Update on treatment of worsening pharyngitis

The Buzz: There's a new possibility to consider when evaluating patients with worsening pharyngitis
Citation: Avoiding sore throat morbidity and mortality: when is it not "just a sore throat?" American Family Physician January 1, 2011 Vol 83:1 p26-7 
Summary: Fusobacterium necrophorum (Fn) is a newly recognized bacterial cause of sore throat and can result a potentially very serious complication called Lemierre syndrome, or septic thrombophlebitis of the internal jugular vein resulting in metastatic pulmonary infections. Patients typically complain of a sore throat which initially improves after 4-5 days but then worsens with symptoms including rigors, fever, night sweats. Mortality is up to 5% of those affected. Lemierre syndrome occurs most often in those aged 15-30 years. Unfortunately there is no laboratory method for diagnosing Fn infections.

So what's a doc to do? First of all, the article reminds us of the differential diagnosis of worsening sore throat including non-group A strep, untreated group A strep (often due to a false negative rapid strep test which can miss up to 10% of cases), infectious mononucleosis, acute HIV infection, peritonsillar abscess, and Lemierre syndrome. Second, we should remember to consider antibiotic treatment in patients with 3 or more of the following: fever, absence of cough, tender anterior cervical lymph nodes and tonsillar exudate. Penicillin remains the drug of choice for presumed strep infections. It also has activity against Fn. If we suspect Lemiere syndrome (recurrence of sore throat with new rigors or fever), clindamycin can be used in well-appearing patients though ER referral/hospital admission for IV antibiotics should be considered for ill-appearing patients with high fevers, rigors, or unilateral neck swelling.
Commentary: While the data are still being gathered, it's a good idea to keep this info in mind when treating patients with persistent or worsening symptoms. 
By: Spencer Blackman MD

What are the most effective lifestyle changes for improvements in lipid profiles?

The Buzz: Various lifestyle modifications can benefit lipid profiles

Citation: "Diet and Exercise in the Management of Hyperlipidemia" AFP, 81;9 May 1, 2010 1097-1101

Summary: This review article is a compilation of various primary studies and meta analysis regarding specific life style modifications and their affect on lipids. Data summarized below:

• Limit saturated fats to < 7% of calories and eliminate trans fats = LDL ↓9-12%
• Increase intake of soluble fiber (3 oz oats per day, psyllium supplement) = LDL  ↓ 5 mg/dL  
• Isocalorically increase consumption of tree nuts ( .5 oz almonds, walnuts, or pecans per day) = LDL ↓ 2-19%
• 1.5 oz soy protein per day - tofu and soy foods to replace meats = ↓ LDL 5mg/dL
  ↑ HDL 0.8 mg/dL 
•  One alcoholic drink for females, two for males = ↓  LDL 7.8 mg/dL
  ↑ HDL 9-13 mg/dL 
• 1 oz Promise, Active, or Benecol spread per day  = ↓ LDL 10% 
• Increase intake of marine omega-3 fatty acids (EPA/DHA) = ↓ Triglycerides in a dose-dependant fashion
• Mediterranian Diet = ↓ total cholesterol:HDL ratio > 12% 
• Portfolio Diet  = ↓ LDL 29-35% 
• Aerobic exercise >120 min/week = ↓ LDL 4mg/dL
  ↑ HDL 1.9 - 2.5 mg/dL

Other pearls include:

• Dietary advice from physicians results in ↓ cholesterol 6.2/ mg/dL and ↓ LDL 7.0 mg/dL.
• Dietary advice from a dietitian results in and additional ↓ cholesterol 9.7 mg/dL.
• The greatest reduction results from avoidance of saturated and trans fats, increase in polyunsaturated and monunsaturated fats, moderate ETOH intake, supplementation with plant sterols or stanols (eg Promise spread), and isocalorically increasing consumption of tree nuts

Commentary: This study helps to quantify the effects of commonly recommended lifestyle modifications on lipid levels. Some of the recommendations, although showing impressive reductions in lipids, require a motivated patient. 

By: Steven Winiarski D.O.

Cochrane: Opioids for OA?

The Buzz: In OA of the hip and knee, opioids provide modest benefits that do not outweigh the risks
Citation: "Cochrane for Clinicians: Opioids for Osteoarthritis of the Knee or Hip" AFP May 1, 2010 81:9 1094-95 
Summary: The study authors reviewed ten outpatient trials involving 2,268 patients, reporting a response rate of 35% of patients in the treatment group, vs 31% in the control group (number needed to treat [NNT] = 25), as defined by a reduction of at least half of their pain. This was offset by adverse effects, though major adverse events were rare. No one opioid was found to be superior. The article authors recommend clinicians consider other interventions as outlined  by the Osteoarthritis Research Society International. They also recommended tramadol, as well as codeine, in patients with refractory pain.
Commentary: This seemingly focused review brings up a number of larger issues, including the overuse of narcotic medications (hydrocodone is the most prescribed medication in the US), and the approach to chronic pain. In addition, it points out a very useful resource available to California clinicians, the California Prescription Drug Monitoring Program (register here), which allows real-time controlled prescription reports on individual patients.
By: Spencer Blackman MD