Many patients have been told to take antibiotics before dental procedures.  This recommendation was made to prevent an infection of the lining or valves of the heart called infective endocarditis (IE).  Patients who had leaky heart valves or other heart conditions that were thought to increase the risk of IE were told to take antibiotics before seeing the dentist.

Last week the American Heart Association published new guidelines about which patients should receive antibiotics to prevent IE.  These guidelines are based on the realization that in most patients, dental and other medical procedures are exceedingly unlikely to result in IE, and that antibiotics are more likely to cause harm than benefit in all patients except in those at highest risk for IE.

The only patients for whom preventive antibiotics are now recommended are those with

artificial heart valves
a history of having had IE
certain specific, serious congenital (present from birth) heart conditions, including:
- unrepaired or incompletely repaired cyanotic congenital heart disease, including those with palliative shunts and conduits
- a completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter interventions, during the first six months after the procedure
-any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or prosthetic device
a cardiac transplant which develops a problem in a heart valve

That means the vast majority of the people taking antibiotics before dental procedures can stop.  Obviously, if you’re not sure if this applies to you, check with your doctor.

Thanks to Dr. Yaron Elad for pointing me to the new recommendations.

I have many patients who swear by alternative therapies that are unproven or, worse, proven not to work.  How should I counsel them?  On the one hand, each individual is unique and it’s possible that what applies to thousands of patients in a study shouldn’t be generalized to the specific patient sitting in my office right now.  On the other hand, we all (I included) have a staggering capacity for self-delusion, and it’s possible that my patient is just engaging in wishful thinking because he sincerely wants the therapy to help.

This week’s Annals of Internal Medicine published a study which offers a case in point.  The study was the most rigorous review of previous studies that tested chondrointin’s benefits for arthritis pain.  The study was also discussed in this editorial in Annals, and it was covered in this LA Times article.

The conclusion of the study was fairly definitive.

Large-scale, methodologically sound trials indicate that the symptomatic benefit of chondroitin is minimal or nonexistent.

Well, that’s that, right?  The only reason to take chondrointin over placebo is if the chondrointin is cheaper.  Nevertheless, many of my patients use chondrointin for arthritis pain and swear by it.  The editorial offers them, and me, some advice.

However, some patients are convinced that it helps, which could be because of a placebo response or even a therapeutic response resulting from enhanced absorption or limited metabolism of chondroitin. Because no frequent or severe adverse effects have been reported, chondroitin sulfate should not be considered dangerous. If patients say that they benefit from chondroitin, I see no harm in encouraging them to continue taking it as long as they perceive a benefit.

So like chicken soup, chondrointin might not help, but it probably won’t hurt.

This week’s Journal of the American Medical Association published a study that may be a turning point in treatment of type 1 diabetes.  The study received much media coverage, including this LA Times article.

Type 1 diabetes is a very different disease than the much more common type 2 diabetes.  (They should probably just have entirely different names.)  Type 2 diabetes is predominantly a disease of overweight adults and results from insulin resistance, meaning a decrease in insulin’s ability to function.  It is usually treated with oral medications.  Type 1 diabetes is an auto-immune disease that usually strikes in childhood or young adulthood.  In it, the immune system destroys the cells in the pancreas that produce insulin leading to an absence of insulin in the body.  The only treatment for type 1 is insulin.

This study is promising because it hints at a possible way to reverse or delay type 1 diabetes as soon as it is diagnosed.  In the study 15 patients with newly diagnosed type 1 diabetes underwent chemotherapy to severely suppress their immune system.  After that, their immune system was rescued by giving them their own stem cells, which were collected before the chemotherapy.  Most of the patients did not require insulin for their diabetes for months, some for years, after the treatment, and there were no major adverse outcomes.

This study is small and needs to be duplicated with more patients, and hopefully with more prolonged benefits, but it’s a potentially novel treatment for a serious chronic problem.

Tangential Miscellany:

Two weeks ago, I wrote about an interview in U.S. News and World Report of Dr. Jerome Groopman about mistakes that doctors make by not spending enough time listening to patients.  In the current issue they published my letter in response.  (It’s the second letter on the page.)

Most of my patients know that I’m a big fan of technology.  From electronic medical records to viewing diagnostic images over the web, I love finding tools that help me take better care of patients.  A study in this week’s New England Journal of Medicine is an important cautionary tale that reminds us that new technologies should always be tested rigorously.

The study examined the use of a technology called computer-aided detection to assist radiologists in interpreting screening mammograms.  Computer-aided detection involves computer software that analyzes mammogram images and identifies suspicious abnormalities.  It was approved by the FDA in 1998 and has gained popularity since then.  The study was also covered in yesterday’s Los Angeles Times.

The study found that the technology actually decreased accuracy when compared to a radiologist reading the mammograms without computer assistance.  Computer assistance lead to an increase in potential abnormalities being identified that overwhelmingly turned out to be benign.  The number of women recalled for additional imaging increased by 32% and the number of biopsies increased by 20%, but the number of actual cancers detected did not increase.  So computer assistance only led to unnecessary procedures and didn’t assist in diagnosis.

So for now, we should leave mammogram interpretation to trained humans, and let computers do what they’re best at – connecting you to educational articles from your doctor!

Tangential Miscellany:

Drum roll, please.  The following are the winners of the Pedometer Project for March.

The winner with most steps was Sari A.  In her honor I’ll be donating platelets at Cedars-Sinai on April 12.

The winner for most improved walker in March was Victoria W.  In her honor I will volunteer at the Simms/Mann Clinic on April 18.

The winner for weight loss was Douglas C.  In his honor I will volunteer at the Simms/Mann Clinic on May 2.

My congratulations to all the participants!  The Project will continue through the end of April.