Linagliptin (Tradjenta), another incretin therapy for treatment of Type 2 Diabetes, has been approved by the FDA. Linagliptin is to be used in conjunction with diet and exercise to control the sugar levels in adults with diabetes.

The new dipeptidyl peptidase-4 (DPP-4) inhibitor has been studied as monotherapy or as an add-on to other diabetic medications in a series of eight clinical trials but it has not yet been assessed in combination with insulin. All studies showed an improvement in diabetic control (HbA1c) compared with placebo.

Unlike the other approved DPP-4 inhibitors sitagliptin (Januvia) and saxagliptin (Onglyza), linagliptin is not excreted through the kidneys, so it may suit patients with renal problems better. However, linagliptin is contraindicated in patients with diabetic ketoacidosis.

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Summary:
Obese older adults experienced improvements in physical function when combining weight loss with exercise that were superior to either intervention alone.

Basis for study:
Declines in physical function among the elderly are exacerbated by obesity, but the best treatment approach for this population — in particular, whether weight loss is helpful — is controversial.

Results:
Among the 93 completers, scores improved by 21% in the combined intervention group vs 12% in the diet group, 15% in the exercise group, and 1% in the control group. Decreases in body weight were seen in the diet group (10%) and the combined group (9%), but not in the exercise-alone or control groups. A small number of musculoskeletal injuries related to exercise occurred.

N Engl J Med. 2011 Mar 31;364(13):1218-29

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Common Stomach Ulcer Symptoms

Pain
Epigastric pain (dyspepsia), is present in 80-90% of patients. However, this complaint is not sensitive nor specific enough to serve as a reliable diagnostic criterion for peptic ulcer disease. The clinical history cannot distinguish duodenal from stomach ulcers accurately. Less than 1/4 of patients with dyspepsia have ulcer disease at endoscopy. In patients with NSAID-induced ulcers, up to half are asymptomatic.

Pain is typically well localized to the epigastric region and is not severe. It is usually described as gnawing, dull, aching, or “hunger-like”. Typical features of stomach ulcer pain are rhythmicity and periodicity. Rhythmicity means that the pain fluctuates in intensity throughout the day and night. Half of patients report relief of pain with food or antacids (especially duodenal ulcers) and a recurrence of pain 2-4 hours later. 2/3 of duodenal ulcers and 1/3 of stomach ulcers cause nocturnal pain that awakens the patient.

A change from a patient’s typical rhythmic discomfort to constant or radiating pain may reflect ulcer penetration or perforation. Most patients have symptomatic periods lasting up to several weeks with intervals of months to years in which they are pain-free (periodicity).

Other stomach ulcer symptoms
Nausea and anorexia may occur with gastric ulcers. Significant vomiting and weight loss are unusual with uncomplicated ulcer disease and suggest gastric outlet obstruction or gastric malignancy.

Physical findings
The physical examination is often unremarkable in uncomplicated peptic ulcer disease. Mild, localized epigastric tenderness to deep palpation may be present. Fecal occult blood testing is positive in one-third of patients.

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Hepatitis C patients will likely have two new treatment options after an FDA advisory committee unanimously endorsed a second new HCV drug.

The FDA’s Antiviral Drugs Advisory Committee voted 18-0 on Thursday that telaprevir, a protease inhibitor made by Vertex Pharmaceuticals, appears to be a safe and effective new option for hepatitis C, genotype 1 patients. On Wednesday, the panel voted unanimously to approve Merck’s protease inhibitor boceprevir for the same indication.

Panelists were in unanimous agreement that adding a protease inhibitor to treatment with pegylated interferon and ribavirin will become the new standard of care for HCV genotype 1 patients.

If the FDA follows the advice of its advisory panel and approves telaprevir and boceprevir, the two agents would be the first HCV treatments to target the virus directly. The current standard HCV treatment regimen of pegylated interferon and ribavirin works instead to boost patients’ immune responses.

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Introduction:
Lyme disease (or Lyme borreliosis), is an infectious inflammatory disease. It is the most common tick-borne disease in the Northern Hemisphere.

Causes:
Lyme disease is caused by at least 3 species of bacteria (genus Borrelia). Certain ticks (“hard ticks”) carry these bacteria. The ticks pick up the bacteria when they bite rodents/sheep/deers that are infected with Lyme disease. You end up getting the disease if you are bitten by an infected tick.

Incidence:
Lyme disease was first discovered in the United States in the town of Old Lyme (thus the name), Connecticut, in 1975. Cases have now been reported in most parts of the United States. Lyme disease is usually seen during the late spring, summer, and early fall.

Risk factors:
Exposure in tick-infested area, commonly in May to September

There are 3 stages of Lyme disease.

• Stage 1 is called primary Lyme disease.
• Stage 2 is called secondary Lyme disease and early disseminated Lyme disease.
• Stage 3 is called tertiary Lyme disease and late persistent Lyme disease.

Early symptoms (primary Lyme disease):

Not everyone infected with these bacteria presents with symptoms. If a person does get ill, the first symptoms resemble that of influenza:

• Fever/Chills
• Headache
• Lethargy/Fatigue
• Muscle/Joint pain
• Rash (erythema chronicum migrans) – a “bull’s eye” rash, a flat or slightly raised red spot at the location of the tick bite. Often there is a clear area in the center. It can be larger than 1 – 3 inches in diameter.

Symptoms at the 2nd stage of the disease (secondary Lyme disease):

• Neurological – facial palsy, meningitis (headaches, neck stiffness, and sensitivity to light), radiculoneuritis, encephalitis, memory loss, sleep disturbances, or mood changes
• Joint pain (usually large joint – monoarthritis)
• Orchitis, hepatitis, or iritis

Tertiary Lyme disease symptoms:

• Acrodermatitis chronica atrophicans
• Chronic encephalomyelitis – cognitive impairment, legs weakness, awkward gait, facial palsy, bladder problems, vertigo, and back pain
• Frank psychosis/Confusion
• Joints Inflammation – knees (usually), ankles, elbows, wrist, hips, and shoulders
• Lyme encephalopathy
• Polyneuropathy
• Profound fatigue
• Recurrent synovitis
• Recurrent tendonitis and bursitis

Signs and tests:
Lyme disease is diagnosed clinically based on symptoms that the patient has, objective physical findings (such as erythema migrans, facial palsy or arthritis) or a history of possible exposure to infected ticks. A physical exam may show joint, heart, or brain problems in people with advanced Lyme disease.

The serological laboratory tests widely available and employed are the Western blot and ELISA. A two-tiered protocol is recommended by the CDC: the sensitive ELISA test is performed first. If it is positive or equivocal, then the more specific Western blot is done. Serological testing can be used to support a clinically suspected case, but is not diagnostic by itself.

Treatment:
Antibiotics are the primary treatment for Lyme disease. The most appropriate antibiotic treatment depends upon the patient and the stage of the disease. According to the Infectious Diseases Society of America guidelines, the antibiotics of choice are doxycycline (in adults), amoxycillin (in children), erythromycin (for pregnant women) and ceftriaxone. Duration of treatment is 10 to 28 days. Alternative choices are cefuroxime and cefotaxime. Treatment of pregnant women is similar, but tetracycline should not be used.

Prognosis:
If diagnosed in the early stages, Lyme disease can be cured with antibiotics.

Some patients with Lyme disease have fatigue, joint or muscle pain, and neurocognitive symptoms persisting for years, despite antibiotic treatment. Patients with tertiary Lyme disease have been shown to experience a level of physical disability equivalent to that seen in congestive heart failure.

Complications:
Advanced stages of Lyme disease can cause long-term joints inflammation (Lyme arthritis) and heart rhythm problems. Neurological problems are also possible, and may include:

• Decreased concentration
• Facial Palsy
• Memory disorders
• Nerve damage
• Numbness
• Pain
• Sleep disorders
• Vision problems

Prevention:

• Careful examination of skin for ticks after outdoor activities
• Prompt removal of ticks may limit transmission
• Clothing that covers the ankles should be worn in endemic areas, and the use of insect repellents containing DEET is recommended
• Prophylactic treatment with 1 dose of 200mg doxycycline within 72 hours of a tick bite in highly endemic areas has been suggested

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Leprosy is a chronic granulomatous infection caused by Mycobacterium Leprae, an acid-fast bacillus. It prefers to infect cooler regions of the body like the skin, mucous membranes and peripheral nerves. M. leprae’s incubation period is frequently 3 to 5 years, although a range of 6 months to several decades has been seen. Spread via respiratory transmission, possible via broken skin.

 

Risk factors:

• Close family contacts of untreated leprosy patients have 8-fold increased risk
• Impaired cell-mediated immunity
• Poor socio-economic status

Signs and symptoms:
Skin lesions and/or enlarged nerves accompanied by sensory loss

Physical examinations:
Indeterminate:

• 1 or more hypopigmented or hyperpigmented macules
• Anesthetic patches, although sensation is preserved in early stages

Tuberculoid:

• Initial hypopigmented, hypesthetic macules with sharp demarcations
• Nerve involvement occurs early:
  • ulnar, peroneal (causing foot drop) and greater auricular nerves may be palpable and visibly enlarged;
  • neuritic pain;
  • muscle atrophy – small muscles of the hand;
  • facial nerve involvement leads to lagopthalmos, keratitis and corneal ulceration.

Lepromatous:

• More generalized, sometimes non-distinct lesions
• Nerve involvement occurs later: affects distal extremities initially

General prevention:

• Early case finding to supress infectiousness and control spread
• Anti-leprosy prophylaxis not recommended by WHO

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Ovarian cancer commonly occurs in the mid-50s and arises mostly from the epithelium. It can also be from the stroma or germ cells of the ovary. Ovarian cancer is the leading cause of gynecologic cancer death in women.

Risk factors:

• Familial cancer syndromes
• History of infertiliy
• History of endometriosis
• Environmental

Screening:
There is no effective screening available for ovarian cancer. Routine use of CA-125 and transvaginal ultrasound for screening in women of average risk is discouraged. Annual pelvic examinations are recommended, especially in postmenopausal women. An adnexal mass in a premenarchal female or a palpable adnexa in a postmenopausal female warrants further evaluation.

Women with a family history of a hereditary ovarian cancer syndrome should undergo pelvic examinations, CA-125 and transvaginal ultrasonography every 6 to 12 months.

Signs and symptoms of ovarian cancer:

• Bloating
• Early satiety (feeling full easily), anorexia (loss of appetitie), dyspepsia (gastric pain)
• Sense of abdominal fullness, increased abdominal size
• Abdomino-pelvic cramping
• Urinary frequency in the absence of infection
• Fatigue
• Dyspareunia (deep pain when having sex)
• Weight loss

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An FDA advisory committee has voted unanimously to recommend approval? of the investigational drug boceprevir (Victrelis), in combination with peginterferon and ribavirin, to treat hepatitis C genotype 1.

The agency’s Antiviral Drugs Advisory Committee voted 18-0 on Wednesday that boceprevir, made by Merck, appears to be a safe and effective new option to treat a disease that affects between three and four million people in U.S.

The panel was expected to endorse the drug — and the FDA is expected to approve it — since clinical trials showed that in the difficult-to-treat genotype 1 patients boceprevir yielded sustained virological response rates as high as 67%.

In contrast, the rate for patients getting the standard regimen of pegylated interferon injections and ribavirin pills was about 40%.

The drug is one of two hepatitis C virus (HCV) protease inhibitors that will be reviewed during the panel’s two-day meeting this week. The other is telaprevir — slated for review on Thursday — which exhibited even higher sustained response rates than boceprevir.

If the FDA approves the two new drugs as expected, they would be the first HCV protease inhibitors to reach market and are thought to represent a major advance in therapy for genotype 1 hepatitis C.

Until now, treatment has relied on boosting the immune system, rather than attacking the virus directly.

Both boceprevir and telaprevir have attracted major buzz among physicians and patients on the basis of excellent-looking clinical trial results, most recently from two of boceprevir’s pivotal studies published in the New England Journal of Medicine last month.

On Wednesday, the panel discussed Merck’s trial data, which suggest that adding boceprevir to the standard peginterferon-ribavirin combination doubles or triples the sustained viral response rates among certain subsets of patients.

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Quinine sulphate is only approved for the treatment of uncomplicated P. falciparum malaria. The FDA had concluded in their recent evaluation that the data is inadequate to establish the efficacy of quinine sulphate in the treatment of nocturnal leg cramps.

Taking into consideration that leg cramps do not lead to serious consequences, the benefit of using quinine sulphate to treat leg cramps is outweighed by the risks of potentially fatal hematologic reactions. The FDA is thus taking measures to ensure that quinine sulphate is used only for the approved treatment of uncomplicated malaria.

Quinine sulphate may cause unpredictable serious and life-threatening hematological reactions including thrombocytopenia and hemolytic-uremic syndrome/thrombotic thrombocytopenic purpura (HUS/TTP) in addition to hypersensitivity reactions, QT prolongation, serious cardiac arrhythmias. Chronic renal impairment associated with the development of TTP, and fatalities have also been reported. The risk associated with the use of quinine sulphate in the absence of its effectiveness for treatment or prevention of nocturnal leg cramps, outweighs any potential benefit in treating and/or preventing this benign, self-limiting condition.

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Introduction:
Pancreatitis is inflammation of the pancreas. The pancreas is a gland located behind the stomach. Its function is to release the hormones – insulin and glucagon (both are to control blood sugar level), as well as digestive enzymes that will help you digest and absorb food. Most of the time, the enzymes are only active after they reach the small intestine, where they are needed to digest food. When these enzymes somehow become active inside the pancreas, they digest the tissue of the pancreas. This causes swelling, bleeding, and damage to the pancreas.

Different type of pancreatitis:

• Acute pancreatitis
• Chronic pancreatitis

Acute Pancreatitis

Symptoms of acute pancreatitis:
The main symptom of pancreatitis is abdominal pain felt in the upper left side or middle of the abdomen.
Character of the pain:

• Upper abdominal pain spreading to the back
• May be worse within minutes after eating foods with high fat content
• Becomes constant and more severe, lasting for several days
• May be worse when lying on the back

Other symptoms that may occur with this disease include:

• Fever/Chills
• Looking ill
• Nausea and vomiting (prominent symptoms)
• Sweating

Signs of acute pancreatitis:

• Abdominal tenderness or mass
• Fever
• Low blood pressure (if internal bleeding or dehydration has occurred)
• Rapid heart rate
• Rapid breathing rate
• Reduced bowel sounds

Causes of acute pancreatitis:

• Alcohol (commonest)
• Autoimmune
• Gallstones (commonest)
• Idiopathic
• Hypercalcaemia (elevated calcium level in blood)
• hypertriglyceridaemia (elevated fats level in blood)
• hypothermia (low core body temperature)
• Medical procedure – endoscopic retrograde cholangiopancreatography
• Medications such as azathioprine, diuretics
• Mumps
• Steroids
• Trauma

Laboratory tests that can be done:

• Blood amylase level
• Serum blood lipase level
• Urine amylase level
• Complete blood count
• Comprehensive metabolic panel

Possible imaging tests: (usually unnecessary)

• Abdominal CT scan
• Abdominal MRI (most useful among the three)
• Abdominal ultrasound

Diagnosis of acute pancreatitis
The diagnostic criteria for pancreatitis are two of the following three features:

• Abdominal pain characteristic of acute pancreatitis
• Serum amylase and/or lipase ?3 times the upper limit of normal
• Characteristic findings of acute pancreatitis on CT scan

Treatment: (usually supportive)

• Pain medication
• Fluids given through a vein
• Stopping food or fluid by mouth to limit the activity of the pancreas

Prognosis:
Most cases go away in a week. However, some cases develop into a life-threatening illness.
The death rate can be high if there is:

• Hemorrhagic pancreatitis
• Heart, liver or kidney impairment
• Necrotizing pancreatitis

Pancreatitis can return. The likelihood of it returning depends on the cause.

Possible complications:

• Acute kidney failure
• Acute respiratory distress syndrome
• Buildup of fluid in the abdomen
• Heart failure
• High blood glucose
• Pancreatic cysts or abscesses
• Repeat episodes of acute pancreatitis can lead to chronic pancreatitis

Chronic Pancreatitis

Chronic pancreatitis is inflammation of the pancreas that does not heal or improve, leading to permanent damage. When scarring of the pancreas occur, the organ is no longer able to make the right amount of digestive enzymes. As a result, your body may be unable to digest fat and other important parts of food. Damage to the portions of the pancreas that make insulin may lead to diabetes. The condition is most often caused by alcohol abuse over many years. Repeat episodes of acute pancreatitis can also lead to chronic pancreatitis.

Symptoms of chronic pancreatitis:

• Fatty stools (malabsorption of the fats in food)
• Nausea
• Persistent abdominal pain

Causes of chronic pancreatitis:

• Alcohol (commonest)
• Gallstones (commonest)
• Cystic fibrosis
• Idiopathic (commonest)

Prognosis:
This is a serious disease that may lead to disability and death. Reducing alcohol intake can reduce the risk.

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