in men and 8% increase in women (20). These data must be considered in the context of the limitations of measuring alcohol use and defining ALD. The scientific literature has also used a variety of definitions of what constitutes a standard drink (Table 2). Most studies depend on interviews with patients or their families to quantify drinking patterns, a method that is subject to a number of biases, which may lead to invalid estimates of alcohol consumption (21).
Although there are limitations of the available data, the World Health Organization’s Global Alcohol database, which has been in existence since 1996, has been used to estimate the worldwide patterns of alcohol consumption and allow comparisons of alcohol-related morbidity and mortality (22). The burden of alcohol-related disease is the highest in the developed world, where it may account for as much as 9.2% of all disability-adjusted life years. However, even in the developing regions of the world, alcohol accounts for a major portion of the global disease burden, and is projected to take on increasing importance in those regions over time (22,23).
Table 1. Grading system for recommendations
Classification Description
Class I Conditions for which there is evidence and/or general agreement that a given diagnostic evaluation, procedure or treatment is beneficial, useful, and effective
Class II Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a diagnostic evaluation, procedure, or treatment
Class IIa Weight of evidence/opinion is in favor of usefulness/efficacy
Class IIb Usefulness/efficacy is less well established by evidence/opinion
Class III Conditions for which there is evidence and/or general agreement that a diagnostic evaluation/ procedure/treatment is not useful/effective and in some cases may be harmful
Level of evidence
Level A Data derived from multiple randomized clinical trials or meta-analyses
Level B Data derived from a single randomized trial or nonrandomized studies
Level C Only consensus opinion of experts, case studies, or standard of care

15 May, 2015

Who can we trust

Source: Selling Sickness

Who Can We Trust?

A new study just published in the Journal of General Internal Medicine involving Canadian, US and French physicians shows that the majority of family doctors receive little or no information about a drug’s harmful side effects by the pharmaceutical sales reps. The study found that in nearly 60 per cent of promotional visits to the doctors office, the drug reps failed to provide any information about common or serious side-effects of the promoted drug, and also failed to inform doctors about the types of patients who should not use the drug.
This is frightening news for patients. If our doctors are being kept in the dark about harmful side effects, who can we trust? Clearly, this study is revealing and we need a better system for educating our doctors. They shouldn’t be educated by the pharmaceutical sales reps who have financial gain in promoting the benefits of their products. Maybe it’s time for academic detailing? I (KW) have personally been involved in testifying on the state level in Minnesota and Wisconsin promoting academic detailing legislation.
Just yesterday I saw a TV commercial promoting Cymbalta for lower back pain.  Its advertising message was “Imagine a day with less pain.” The only thing I could imagine was the # of people flocking to their doctors offices asking about this drug. I wonder, however, how many will be told that Cymbalta is actually an antidepressant that carries a serious black box warning for suicidality and other psychiatric side effects. According to this study, it’s very unlikely that the sales reps offered up this information to the doctors.
Who pays the price for this lack of disclosure? We do. If the doctors are unaware of the potential harms from the drugs they prescribe, patients inevitably suffer the consequences.
It’s time for a new system. Patients and doctors deserve better.

14 May, 2015

Vitamin D for the treatment of chronic painful conditions in adults

Chronic pain is pain of moderate or severe intensity lasting three months or more. It can have a variety of causes, but most comes from musculoskeletal conditions such as arthritis, or pain in muscles. Chronic pain usually affects older people more than younger people. Chronic pain is disabling, and has a large negative impact on quality of life.
Vitamin D has a variety of roles in the body. It is made in the skin through the action of sunlight and can also be obtained from food. A lack of vitamin D has been implicated in a number of conditions, including chronic pain. Additionally, associations of such diverse types of pain as headache, abdominal pain, knee pain, and back pain with season of the year and latitude provide indirect support for a role for vitamin D. The possibility of a link between low levels of vitamin D and chronic pain has attracted interest because - if it were true - vitamin D would be an inexpensive and relatively safe treatment.
We searched scientific databases for studies comparing vitamin D supplementation with placebo (a dummy treatment) or active medicines for the treatment of chronic painful conditions in adults. The evidence is current to February 2015.
There is a small amount of evidence supporting this link but it is not of high quality and may not be reliable. This update of a review sought high quality evidence from randomised controlled trials (studies where participants are randomly allocated to receive one of several treatments) on vitamin D for chronic painful conditions.
We found no consistent pattern that vitamin D treatment was better than placebo for any chronic painful condition, but the studies had methodological shortcomings (low quality evidence).
More research is needed to determine if vitamin D is a useful pain treatment in any particular chronic painful condition. That research should examine whether any effect is restricted to people who are vitamin D deficient. It should also examine how much vitamin D is required, and for how long, before beneficial effects occur.
Authors' conclusions: 
The evidence addressing the use of vitamin D for chronic pain now contains more than twice as many studies and participants than were included in the original version of this review. Based on this evidence, a large beneficial effect of vitamin D across different chronic painful conditions is unlikely. Whether vitamin D can have beneficial effects in specific chronic painful conditions needs further investigation.

13 May, 2015

Seborrhoeic dermatitis

Picture of acute form of Seborrhoeic Dermatiti...
Picture of acute form of Seborrhoeic Dermatitis. Português: Forma aguda de dermatite seborreica. (Photo credit: Wikipedia)
BACKGROUND: Seborrhoeic dermatitis is a chronic inflammatory skin condition that is distributed worldwide. It commonly affects the scalp, face and flexures of the body. Treatment options include antifungal drugs, steroids, calcineurin inhibitors, keratolytic agents and phototherapy.
OBJECTIVES: To assess the effects of antifungal agents for seborrhoeic dermatitis of the face and scalp in adolescents and adults.A secondary objective is to assess whether the same interventions are effective in the management of seborrhoeic dermatitis in patients with HIV/AIDS. SEARCH
METHODS: We searched the following databases up to December 2014: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 11), MEDLINE (from 1946), EMBASE (from 1974) and Latin American Caribbean Health Sciences Literature (LILACS) (from 1982). We also searched trials registries and checked the bibliographies of published studies for further trials.
SELECTION CRITERIA: Randomised controlled trials of topical antifungals used for treatment of seborrhoeic dermatitis in adolescents and adults, with primary outcome measures of complete clearance of symptoms and improved quality of life.
DATA COLLECTION AND ANALYSIS: Review author pairs independently assessed eligibility for inclusion, extracted study data and assessed risk of bias of included studies. We performed fixed-effect meta-analysis for studies with low statistical heterogeneity and used a random-effects model when heterogeneity was high.
MAIN RESULTS: We included 51 studies with 9052 participants. Of these, 45 trials assessed treatment outcomes at five weeks or less after commencement of treatment, and six trials assessed outcomes over a longer time frame. We believe that 24 trials had some form of conflict of interest, such as funding by pharmaceutical companies.Among the included studies were 12 ketoconazole trials (N = 3253), 11 ciclopirox trials (N = 3029), two lithium trials (N = 141), two bifonazole trials (N = 136) and one clotrimazole trial (N = 126) that compared the effectiveness of these treatments versus placebo or vehicle. Nine ketoconazole trials (N = 632) and one miconazole trial (N = 47) compared these treatments versus steroids. Fourteen studies (N = 1541) compared one antifungal versus another or compared different doses or schedules of administration of the same agent versus one another. KetoconazoleTopical ketoconazole 2% treatment showed a 31% lower risk of failed clearance of rashes compared with placebo (risk ratio (RR) 0.69, 95% confidence interval (CI) 0.59 to 0.81, eight studies, low-quality evidence) at four weeks of follow-up, but the effect on side effects was uncertain because evidence was of very low quality (RR 0.97, 95% CI 0.58 to 1.64, six studies); heterogeneity between studies was substantial (I(2) = 74%). The median proportion of those who did not have clearance in the placebo groups was 69%.Ketoconazole treatment resulted in a remission rate similar to that of steroids (RR 1.17, 95% CI 0.95 to 1.44, six studies, low-quality evidence), but occurrence of side effects was 44% lower in the ketoconazole group than in the steroid group (RR 0.56, 95% CI 0.32 to 0.96, eight studies, moderate-quality evidence).Ketoconozale yielded a similar remission failure rate as ciclopirox (RR 1.09, 95% CI 0.95 to 1.26, three studies, low-quality evidence). Most comparisons between ketoconazole and other antifungals were based on single studies that showed comparability of treatment effects. CiclopiroxCiclopirox 1% led to a lower failed remission rate than placebo at four weeks of follow-up (RR 0.79, 95% CI 0.67 to 0.94, eight studies, moderate-quality evidence) with similar rates of side effects (RR 0.9, 95% CI 0.72 to 1.11, four studies, moderate-quality evidence). Other antifungalsClotrimazole and miconazole efficacies were comparable with those of steroids on short-term assessment in single studies.Treatment effects on individual symptoms were less clear and were inconsistent, possibly because of difficulties encountered in measuring these symptoms.Evidence was insufficient to conclude that dose or mode of delivery influenced treatment outcome. Only one study reported on treatment compliance. No study assessed quality of life. One study assessed the maximum rash-free period but provided insufficient data for analysis. One small study in patients with HIV compared the effect of lithium versus placebo on seborrhoeic dermatitis of the face, but treatment outcomes were similar.
AUTHORS' CONCLUSIONS: Ketoconazole and ciclopirox are more effective than placebo, but limited evidence suggests that either of these agents is more effective than any other agent within the same class. Very few studies have assessed symptom clearance for longer periods than four weeks. Ketoconazole produced findings similar to those of steroids, but side effects were fewer. Treatment effect on overall quality of life remains unknown.... (Read All)
Comments from Clinical Raters
General Practice(GP)/Family Practice(FP)
Interesting information (particularly on interfungal treatment differences) on a difficult to treat chronic condition. Quality of data needs improvement eg. Improved study design, longer duration of evaluation, improved reporting etc., as already mentioned in the study.





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