Urticaria - Hives

This is a common condition and you may have experienced it by your self or you may know someone who has experienced it. It is an allergic condition, usually due to food or drugs.

Condition is characterized by red, swollen, elevated patches of skin and itching. Usually these reactions are confined to skin and does not give rise to life threatening problems. But it can be an early sign of an impending anaphylactic reaction or angioedema, where these signs of urticaria presents with joint swelling / joint pain, breathing difficulties, swallowing difficulties, abdominal pain or low blood pressure. If any of these signs present immediate medical interventions should occur.

In case of a simple urticaria, the possibility of a life threatening condition should be excluded by a history and a physical examination. Usually in the history we can identify a precipitating factor for the allergic reaction. Once it is out of the way, we can re-assure the patient and the parents.

Treatment involve preventing contact with the allergic substance (food, drug or animal) and starting an anti-histamine drugs like piriton (chlophenamine maleate), Citrizine or Phenergan. With these drugs an anti-inflammatory medication like prednisolone is given for about 3 days duration.


If your child develops symptoms suggestive of urticaria best thing to do would be to present to a medical practitioner and get re-assured.

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Cervical Spondylosis Treatment

As mentioned in the previous post, cervical spondylosis is a common condition of the elderly and middle age. It is initially suspected on clinical presentation. Then diagnosed using X-rays and MRI scan. X- ray of the neck (antero - posterior and lateral views) would show age related degenerative changes in the cervical spine. But X-ray can not show the nerve entrapment. Thus a MRI scan would be the investigation of choice to confirm the diagnosis. MRI scan will show inter vertebral disk herniation and nerve entrapment clearly as shown in the MRI scan image below.

The main stay of treatment is pain killers (non steroid anti inflammatory drugs - NSAIDs), physiotherapy and life style modifications. But in severe symptoms your physician may recommend surgical interventions like cervical laminectomy procedures, which involves dissecting out a part of the vertebrae that causes compression effects.

For more severe cases that involve cervical disk herniation, total removal of vertebrae and reconstruction of vertebrae is also performed. It's a relatively higher risk procedure compared to cervical laminectomy.

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Cervical Spondylosis

I am sure most of you have heard the term. Cervical Spondylosis is a term given to a condition where there is signs and symptoms of nerve entrapment at the level of cervical nerve roots or / and the cervical spinal cord.

This condition is caused by degenerative changes associated with cervical inter vertebral disks, ligaments associated with cervical spine and cervical vertebrae. Due to degenerative processes, elastic properties of inter vertebral disks are reduced, making them prone to herniation when subjected to compression forces. Ligaments that support the cervical spine also undergo degenerative changes resulting in loosing of elastic properties and calcification. These changes results in stiffening of the cervical spine as well as nerve root entrapment when cervical spine is stretched.

Disk herniation would give rise to narrowing of the cervical spine, resulting in compression of cervical spinal cord as well as the nerve roots emerging from the cervical spine. These nerve roots which arise from the lower cervical spine supplies upper limbs. They provide motor as well as sensory supply to upper limbs. Entrapment of these nerves give rise to the typical symptom of pain radiating down the arm when you look to a side, flex or extend your neck. Apart from neck and shoulder pain, suboccipital pain and headaches are common associations with this condition.

Check out the next post for Diagnosis and Treatment of cervical spondylosis.

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Depressive Symptoms Raise Risk for Opioid Misuse

Opioid misuse has long been associated with chronic illnesses. But it's association with depression was not as much popular. But a recent study shows an increase risk of opioid misuse in patients with Depressive symptoms.

July 13, 2012 — Depressive symptoms appear to raise the risk for opioid misuse in patients with no history of substance abuse disorders (SUDs) who are receiving long-term opioid therapy, new research suggests.

In a large study, investigators at the University of Washington School of Medicine in Seattle found that depression in the absence of substance abuse is significantly associated with the use of opioids for stress or sleep and with the use of more opioids than prescribed.
"Our study suggests that if depressed patients are not in full remission, they remain at increased risk of opioid misuse," the authors, led by Alicia Grattan, MD, write.

The study is published in the July/August issue of Annals of Family Medicine.

Tackling Opioid Abuse

This article is 1 of a series in the same issue of the journal that investigated opioid use for the management of chronic pain and the rising levels of misuse, overdose, and addiction associated with opioid pain medications.

Although depression may be a risk factor for opioid misuse, "it has been difficult to tease out the contribution of co-occurring substance abuse," Dr. Grattan and colleagues write.
To investigate, they interviewed 1334 patients at 2 of the largest health plans in the United States — Group Health Cooperative and Kaiser Permanente of Northern California. All of the participants were receiving long-term opioid therapy for noncancer pain, and none had a history of substance abuse.
The patients were asked about 3 forms of inappropriate opioid use: self-medicating for symptoms other than pain; self-increasing their dose; and giving to or getting opioids from other people. Depressive symptoms were evaluated using the 8-item Patient Health Questionnaire (PHQ-8).

For non-pain symptoms, 36.9% of patients without depression (PHQ-8 score, 0 - 4) misused opioids, compared with 40.2% of patients with mild depression (PHQ-8 score, 5 - 9), 47.2% of those with moderate depression (PHQ-8 score, 10 - 14), and 51.8% of those with severe depression (PHQ-8 score, 15 or higher).

Patients with moderate and severe depression were 1.75 (P = .031) and 2.42 (P = .001) times more likely, respectively, to misuse their opioid medications for non-pain symptoms than were nondepressed patients.

Patients with mild, moderate, and severe depression were 1.93 (P < .001), 2.89 (P < .001), and 3.13 (P < .001) times more likely, respectively, to use more opioids than prescribed compared with nondepressed patients.

There was no statistically significant association between depressive symptoms and either giving opioids to others or getting them from others.

These results "begin to clarify the types of opioid misuse associated with depression among patients without SUDs," the investigators note.

Self-Medicating for Non-Pain Symptoms


Reached for comment, Amanda L. Divin, PhD, assistant professor, Department of Health Sciences, Western Illinois University in Macomb, told Medscape Medical News that the findings "are in line with the idea of patients self-medicating their non-pain symptoms with opioids."

As reported previously by Medscape Medical News, Dr. Divin and her colleagues found evidence that college students may abuse opioid painkillers, sedatives, and other prescription drugs to inappropriately self-medicate for psychological distress.

"The pharmacological properties of opioids make it such that opioids are used for a variety of reasons, such as inducing euphoria (why people may use if depressed), reducing tension, anxiety, and aggression, and inducing a general calming effect (why people may use for depression, anxiety, sleep disturbances, or stress)," said Dr. Divin.

She said a "huge strength" of the new study is that researchers excluded participants with known SUDs.

"People with SUDs are known to have higher rates of depression, opioid misuse, nonadherence, and aberrant behaviors. To find these results in a sample of subjects with no known SUDs, to me, strengthens the argument that no one is immune from the potentially dangerous mood-impacting side effects of opioids," Dr. Divin said.

Practical Implications


Echoing Dr. Divin's thoughts, Dr. Grattan and colleagues acknowledge in their article that it is hard to tease out a causal relationship between opioid misuse and depression.

They point out that, historically, opioids have been used to treat psychological distress (mania and melancholia), as well as physical pain, and more recent studies have suggested the use of opioids for treatment-resistant depression and anxiety. It is possible that depressed patients may experience their pain as more severe, which may prompt misuse.

"At this point, it is not clear whether opioids are substituting for, or even disrupting, the appropriate treatment of depression," Dr. Grattan and colleagues say. They emphasize that there is currently no evidence from controlled trials that opioids are adequate treatment for depression.

Dr. Divin believes this study has "several practical implications, which shouldn't be overlooked."
First, she explained, because opioids "can/do have depressant qualities on the body systems (eg, depressed affect, respiration, etc) that mimic signs/symptoms of depression, it's important to differentiate what is causing these changes in mood and behavior; is it using the opioids or is the patient suffering from depression?"

Second, "better tracking of [opioid] refills and refill requests, along with directly discussing with the patient the amount of drug being taken, if/why they are taking more than the amount prescribed, etc, should be done, especially considering the more severe the depression the more likely to use more opioids than prescribed," Dr. Divin said. Regular depression screening of patients on long-term opioid therapy is also needed, she said.

Move to More Conservative Prescribing


In an editorial accompanying the article, Michael Von Korff, ScD, from Group Health Research Institute in Seattle, who worked on the study, notes that the pendulum is swinging in the direction of "more selective and conservative" opioid prescribing, given epidemic levels of drug overdose and addiction involving prescription opioids.

Estimates are that the volume of prescribed opioids increased 600% from 1997 to 2007; during roughly the same period, the number of unintentional lethal overdoses involving prescription opioids increased more than 350%, from approximately 4000 in 1999 to more than 14,000 in 2007.

The coauthors of a second commentary assert that opioids are not appropriate therapy for chronic noncancer pain for most patients in primary care settings because of the power of opioids to do harm and the availability of safer, alternative treatments for chronic pain, including physical therapy, cognitive behavioral therapy, low-dose tricyclic medications, and treatment of co-occurring psychiatric illnesses.

In their article, Roger A. Rosenblatt, MD, MPH, and Mary Catlin, BSN, MPH, both from University of Washington, Seattle, suggest that when other interventions fail or are inadequate, "cautious evidence-based consideration of low-dose opioids as an adjunct to other therapies may be considered."
Yet they remind clinicians that entering into long-term opioid therapy "requires a long-term commitment by clinician and patient alike to use this powerful, precious, and dangerous medication with care and diligence. As clinicians and patients, we need to develop a generous measure of respect for the power of opioids to do harm as well as provide relief from pain."

REMS Approved for Opioids


In April 2011, as reported by Medscape Medical News, the US Food and Drug Administration (FDA) unveiled an opioid education program for prescribers, called the opioid Risk Evaluation and Mitigation Strategy (REMS).

On July 9, as reported by Medscape Medical News, the FDA approved REMS for extended-release (ER) and long-acting (LA) opioid analgesics in the treatment of moderate to severe chronic pain. The plan requires more than 20 opioid manufacturers to provide continuing education programs on proper use of these drugs, said Margaret Hamburg, MD, commissioner of the FDA, during a press conference.
The study was supported by the National Institute for Drug Abuse. The study authors, editorial writers, and Dr. Divin have disclosed no relevant financial relationships.


Ann Fam Med. 2012;10:302-303,304-311. Abstract, Editorial, Editorial

Original article at medscape here

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Low Vitamin D May Blunt Effectiveness of Asthma Treatment

A study showing relationship between poor lung functions and ineffective response to asthma treatment with Vitamin D deficiency.

July 13, 2012 — When using inhaled corticosteroids to treat patients with persistent asthma, vitamin D levels should be closely monitored and supplemented, if necessary, according to results from a multicenter placebo-controlled study of 1041 children with mild to moderate persistent asthma. Ann Chen, MD, MPH, assistant professor in the Department of Population Medicine at Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, and colleagues found that children with asthma who are deficient in vitamin D show less improvement over the course of a year's therapy with corticosteroids than do children who have more normal levels.

"In asthmatic children treated with inhaled corticosteroids, vitamin D deficiency is associated with poorer lung function than [in] children with vitamin D insufficiency or sufficiency," the authors write.
The findings were published online July 13 in the American Journal of Respiratory and Critical Care Medicine.

Dr. Chen and colleagues note that the prevalence of both asthma and vitamin D deficiency have increased in recent years, suggesting there may be a causal link between the 2. "Multiple studies have supported the hypothesis that asthma and vitamin D deficiency are related," they write, "but few studies have examined the direct effects of vitamin D levels and corticosteroid treatment on lung function in children with asthma."

To look more closely into that possible association, the investigators analyzed data from the Childhood Asthma Management Program, a multicenter trial of 1041 children diagnosed with mild to moderate persistent asthma. All the children were between 5 and 12 years of age.

On the children's entry into the study, administrators measured levels of 25-hydroxyvitamin D in their serum and then randomly assigned them to receive 1 of 3 agents: the inhaled corticosteroid budesonide, the nonsteroidal anti-inflammatory agent nedocromil, or placebo. Data regarding baseline vitamin D levels were available for 1024 children.

Spirometry readings were obtained before and after the children used their inhalers. Those tests were conducted at intake into the study and again after a year of therapy.

The investigators also categorized the children into 3 groups according to their serum levels of vitamin D: those who had sufficient levels (>30 ng/mL), those deemed to have insufficient levels (20 - 30 ng/mL), and those with deficient levels (<20 ng/mL).

Main outcome measures were changes in prebronchodilator forced expiratory volume in 1 second (FEV₁), bronchodilator response, and provocative concentration of methacholine producing a 20% decline in FEV₁.

The researchers report that of the 1024 children, 663 (nearly 65%) had sufficient levels of vitamin D, 260 (just over 25%) had insufficient levels, and 101 (roughly 10%) had deficient levels.
Compared with children who had sufficient or insufficient levels of vitamin D, those with deficient levels were more likely to be older and black and to have a higher body mass index, the researchers write.

Among children being treated with corticosteroids, those who were vitamin D deficient were less likely than other children taking the same drug to show big improvements in prebronchodilator FEV₁ scores after 12 months of treatment.

More specifically, children with insufficient levels of vitamin D showed a 330-mL increase, those with sufficient levels showed a 290-mL increase, and children with vitamin D deficiencies had only a 140-mL increase in prebronchodilator FEV₁. That difference was significant to a P value of < .007, after adjustments for age, sex, race, body mass index, number of visits to emergency departments, and the season of the year that serum for the vitamin D specimen had been drawn.

The investigators do acknowledge a couple of limitations of the study; namely, that the sample size of children with vitamin D deficiencies was relatively small (101 children) and that vitamin D levels were assessed only once, on entry into the trial.

Even so, Dr. Wu and colleagues say the present study is the first to suggest that vitamin D sufficiency in patients treated with inhaled corticosteroids is associated with improved lung function in patients with mild to moderate persistent asthma. They suggest monitoring vitamin D levels and, if they are found to be low, considering supplementation.

This study was funded by the National Heart, Lung, and Blood Institute, the Childhood Asthma Management Program, and the National Center for Research Resources. The authors have disclosed no relevant financial relationships.


Am J Respir Crit Care Med. Published online July 13, 2012.

Original Article from medscape: here

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