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First hope for patients with peanut Allergy

MD-FM Thursday February 6, 2014 




Sarah:

MD-FM, Medical News from around the world with Peter Goodwin.

 

SEGMENT 1: ALLERGY: Encouraging results for oral immunotherapy in patients with peanut allergy 

 

PETER:

Hello, and with me is Sarah Maxwell. To begin with: Children with peanut allergies could soon benefit from a type of oral-immunotherapy treatment, in which they eat peanut protein in increasingly large amounts, to build up tolerance…

 

SARAH:

That’s right. After six-months of treatment, in a study, published in The Lancet, 84 to 91 per cent of children with varying severities of peanut allergy, including some with anaphylaxis, could tolerate 800 milligrams of peanut protein per day. That’s roughly five peanuts –at least 25 times as much as they could tolerate before therapy. Study co-author Pamela Ewan:

 

EWAN:

What we’ve managed to show is a much higher efficacy rate than other studies and a much more acceptable and lower side effect rate, because our regime is different: we’ve gone for a more gentle regime, it increases more gently, we start at a very low level, and we eventually reach quite a high dose. I should add that that was only after 6 months of treatment and we do know, from some earlier studies that we’ve done, that gradually the amount that patients tolerate seems to go up with time.

 

SARAH:

That was Dr Pamela Ewan, from Cambridge University in the UK.

 

PETER:

Up to now the only way to prevent severe reactions for these children has been to avoid peanut-containing foods altogether hasn’t it? And that can cause quite a lot of stress and fear for families… So, when will this treatment be available?

 

SARAH:

Well, the team are currently looking into the long-term effects of this approach, and trying to find the optimal treatment duration. But, Dr. Ewan says it’s on the horizon:

 

EWAN:

We are now planning to roll this out as a therapy. What we are working on is starting this in our own hospital and we are hoping to open a clinic within the next year and we’d like to set up a network of clinics where this treatment would be offered and that, of course, would be not only in the UK but in other countries.

 

SARAH:

Pamela Ewan, from the UK.

 


SEGMENT 2: For patients with rheumatoid arthritis, using 7.5 mg glucocorticoids daily is reasonable long-term 

 

PETER:

Research in patients with rheumatoid arthritis has found that treatment with eight milligrams or more of glucocorticoids per day, was associated with an increased mortality risks…

 

SARAH:

Yes, and above this threshold, the mortality-risk went up with the dose of glucocorticoids. The study on this, reported in Arthritis and Rheumatology, monitored about 780 patients with RA for an average of around ten years each:

 

BIJLSMA:

I think that makes very much sense because we know that a dosage of 8 mg is around and about comparable with physiology. So it seems to be that 7.5 to 8 mg is a threshold that is do-able, and we know that if you are able to treat your patients with a dosage below that, you can continue for quite a long period of time without getting too many problems for patients. So I wouldn’t say it’s “safe” but it’s reasonable.

 

SARAH:

That was Professor Hans Bijlsma, from the University of Utrecht in the Netherlands, who did not participate in the study. He said that when patients with RA need glucocorticoids, they usually begin on 10 mg daily. And, as long as patients are responding, doses are then titrated down to as much as five mg, or even lower. For those who don’t respond, he recommends combination therapy:

 

BIJLSMA:

I always say that glucocorticoids is not a monotherapy, you should always use glucocorticoids in combination with other disease modifying anti-rheumatic drugs and, there, you have more choices in changing, adding, or going to other drugs as well. That’s what we do in daily practice. So I would not advise to increase doses for regular rheumatoid arthritis patients above the 10 mg –you have to add other medication.

 

SARAH:

Hans Bijlsma added that doses of glucocorticoids should only be increased –and only for a very limited period of time  --if a patient has extra-articular signs of RA, like inflammation of blood vessels.



SEGMENT 3: Study identifies which adrenal incidentalomas raise cardiovascular risk

 

PETER:

Patients with incidentally discovered adrenal tumours of intermediate phenotype, or subclinical Cushing's syndrome, are at increased risk of cardiovascular events and all-cause mortality, compared to those with stable non-secreting adrenal incidentalomas. That’s the finding of a study looking at 200 patients, published in The Lancet Diabetes & Endocrinology. It found after a dexamethasone suppression test, there was an independent correlation between cardiovascular events and cortisol concentrations.

 

SEGMENT 4: PCR-based test for tuberculosis should only be implemented in tuberculosis hotspots

 

PETER:

The advantages of the new rapid test for tuberculosis don’t outweigh those of smear microscopy enough to justify replacing it widely...

 

SARAH:

Yes, that’s the finding of the first real-life study looking at the “Xpert MTB/RIF” test for TB. It confirmed that a healthcare worker with minimal training can do this rapid test, that it was much more accurate than the standard test, much faster: results were available in two hours, so that the number of people who started treatment on the same day was improved and dropout rates were cut by half. And the test can also detect drug-resistant TB, which the microscopy test doesn’t…

 

PETER:

Well, this all sounds good. So where’s the ‘but’?

 

SARAH:

Well, the test is very expensive. And actually the results, reported in The Lancet, show it didn’t change the number of TB cases treated over the course of the study or the overall severity of TB-related illness:

 

DHEDA:

After taking into account all the pros and cons, I support that this test be made available in all African countries. The question is: should you make it available at every clinic? I don’t think the answer to that question is yes. But I think what our study shows is that you can use it in certain TB hotspots, like prisons, and mines, and certain very high burden clinics where it might be advantageous. So that would be my take on the whole thing. The other argument is that, you know, we need better point of care tests, so something that is much cheaper and that’s more suited to clinics, and this is not that test yet.

 

SARAH:

That was senior study author Professor Keertan Dheda, from Cape Town University in South Africa.

 


SEGMENT 5: Physiologic consequences of sleep apnoea predict long-term risk of cardiovascular events and mortality 

 

PETER:

For patients with obstructive sleep apnoea, measuring the frequency of episodes of apnoea and hypopnea per-hour of sleep using the apnoea-hypopnea index (AHI) is not sufficient for predicting the risk of cardiovascular events and all-cause mortality long-term…

 

SARAH:

Yes, the actual physiological consequences of sleep apnoea were apparently better predictors than the AHI for: all-cause mortality, hospitalization for congestive heart failure and stroke. Lead study author Tetyana Kendzerska:

 

KENDZERSKA:

Cardiovascular events in patients with obstructive sleep apnoea are better predicted by sleep time spent with oxygen desaturation and other measures such as sleep time, the number of awakenings, periodic leg movements, heart rate and daytime sleepiness, than the traditional apnoea-hypopnea index. And the single strongest predictor was the amount of sleep time spent with oxygen desaturation less than 90 per cent.

 

SARAH:

Dr. Tetyana Kendzerska, from the University of Toronto. The study, published in PloS Medicine, looked at over 10,000 people with suspected obstructive sleep apnoea, who had polysomnography and were followed for about six years…

 

PETER:

These are important findings then: because practitioners tend to focus on AHI index alone to establish the severity of OSA, don’t they?

                                                                              

SARAH:

That’s right, and Dr. Kendzerska said clinicians really should consider all related variables that can be measured during polysomnography.


IN BRIEF 1: Fecal immunochemical tests sensitive and specific for detecting colorectal cancer
   

PETER:

Finally in brief: simple at-home Fecal Immunochemical Tests detected 4 out of 5 colorectal cancers in only one round of testing, according to a meta-analysis, published in Annals of Internal Medicine. The study also found that the immunochemical tests correctly identified 94 per cent of patients who didn’t have colorectal cancers. By comparison, other studies have already shown that the familiar Fecal Occult Blood test detects fewer than 50 per cent of cancers after a single round of testing, which could put some people off using it altogether.

IN BRIEF 2: Elevated blood pressure in young adulthood is a warning sign of cardiovascular disease in middle age

 

PETER:

The risks of heart disease in middle age associated with high-blood pressure are detectable in young adulthood. That’s according to a study, published in JAMA, that analysed data on nearly 5,000 young adults who were followed for 25 years. The higher their blood pressure was early on, the greater the risk of coronary artery calcification by middle age.

That's all from MDFM for now. Sarah Maxwell and I will be back with more next week, so until then, from me Peter Goodwin, goodbye!

 

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