December 23, 2009 | 9:44 pm

End of Year Cheer

Posted by Albert Fuchs, M.D.

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Short work weeks make for short posts, doubly so when virtually all the health-related news is about the healthcare bill in Congress.  So I’ll end the year with two unrelated bits of good news.

The first is that the H1N1 flu pandemic is mostly behind us.  The peak numbers of people getting sick both nationally and in California was about two months ago, with decreasing numbers ever since.  As predicted by yours truly in April, the world did not end (though a bunch of my patients were plenty miserable).

The second bit of good news is that Americans are living longer then ever.  In 2007, the most recent year for which statistics are available, average life expectancy at birth crept up to a record high of 77.9 years.  That’s an average, so many of us will live longer.  So for everyone who had a mediocre 2009, here’s hoping you have many better years ahead.

Learn more:

Follow the H1N1 flu trends at the Centers for Disease Control FluView Weekly Report or at Google Flu Trends

The statistic about your increasing life expectancy is from the LA Times Booster Shots post: U.S. birth rates back on the rise

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor despite the fact that you read or comment on my posts.  Leaving a comment on a post is a wonderful way to enter into a discussion with other readers, but I will not respond to comments (just because of time constraints).

December 18, 2009 | 8:46 pm

Mollified about Mercury (or Calm about Catfish)

Posted by Albert Fuchs, M.D.

Mercury in high doses is known to be toxic.  So if you were thinking about breaking your glass thermometer and drinking the contents on a lark, I beg you to reconsider.  This has raised concern about possible harm from eating seafood since many species of seafood are known to contain trace amounts of mercury.  Much hand-wringing has ensued.  Should we shun salmon?  Avoid albacore?

The most recent issue of The Medical Letter, a publication I frequently cite, summarizes the scientific literature and attempts to clarify the issue.

Mercury exposure during pregnancy has been associated with problems with neurological development in the developing babies, though the results of studies of the effects of seafood intake during pregnancy have been mixed.  Still, because neurodevelopment appears to be the biggest effect of mercury toxicity, concern has focused on pregnant and breastfeeding women and small children.  The FDA (see link below) has recommended that pregnant and breastfeeding women limit their intake of seafood high in mercury.

In non-pregnant adults, no harm has been shown from mercury exposure from seafood.  One possible reason is that the omega-3 polyunsaturated fatty acids (PUFAs) in fish oil have a beneficial protective effect that could outweigh any harm from the mercury in fish.

The authors of the article conclude:

Public health agencies have recommended limiting the intake of seafood with a substantial mercury content during pregnancy. Since the typical US seafood diet has a healthy ratio of omega-3 PUFAs to methylmercury and PCBs, the net effect of eating fish in the US is likely to be a protective one.

This is reassuring.  I’m going to celebrate with a jar of herring.

Learn more:

The Medical Letter article:  Mercury in Fish (by subscription only)

FDA advisory for Women Who Might Become Pregnant, Women Who are Pregnant, Nursing Mothers and Young Children:  What You Need to Know About Mercury in Fish and Shellfish

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor despite the fact that you read or comment on my posts.  Leaving a comment on a post is a wonderful way to enter into a discussion with other readers, but I will not respond to comments (just because of time constraints).

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December 11, 2009 | 3:13 pm

Expired Medications (or Medicines From The Mesozoic)

Posted by Albert Fuchs, M.D.

Every primary care physician occasionally encounters questions similar to the following.

“I just found some of my blood pressure medicines.  The container fell behind the couch a year ago.  The expiration date was last month.  Can I still use them?”

or

“I know you just prescribed amoxicillin for my sore throat, but I just found some amoxicillin in my cupboard that I bought during the Nixon administration.  Can I take that?”

The bigger question is, what happens to medications after they expire?  Fortunately this issue of The Medical Letter reviews this ever-fresh topic.

The first reassuring fact is that medications are not more harmful as they degrade.  So medicines don’t deteriorate into something toxic, just something ineffective.  Any side-effects you get from taking an expired medicine are just the side-effects from the active medication, not from the process of degradation.

So all we have to worry about is whether the expired medication will still work, not whether it will harm us.  The efficacy of medicines in tablets lasts much longer than that of liquid medications.  Liquid medications that have become cloudy, discolored or have solid particles forming in them should not be used. The shelf life of eye drops is limited not by the stability of the medication, but by the preservative which eventually stops working and allows germs to grow in the solution.  Epinephrine in epinephrine autoinjectors is particularly unstable and degrades shortly after the expiration date. Since epinephrine is a rarely-used but life-saving medicine, it should be replaced promptly at the expiration date.

Tablets on the other hand frequently retain most of their efficacy for years if kept in a dry location in reasonable temperatures.  In their original unopened containers, many medications keep 90% of their potency 5 years after their expiration date.

So the recently expired blood pressure medications in the question above should be fine.  The 35 year old amoxicillin is likely to be ineffective, but not toxic.  And since amoxicillin is cheap, I would recommend purchasing a brand new twenty-first century batch.

Tangential miscellany:

A bright and joyous Hanukah to all my readers!

Learn more:

The Medical Letter article:  Drugs Past Their Expiration Date (by subscription only)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor despite the fact that you read or comment on my posts.  Leaving a comment on a post is a wonderful way to enter into a discussion with other readers, but I will not respond to comments (just because of time constraints).

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December 4, 2009 | 4:46 pm

Lemierre Syndrome: Rethinking Pharyngitis in Young Adults

Posted by Albert Fuchs, M.D.

One of the first outpatient problems a primary care trainee learns to manage is sore throat.  The current algorithm is fairly simple.  Most sore throats are caused by viruses and will not improve with antibiotics.  Symptomatic medication for pain and fever is the best we can offer.  But a significant minority of sore throats is caused by a bacterium called group A β-hemolytic streptococcus.  These cases are more commonly known as “strep throat”.  In strep throat antibiotics shorten the duration of symptoms by a day or two, but more importantly antibiotics prevent acute rheumatic fever, a potentially dangerous complication of untreated strep throat.

So the algorithm for evaluating sore throats is: decide if it’s strep.  If it is (or has a reasonable likelihood of being) strep then treat with antibiotics; otherwise don’t.

An article in this issue of Annals of Internal Medicine suggests that this algorithm is inadequate in adolescents and young adults.  The reason is that about 10% of sore throats in patients between 15 and 24 years old is caused by a bacterium called Fusobacterium necrophorum.  (Please memorize that name and mention it at your next holiday party.)  F. necrophorum also causes Lemierre Syndrome, a bacterial infection of the internal jugular vein that results in the bacteria spreading elsewhere in the body.  Lemierre Syndrome frequently results in permanent harm and is sometimes fatal.  Though much remains unknown about F. necrophorum, it appears to cause sore throats as commonly as strep in adolescents and young adults, and Lemierre Syndrome in this age group appears to be more common than acute rheumatic fever.

Diagnosing F. necrophorum pharyngitis is problematic.  F. necrophorum doesn’t grow on a standard throat culture.  (It’s anaerobic, meaning it only grows in the absence of oxygen.)  And specific molecular tests for it are not commercially available.

So the author recommends that antibiotics be prescribed for 15 to 24 year olds with sore throats and at least 3 of the following 4 findings.

• history of fever
• pus on the tonsils
• swollen tender lymph nodes in the neck
• absence of cough

(Note for doctors: use penicillins or cephalosporins.  Macrolides are ineffective against F. necrophorum.)

In that age group worsening symptoms or neck swelling should be alarm signs that F. necrophorum is present.

Our simplest clinical problem just got more complicated.  That’s a good sign that we’re learning something.

Learn more:

Annals of Internal Medicine article:  Expand the Pharyngitis Paradigm for Adolescents and Young Adults

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor despite the fact that you read or comment on my posts.  Leaving a comment on a post is a wonderful way to enter into a discussion with other readers, but I will not respond to comments (just because of time constraints).

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