Scripps Health: Primary Care Summer Conference

SAN DIEGO – Never underestimate the importance of providing early education and positive reinforcement to patients who have sustained a traumatic brain injury.

"If you educate them, you’ll prevent a lot of emotional upset about what’s going to be happening over the next weeks or months," Dr. Michael A. Lobatz said at a meeting on primary care medicine sponsored by the Scripps Clinic. "When I see a patient with an acute concussive injury, I will tell them, ‘It’s going to get better; 85% of patients get better. The prognosis is good. Hang in there. We’re going to shut down some of your activity, but we’re going to wait for this to get better and you’re going to heal up.’ "

He makes it a point to tell them that memory deficits are common after a TBI, and that such symptoms as dizziness, irritability, a decreased ability to process information and tasks, sleep disturbance, and impulsiveness may also occur. "If you do that, you will often avoid that shattered sense of self that people come away with when they’re left hanging, not understanding what’s actually going on with them," said Dr. Lobatz, a neurologist and the medical director at the Scripps Rehabilitation Center, Encinitas, Calif.

The Centers for Disease Control and Prevention estimates that each year, 1.7 million TBIs occur in the United States. Of these, about 1.4 million involve visits to the emergency department, 275,000 involve hospitalizations, and 52,000 result in death. Dr. Lobatz defined TBI as a bump, blow, or jolt to the head that disrupts the normal function of the brain. "This may range from mild to severe, with extended periods of loss of consciousness or prolonged periods of amnesia," he said. But most of the TBIs that occur are very mild, may resolve on their own, and might not even need medical attention.

There are at least 16 different grading systems for trying to measure severity of TBI, he said, the most recent being about 10 years old. "The good news is, the American Academy of Neurology is working on a new grading system that will probably published by November of this year," he said. "That will be very useful and most updated based on class I evidence."

According to current AAN guidelines, a grade 1 concussion is marked by spotty confusion, no loss of consciousness, and concussion symptoms that last less than 15 minutes; a grade 2 concussion is marked by spotty confusion, no loss of consciousness, and concussive symptoms or abnormalities that last longer than 15 minutes. By contrast, a grade 3 concussion is marked by any loss of consciousness whether brief (seconds) or prolonged (minutes).

The guidelines also include ratings for three different levels of posttraumatic amnesia. Mild injury is defined as a Glasgow Coma Scale (GCS) score of 13-15, with 15 being completely normal, plus a 0- to 20-minute loss of consciousness (LOC) and amnesia lasting less than 24 hours. A moderate injury is defined as LOC lasting 20 minutes to 6 hours with a GCS score of 9-12. A severe injury is defined as LOC lasting longer than 6 hours with a GCS score of 3-8. Dr. Lobatz noted that patients who have longer periods of anterograde amnesia "tend to have a more prolonged course to recovery or incomplete recovery. When you take your history, ask [patients] what they remember, not what they were told happened or what they think happened by their own logical deduction. When you preface your question like that, you’ll get more accurate information."

Sorting out preinjury vs. postinjury factors in TBI patients is no easy task. For example, preexisting factors "could be that they have some ADHD, poor school performance, or depression," he said. "Postinjury factors might include disruption of relationships, school, or work. You need an open mind when you see these patients, and you cannot do this [assessment] in 10 minutes."

The process is further complicated in the assessment of soldiers who present with a TBI and also have concomitant posttraumatic stress disorder. Distinguishing which symptoms stem from the TBI and which stem from the PTSD "is a little bit of the art of evaluating the soldier these days, trying to understand which one is more predominant," Dr. Lobatz said. "In our experience at Scripps in treating well over 100 of these soldiers, we find that it’s often mixed. They often have both problems going on. When the PTSD symptoms are overwhelming, that needs to be addressed first. When that’s cleared up, they can come back and get therapy for their concussive injury. Sometimes it’s the other way around and [both] can be addressed simultaneously with cognitive therapy."

The impact of the TBI varies depending on the severity of initial injury; the rate or completeness of physiological recovery; the functions affected; the meaning of dysfunction to the individual; and the resources available to aid recovery. "We try to strengthen what is weak with repetitive activities," Dr. Lobatz said. "When we realize that we cannot strengthen what is weak – that there are permanent deficits – we teach people to adapt. That is what rehabilitation is all about: Strengthen what is possible to be strengthened and adapt to what cannot be strengthened."

In athletes who are still experiencing symptoms of a concussion, return to play is not advised. If they return before they’re fully healed and then suffer another injury, that second injury "is potentially much more severe than the first," Dr. Lobatz warned. "There may not be a loss of consciousness, but there is a much more likely possibility of swelling in the brain, and there can be as much as 50% mortality in severe cases. Furthermore, there is a much higher risk of long-term complications where patients do not return to normal. They are left with long-term deficits."

To help objectify when it’s okay to return to play, Dr. Lobatz recommended administering the ImPACT test, a computer-based assessment which provides a baseline of neurocognitive skills and takes about 30 minutes to complete. In addition, a consensus statement from the Third International Conference on Concussion in Sport provides a staged system of gradual return to physical activity (Br. J. Sports Med. 2009;43:i76-84). It calls for no activity immediately after the injury, and progresses in a stepwise fashion to light aerobic exercise, sport-specific exercise, noncontact training, full contact practice, and eventual return to play.

Early on, "you may want to pull the student out of school for a week or two, for physical rest and mental rest," Dr. Lobatz said.

He also recommended the Acute Concussion Evaluation–Physician/Clinician Office Version, a checklist that "helps you identify red flags, make a diagnosis, look at risk factors for protracted recovery," he said. It can be downloaded free of charge from the U.S. Centers for Disease Control and Prevention website.

Dr. Lobatz said that he had no relevant financial disclosures to make.

SAN DIEGO – Never underestimate the importance of providing early education and positive reinforcement to patients who have sustained a traumatic brain injury.

"If you educate them, you’ll prevent a lot of emotional upset about what’s going to be happening over the next weeks or months," Dr. Michael A. Lobatz said at a meeting on primary care medicine sponsored by the Scripps Clinic. "When I see a patient with an acute concussive injury, I will tell them, ‘It’s going to get better; 85% of patients get better. The prognosis is good. Hang in there. We’re going to shut down some of your activity, but we’re going to wait for this to get better and you’re going to heal up.’ "

He makes it a point to tell them that memory deficits are common after a TBI, and that such symptoms as dizziness, irritability, a decreased ability to process information and tasks, sleep disturbance, and impulsiveness may also occur. "If you do that, you will often avoid that shattered sense of self that people come away with when they’re left hanging, not understanding what’s actually going on with them," said Dr. Lobatz, a neurologist and the medical director at the Scripps Rehabilitation Center, Encinitas, Calif.

The Centers for Disease Control and Prevention estimates that each year, 1.7 million TBIs occur in the United States. Of these, about 1.4 million involve visits to the emergency department, 275,000 involve hospitalizations, and 52,000 result in death. Dr. Lobatz defined TBI as a bump, blow, or jolt to the head that disrupts the normal function of the brain. "This may range from mild to severe, with extended periods of loss of consciousness or prolonged periods of amnesia," he said. But most of the TBIs that occur are very mild, may resolve on their own, and might not even need medical attention.

There are at least 16 different grading systems for trying to measure severity of TBI, he said, the most recent being about 10 years old. "The good news is, the American Academy of Neurology is working on a new grading system that will probably published by November of this year," he said. "That will be very useful and most updated based on class I evidence."

According to current AAN guidelines, a grade 1 concussion is marked by spotty confusion, no loss of consciousness, and concussion symptoms that last less than 15 minutes; a grade 2 concussion is marked by spotty confusion, no loss of consciousness, and concussive symptoms or abnormalities that last longer than 15 minutes. By contrast, a grade 3 concussion is marked by any loss of consciousness whether brief (seconds) or prolonged (minutes).

The guidelines also include ratings for three different levels of posttraumatic amnesia. Mild injury is defined as a Glasgow Coma Scale (GCS) score of 13-15, with 15 being completely normal, plus a 0- to 20-minute loss of consciousness (LOC) and amnesia lasting less than 24 hours. A moderate injury is defined as LOC lasting 20 minutes to 6 hours with a GCS score of 9-12. A severe injury is defined as LOC lasting longer than 6 hours with a GCS score of 3-8. Dr. Lobatz noted that patients who have longer periods of anterograde amnesia "tend to have a more prolonged course to recovery or incomplete recovery. When you take your history, ask [patients] what they remember, not what they were told happened or what they think happened by their own logical deduction. When you preface your question like that, you’ll get more accurate information."

Sorting out preinjury vs. postinjury factors in TBI patients is no easy task. For example, preexisting factors "could be that they have some ADHD, poor school performance, or depression," he said. "Postinjury factors might include disruption of relationships, school, or work. You need an open mind when you see these patients, and you cannot do this [assessment] in 10 minutes."

The process is further complicated in the assessment of soldiers who present with a TBI and also have concomitant posttraumatic stress disorder. Distinguishing which symptoms stem from the TBI and which stem from the PTSD "is a little bit of the art of evaluating the soldier these days, trying to understand which one is more predominant," Dr. Lobatz said. "In our experience at Scripps in treating well over 100 of these soldiers, we find that it’s often mixed. They often have both problems going on. When the PTSD symptoms are overwhelming, that needs to be addressed first. When that’s cleared up, they can come back and get therapy for their concussive injury. Sometimes it’s the other way around and [both] can be addressed simultaneously with cognitive therapy."

The impact of the TBI varies depending on the severity of initial injury; the rate or completeness of physiological recovery; the functions affected; the meaning of dysfunction to the individual; and the resources available to aid recovery. "We try to strengthen what is weak with repetitive activities," Dr. Lobatz said. "When we realize that we cannot strengthen what is weak – that there are permanent deficits – we teach people to adapt. That is what rehabilitation is all about: Strengthen what is possible to be strengthened and adapt to what cannot be strengthened."

In athletes who are still experiencing symptoms of a concussion, return to play is not advised. If they return before they’re fully healed and then suffer another injury, that second injury "is potentially much more severe than the first," Dr. Lobatz warned. "There may not be a loss of consciousness, but there is a much more likely possibility of swelling in the brain, and there can be as much as 50% mortality in severe cases. Furthermore, there is a much higher risk of long-term complications where patients do not return to normal. They are left with long-term deficits."

To help objectify when it’s okay to return to play, Dr. Lobatz recommended administering the ImPACT test, a computer-based assessment which provides a baseline of neurocognitive skills and takes about 30 minutes to complete. In addition, a consensus statement from the Third International Conference on Concussion in Sport provides a staged system of gradual return to physical activity (Br. J. Sports Med. 2009;43:i76-84). It calls for no activity immediately after the injury, and progresses in a stepwise fashion to light aerobic exercise, sport-specific exercise, noncontact training, full contact practice, and eventual return to play.

Early on, "you may want to pull the student out of school for a week or two, for physical rest and mental rest," Dr. Lobatz said.

He also recommended the Acute Concussion Evaluation–Physician/Clinician Office Version, a checklist that "helps you identify red flags, make a diagnosis, look at risk factors for protracted recovery," he said. It can be downloaded free of charge from the U.S. Centers for Disease Control and Prevention website.

Dr. Lobatz said that he had no relevant financial disclosures to make.

SAN DIEGO – Never underestimate the importance of providing early education and positive reinforcement to patients who have sustained a traumatic brain injury.

"If you educate them, you’ll prevent a lot of emotional upset about what’s going to be happening over the next weeks or months," Dr. Michael A. Lobatz said at a meeting on primary care medicine sponsored by the Scripps Clinic. "When I see a patient with an acute concussive injury, I will tell them, ‘It’s going to get better; 85% of patients get better. The prognosis is good. Hang in there. We’re going to shut down some of your activity, but we’re going to wait for this to get better and you’re going to heal up.’ "

He makes it a point to tell them that memory deficits are common after a TBI, and that such symptoms as dizziness, irritability, a decreased ability to process information and tasks, sleep disturbance, and impulsiveness may also occur. "If you do that, you will often avoid that shattered sense of self that people come away with when they’re left hanging, not understanding what’s actually going on with them," said Dr. Lobatz, a neurologist and the medical director at the Scripps Rehabilitation Center, Encinitas, Calif.

The Centers for Disease Control and Prevention estimates that each year, 1.7 million TBIs occur in the United States. Of these, about 1.4 million involve visits to the emergency department, 275,000 involve hospitalizations, and 52,000 result in death. Dr. Lobatz defined TBI as a bump, blow, or jolt to the head that disrupts the normal function of the brain. "This may range from mild to severe, with extended periods of loss of consciousness or prolonged periods of amnesia," he said. But most of the TBIs that occur are very mild, may resolve on their own, and might not even need medical attention.

There are at least 16 different grading systems for trying to measure severity of TBI, he said, the most recent being about 10 years old. "The good news is, the American Academy of Neurology is working on a new grading system that will probably published by November of this year," he said. "That will be very useful and most updated based on class I evidence."

According to current AAN guidelines, a grade 1 concussion is marked by spotty confusion, no loss of consciousness, and concussion symptoms that last less than 15 minutes; a grade 2 concussion is marked by spotty confusion, no loss of consciousness, and concussive symptoms or abnormalities that last longer than 15 minutes. By contrast, a grade 3 concussion is marked by any loss of consciousness whether brief (seconds) or prolonged (minutes).

The guidelines also include ratings for three different levels of posttraumatic amnesia. Mild injury is defined as a Glasgow Coma Scale (GCS) score of 13-15, with 15 being completely normal, plus a 0- to 20-minute loss of consciousness (LOC) and amnesia lasting less than 24 hours. A moderate injury is defined as LOC lasting 20 minutes to 6 hours with a GCS score of 9-12. A severe injury is defined as LOC lasting longer than 6 hours with a GCS score of 3-8. Dr. Lobatz noted that patients who have longer periods of anterograde amnesia "tend to have a more prolonged course to recovery or incomplete recovery. When you take your history, ask [patients] what they remember, not what they were told happened or what they think happened by their own logical deduction. When you preface your question like that, you’ll get more accurate information."

Sorting out preinjury vs. postinjury factors in TBI patients is no easy task. For example, preexisting factors "could be that they have some ADHD, poor school performance, or depression," he said. "Postinjury factors might include disruption of relationships, school, or work. You need an open mind when you see these patients, and you cannot do this [assessment] in 10 minutes."

The process is further complicated in the assessment of soldiers who present with a TBI and also have concomitant posttraumatic stress disorder. Distinguishing which symptoms stem from the TBI and which stem from the PTSD "is a little bit of the art of evaluating the soldier these days, trying to understand which one is more predominant," Dr. Lobatz said. "In our experience at Scripps in treating well over 100 of these soldiers, we find that it’s often mixed. They often have both problems going on. When the PTSD symptoms are overwhelming, that needs to be addressed first. When that’s cleared up, they can come back and get therapy for their concussive injury. Sometimes it’s the other way around and [both] can be addressed simultaneously with cognitive therapy."

The impact of the TBI varies depending on the severity of initial injury; the rate or completeness of physiological recovery; the functions affected; the meaning of dysfunction to the individual; and the resources available to aid recovery. "We try to strengthen what is weak with repetitive activities," Dr. Lobatz said. "When we realize that we cannot strengthen what is weak – that there are permanent deficits – we teach people to adapt. That is what rehabilitation is all about: Strengthen what is possible to be strengthened and adapt to what cannot be strengthened."

In athletes who are still experiencing symptoms of a concussion, return to play is not advised. If they return before they’re fully healed and then suffer another injury, that second injury "is potentially much more severe than the first," Dr. Lobatz warned. "There may not be a loss of consciousness, but there is a much more likely possibility of swelling in the brain, and there can be as much as 50% mortality in severe cases. Furthermore, there is a much higher risk of long-term complications where patients do not return to normal. They are left with long-term deficits."

To help objectify when it’s okay to return to play, Dr. Lobatz recommended administering the ImPACT test, a computer-based assessment which provides a baseline of neurocognitive skills and takes about 30 minutes to complete. In addition, a consensus statement from the Third International Conference on Concussion in Sport provides a staged system of gradual return to physical activity (Br. J. Sports Med. 2009;43:i76-84). It calls for no activity immediately after the injury, and progresses in a stepwise fashion to light aerobic exercise, sport-specific exercise, noncontact training, full contact practice, and eventual return to play.

Early on, "you may want to pull the student out of school for a week or two, for physical rest and mental rest," Dr. Lobatz said.

He also recommended the Acute Concussion Evaluation–Physician/Clinician Office Version, a checklist that "helps you identify red flags, make a diagnosis, look at risk factors for protracted recovery," he said. It can be downloaded free of charge from the U.S. Centers for Disease Control and Prevention website.

Dr. Lobatz said that he had no relevant financial disclosures to make.

SAN DIEGO – A 67-year-old woman with poorly controlled diabetes, diabetic retinopathy, and diabetic nephropathy visits your office for routine follow-up.

Her blood pressure is 165/95 mm Hg, her pulse is 71 beats per minute, her body mass index is 36 kg/m², and labs reveal that her creatinine level is 1.2 mg/dL, her potassium level is 5.5 mmol/L, and she is spilling 3,500 mg of albuminuria in her urine, "which is quite significant," Dr. Kimberly Harper said at a meeting on primary care medicine sponsored by the Scripps Clinic.

This patient is also on insulin, lisinopril 20 mg/day, amlodipine 5 mg/day, and simvastatin 10 mg/day. How would you manage her hypertension? In the clinical opinion of Dr. Harper, a nephrologist at Scripps Clinic, La Jolla, Calif., the best approach would be to advise her to exercise, watch her sodium intake, and lose weight, as well as to increase her dose of lisinopril and add a thiazide diuretic to help control her potassium.

"As physicians managing hypertension, lifestyle modification is of the utmost importance," Dr. Harper said. "This is easier said than done, but if we can motivate our patients to do these things, we can help to get their blood pressure under better control without the side effects of medications."

According to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, for every 10 kg of weight loss, patients typically experience a 5-10 mm Hg reduction in systolic blood pressure, while keeping sodium intake to less than 2,400 mg/day can lead to a 2-8 mm Hg reduction. In addition, at least 30 minutes of aerobic exercise most days of the week can translate into a 4-9 mm Hg reduction, while moderate consumption of alcohol can mean a 2-4 mm Hg reduction. "This is defined as no more than one alcoholic beverage in a setting for women and no more than two alcoholic beverages in a setting for men," Dr. Harper said.

She makes it a point to inform patients on the risk of hyperkalemia, because over time diabetes can cause a type-4 renal tubular acidosis. In addition, all renin-angiotensin-aldosterone system medications can induce hyperkalemia. "I tell patients that hyperkalemia can lead to a fatal cardiac arrhythmia," Dr. Harper said. "Their ears tend to perk up when I say that."

She also instructs patients to follow a diet restricted to less than 2,000-3,000 mg potassium/day, depending on how high their potassium levels are.

In addition, Dr. Harper will often prescribe a thiazide or loop diuretic to help with the excretion of potassium.

She closed her presentation by highlighting experimental treatments for hypertension on the horizon. One is a hypertension vaccine that inhibits angiotensin II. A phase II trial of 24-hour blood pressure monitoring showed that patients who received the vaccine had significantly lower systolic and diastolic blood pressure, compared with those who received placebo (Lancet 2008;371:821-7).

Another emerging treatment is renal denervation, a catheter-based treatment in which radiofrequency is applied to sympathetic nerves in the kidney to help control blood pressure. A randomized trial found that renal denervation reduced blood pressure in treatment-resistant hypertensive patients, compared with those who did not receive the intervention (Lancet 2010;376:1903-9).

Finally, a new potential class of antihypertensive agents, known as vasopeptidase inhibitors, is being studied. These agents inhibit angiotensin-converting enzyme as well as neutral endopeptidase, an enzyme that helps rid the body of excess salt and water and would lower the blood pressure, she said.

Dr. Harper said that she had no relevant financial disclosures to make.

SAN DIEGO – A 67-year-old woman with poorly controlled diabetes, diabetic retinopathy, and diabetic nephropathy visits your office for routine follow-up.

Her blood pressure is 165/95 mm Hg, her pulse is 71 beats per minute, her body mass index is 36 kg/m², and labs reveal that her creatinine level is 1.2 mg/dL, her potassium level is 5.5 mmol/L, and she is spilling 3,500 mg of albuminuria in her urine, "which is quite significant," Dr. Kimberly Harper said at a meeting on primary care medicine sponsored by the Scripps Clinic.

This patient is also on insulin, lisinopril 20 mg/day, amlodipine 5 mg/day, and simvastatin 10 mg/day. How would you manage her hypertension? In the clinical opinion of Dr. Harper, a nephrologist at Scripps Clinic, La Jolla, Calif., the best approach would be to advise her to exercise, watch her sodium intake, and lose weight, as well as to increase her dose of lisinopril and add a thiazide diuretic to help control her potassium.

"As physicians managing hypertension, lifestyle modification is of the utmost importance," Dr. Harper said. "This is easier said than done, but if we can motivate our patients to do these things, we can help to get their blood pressure under better control without the side effects of medications."

According to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, for every 10 kg of weight loss, patients typically experience a 5-10 mm Hg reduction in systolic blood pressure, while keeping sodium intake to less than 2,400 mg/day can lead to a 2-8 mm Hg reduction. In addition, at least 30 minutes of aerobic exercise most days of the week can translate into a 4-9 mm Hg reduction, while moderate consumption of alcohol can mean a 2-4 mm Hg reduction. "This is defined as no more than one alcoholic beverage in a setting for women and no more than two alcoholic beverages in a setting for men," Dr. Harper said.

She makes it a point to inform patients on the risk of hyperkalemia, because over time diabetes can cause a type-4 renal tubular acidosis. In addition, all renin-angiotensin-aldosterone system medications can induce hyperkalemia. "I tell patients that hyperkalemia can lead to a fatal cardiac arrhythmia," Dr. Harper said. "Their ears tend to perk up when I say that."

She also instructs patients to follow a diet restricted to less than 2,000-3,000 mg potassium/day, depending on how high their potassium levels are.

In addition, Dr. Harper will often prescribe a thiazide or loop diuretic to help with the excretion of potassium.

She closed her presentation by highlighting experimental treatments for hypertension on the horizon. One is a hypertension vaccine that inhibits angiotensin II. A phase II trial of 24-hour blood pressure monitoring showed that patients who received the vaccine had significantly lower systolic and diastolic blood pressure, compared with those who received placebo (Lancet 2008;371:821-7).

Another emerging treatment is renal denervation, a catheter-based treatment in which radiofrequency is applied to sympathetic nerves in the kidney to help control blood pressure. A randomized trial found that renal denervation reduced blood pressure in treatment-resistant hypertensive patients, compared with those who did not receive the intervention (Lancet 2010;376:1903-9).

Finally, a new potential class of antihypertensive agents, known as vasopeptidase inhibitors, is being studied. These agents inhibit angiotensin-converting enzyme as well as neutral endopeptidase, an enzyme that helps rid the body of excess salt and water and would lower the blood pressure, she said.

Dr. Harper said that she had no relevant financial disclosures to make.

SAN DIEGO – A 67-year-old woman with poorly controlled diabetes, diabetic retinopathy, and diabetic nephropathy visits your office for routine follow-up.

Her blood pressure is 165/95 mm Hg, her pulse is 71 beats per minute, her body mass index is 36 kg/m², and labs reveal that her creatinine level is 1.2 mg/dL, her potassium level is 5.5 mmol/L, and she is spilling 3,500 mg of albuminuria in her urine, "which is quite significant," Dr. Kimberly Harper said at a meeting on primary care medicine sponsored by the Scripps Clinic.

This patient is also on insulin, lisinopril 20 mg/day, amlodipine 5 mg/day, and simvastatin 10 mg/day. How would you manage her hypertension? In the clinical opinion of Dr. Harper, a nephrologist at Scripps Clinic, La Jolla, Calif., the best approach would be to advise her to exercise, watch her sodium intake, and lose weight, as well as to increase her dose of lisinopril and add a thiazide diuretic to help control her potassium.

"As physicians managing hypertension, lifestyle modification is of the utmost importance," Dr. Harper said. "This is easier said than done, but if we can motivate our patients to do these things, we can help to get their blood pressure under better control without the side effects of medications."

According to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, for every 10 kg of weight loss, patients typically experience a 5-10 mm Hg reduction in systolic blood pressure, while keeping sodium intake to less than 2,400 mg/day can lead to a 2-8 mm Hg reduction. In addition, at least 30 minutes of aerobic exercise most days of the week can translate into a 4-9 mm Hg reduction, while moderate consumption of alcohol can mean a 2-4 mm Hg reduction. "This is defined as no more than one alcoholic beverage in a setting for women and no more than two alcoholic beverages in a setting for men," Dr. Harper said.

She makes it a point to inform patients on the risk of hyperkalemia, because over time diabetes can cause a type-4 renal tubular acidosis. In addition, all renin-angiotensin-aldosterone system medications can induce hyperkalemia. "I tell patients that hyperkalemia can lead to a fatal cardiac arrhythmia," Dr. Harper said. "Their ears tend to perk up when I say that."

She also instructs patients to follow a diet restricted to less than 2,000-3,000 mg potassium/day, depending on how high their potassium levels are.

In addition, Dr. Harper will often prescribe a thiazide or loop diuretic to help with the excretion of potassium.

She closed her presentation by highlighting experimental treatments for hypertension on the horizon. One is a hypertension vaccine that inhibits angiotensin II. A phase II trial of 24-hour blood pressure monitoring showed that patients who received the vaccine had significantly lower systolic and diastolic blood pressure, compared with those who received placebo (Lancet 2008;371:821-7).

Another emerging treatment is renal denervation, a catheter-based treatment in which radiofrequency is applied to sympathetic nerves in the kidney to help control blood pressure. A randomized trial found that renal denervation reduced blood pressure in treatment-resistant hypertensive patients, compared with those who did not receive the intervention (Lancet 2010;376:1903-9).

Finally, a new potential class of antihypertensive agents, known as vasopeptidase inhibitors, is being studied. These agents inhibit angiotensin-converting enzyme as well as neutral endopeptidase, an enzyme that helps rid the body of excess salt and water and would lower the blood pressure, she said.

Dr. Harper said that she had no relevant financial disclosures to make.

SAN DIEGO – Before you formally assess patients who present with back and neck pain, listen carefully to how they characterize their discomfort, Dr. Robert K. Eastlack advised at a meeting on primary care medicine sponsored by Scripps Clinic.

"The history is the critical part of the evaluation," said Dr. Eastlack, fellowship and spine research director in the division of orthopedic surgery at Scripps Clinic, La Jolla, Calif. "It’s like putting a puzzle together. If you sit and listen to your patients – you let them isolate where the problem is – they’ll usually lead you right to the money."

©ugurhan/iStockphoto.com

The location of the pain will help you home in on your differential. Is it neck pain or back pain? Both? What’s the character of the pain? Is it radiating into extremities? Is it a burning pain? Does it occur at night? Does it worsen with certain activities?

"Refer the patient immediately if they have acute weakness, bowel or bladder dysfunction, or unmitigated severe pain," Dr. Eastlack emphasized. "Having said that, 95% of people with back pain and neck pain will get better in 4-6 weeks. The hard part is holding their hand through that period. Everybody wants to know what the best treatment is. The reality is, it usually just takes time."

In the primary care setting, his recommended examination of the lumbar spine includes inspection while the patient is standing, sitting, and walking, as well as palpation of the midline, flank, paraspinal, and gluteal areas to screen for abnormalities. He also recommends a motion assessment to help differentiate potential sources of pain.

"For instance, somebody who has pain when they’re leaning back will sometimes have facet arthritis," Dr. Eastlack said. "They can be managed with NSAIDs, activity management, physical therapy, and sometimes, we’ll send them off to pain management to get injections. Someone who has flexion-related pain can be more problematic in terms of disk abnormalities and associated nerve pinching. By getting a sense of how much motion they have, you get a sense of what they may be able to achieve or improve upon in physical therapy."

Straight leg lifts and internal rotation of the hip can be helpful in assessing knee and hip pain, respectively, while part of his neurological assessment includes a stair step with each leg, toe and heel walk, and great toe dorsiflexion. "If you push down on the great toes of your patients during attempted resistance, they should be able to hold their toes up against your finger strength," Dr. Eastlack said. "If they can’t, they probably have a neurological issue that would probably otherwise go unrecognized. It’s a rapid way for you to recognize that they may have something going on in their spinal canal. Always look for asymmetry, as well."

Rather than fuss with formal neurological motor testing, Dr. Eastlack advises primary care physicians to "boil it down to what’s easy to do. Orthopedic surgeons and neurosurgeons tend to use graded scales. That’s more for study and objective evaluations that we can assess serially." The key is to look for any change from normal. "See whether they can go against your resistance or not. They can either use it fully or they can’t, or they can provide resistance against you that seems normal and symmetric or they can’t. Use that as your parameter."

Sensory evaluation should be focused on light touch, he continued. "You’ll also want to understand the dermatomal regions you’re considering," he said. Deep tendon reflexes of the biceps, brachioradialis, triceps, patella, and Achilles are helpful; however, people with diabetes or thyroid issues are generally not going to have reflexes. Having said that, remember to look for asymmetry.

Standing x-rays of the lumbar spine "are critical," he said. "So many patients who show up in my office have had a CT scan or an MRI scan but no plain x-rays. Instability of the spine can often be better detected on upright or standing x-ray."

CT scans expose patients to far more radiation than x-rays or MRI do, "and they’re not that helpful," Dr. Eastlack said. "Generally speaking, the only time I get a CT scan is if I have an acute trauma patient or if I’m looking for small bone defects that are not well visualized on a radiograph."

Dr. Eastlack said that he had no relevant financial disclosures.

SAN DIEGO – Before you formally assess patients who present with back and neck pain, listen carefully to how they characterize their discomfort, Dr. Robert K. Eastlack advised at a meeting on primary care medicine sponsored by Scripps Clinic.

"The history is the critical part of the evaluation," said Dr. Eastlack, fellowship and spine research director in the division of orthopedic surgery at Scripps Clinic, La Jolla, Calif. "It’s like putting a puzzle together. If you sit and listen to your patients – you let them isolate where the problem is – they’ll usually lead you right to the money."

©ugurhan/iStockphoto.com

The location of the pain will help you home in on your differential. Is it neck pain or back pain? Both? What’s the character of the pain? Is it radiating into extremities? Is it a burning pain? Does it occur at night? Does it worsen with certain activities?

"Refer the patient immediately if they have acute weakness, bowel or bladder dysfunction, or unmitigated severe pain," Dr. Eastlack emphasized. "Having said that, 95% of people with back pain and neck pain will get better in 4-6 weeks. The hard part is holding their hand through that period. Everybody wants to know what the best treatment is. The reality is, it usually just takes time."

In the primary care setting, his recommended examination of the lumbar spine includes inspection while the patient is standing, sitting, and walking, as well as palpation of the midline, flank, paraspinal, and gluteal areas to screen for abnormalities. He also recommends a motion assessment to help differentiate potential sources of pain.

"For instance, somebody who has pain when they’re leaning back will sometimes have facet arthritis," Dr. Eastlack said. "They can be managed with NSAIDs, activity management, physical therapy, and sometimes, we’ll send them off to pain management to get injections. Someone who has flexion-related pain can be more problematic in terms of disk abnormalities and associated nerve pinching. By getting a sense of how much motion they have, you get a sense of what they may be able to achieve or improve upon in physical therapy."

Straight leg lifts and internal rotation of the hip can be helpful in assessing knee and hip pain, respectively, while part of his neurological assessment includes a stair step with each leg, toe and heel walk, and great toe dorsiflexion. "If you push down on the great toes of your patients during attempted resistance, they should be able to hold their toes up against your finger strength," Dr. Eastlack said. "If they can’t, they probably have a neurological issue that would probably otherwise go unrecognized. It’s a rapid way for you to recognize that they may have something going on in their spinal canal. Always look for asymmetry, as well."

Rather than fuss with formal neurological motor testing, Dr. Eastlack advises primary care physicians to "boil it down to what’s easy to do. Orthopedic surgeons and neurosurgeons tend to use graded scales. That’s more for study and objective evaluations that we can assess serially." The key is to look for any change from normal. "See whether they can go against your resistance or not. They can either use it fully or they can’t, or they can provide resistance against you that seems normal and symmetric or they can’t. Use that as your parameter."

Sensory evaluation should be focused on light touch, he continued. "You’ll also want to understand the dermatomal regions you’re considering," he said. Deep tendon reflexes of the biceps, brachioradialis, triceps, patella, and Achilles are helpful; however, people with diabetes or thyroid issues are generally not going to have reflexes. Having said that, remember to look for asymmetry.

Standing x-rays of the lumbar spine "are critical," he said. "So many patients who show up in my office have had a CT scan or an MRI scan but no plain x-rays. Instability of the spine can often be better detected on upright or standing x-ray."

CT scans expose patients to far more radiation than x-rays or MRI do, "and they’re not that helpful," Dr. Eastlack said. "Generally speaking, the only time I get a CT scan is if I have an acute trauma patient or if I’m looking for small bone defects that are not well visualized on a radiograph."

Dr. Eastlack said that he had no relevant financial disclosures.

SAN DIEGO – Before you formally assess patients who present with back and neck pain, listen carefully to how they characterize their discomfort, Dr. Robert K. Eastlack advised at a meeting on primary care medicine sponsored by Scripps Clinic.

"The history is the critical part of the evaluation," said Dr. Eastlack, fellowship and spine research director in the division of orthopedic surgery at Scripps Clinic, La Jolla, Calif. "It’s like putting a puzzle together. If you sit and listen to your patients – you let them isolate where the problem is – they’ll usually lead you right to the money."

©ugurhan/iStockphoto.com

The location of the pain will help you home in on your differential. Is it neck pain or back pain? Both? What’s the character of the pain? Is it radiating into extremities? Is it a burning pain? Does it occur at night? Does it worsen with certain activities?

"Refer the patient immediately if they have acute weakness, bowel or bladder dysfunction, or unmitigated severe pain," Dr. Eastlack emphasized. "Having said that, 95% of people with back pain and neck pain will get better in 4-6 weeks. The hard part is holding their hand through that period. Everybody wants to know what the best treatment is. The reality is, it usually just takes time."

In the primary care setting, his recommended examination of the lumbar spine includes inspection while the patient is standing, sitting, and walking, as well as palpation of the midline, flank, paraspinal, and gluteal areas to screen for abnormalities. He also recommends a motion assessment to help differentiate potential sources of pain.

"For instance, somebody who has pain when they’re leaning back will sometimes have facet arthritis," Dr. Eastlack said. "They can be managed with NSAIDs, activity management, physical therapy, and sometimes, we’ll send them off to pain management to get injections. Someone who has flexion-related pain can be more problematic in terms of disk abnormalities and associated nerve pinching. By getting a sense of how much motion they have, you get a sense of what they may be able to achieve or improve upon in physical therapy."

Straight leg lifts and internal rotation of the hip can be helpful in assessing knee and hip pain, respectively, while part of his neurological assessment includes a stair step with each leg, toe and heel walk, and great toe dorsiflexion. "If you push down on the great toes of your patients during attempted resistance, they should be able to hold their toes up against your finger strength," Dr. Eastlack said. "If they can’t, they probably have a neurological issue that would probably otherwise go unrecognized. It’s a rapid way for you to recognize that they may have something going on in their spinal canal. Always look for asymmetry, as well."

Rather than fuss with formal neurological motor testing, Dr. Eastlack advises primary care physicians to "boil it down to what’s easy to do. Orthopedic surgeons and neurosurgeons tend to use graded scales. That’s more for study and objective evaluations that we can assess serially." The key is to look for any change from normal. "See whether they can go against your resistance or not. They can either use it fully or they can’t, or they can provide resistance against you that seems normal and symmetric or they can’t. Use that as your parameter."

Sensory evaluation should be focused on light touch, he continued. "You’ll also want to understand the dermatomal regions you’re considering," he said. Deep tendon reflexes of the biceps, brachioradialis, triceps, patella, and Achilles are helpful; however, people with diabetes or thyroid issues are generally not going to have reflexes. Having said that, remember to look for asymmetry.

Standing x-rays of the lumbar spine "are critical," he said. "So many patients who show up in my office have had a CT scan or an MRI scan but no plain x-rays. Instability of the spine can often be better detected on upright or standing x-ray."

CT scans expose patients to far more radiation than x-rays or MRI do, "and they’re not that helpful," Dr. Eastlack said. "Generally speaking, the only time I get a CT scan is if I have an acute trauma patient or if I’m looking for small bone defects that are not well visualized on a radiograph."

Dr. Eastlack said that he had no relevant financial disclosures.

SAN DIEGO – With consumers buzzing about the advertised benefits of probiotics for a healthy gut, what’s a primary care physician to recommend?

At a meeting on primary care medicine sponsored by the Scripps Clinic, Dr. Walter J. Coyle emphasized that while probiotics may play a role in the treatment and management of certain gastroenterological conditions, "there are not a lot of well-done randomized, placebo-controlled trials of these drugs. Most GI physicians use probiotics regularly, but our understanding of how these products work and interact with our immune systems and gut lining is still in its infancy."

The majority of probiotics are gram-positive lactic acid producers such as Bifidobacterium and Lactobacillus species, "which survive in transit through the stomach and duodenum," said Dr. Coyle, a gastroenterologist who directs the Scripps Clinic Gastroenterology Fellowship Program. Others include nonpathogenic streptococci, enterococci, Escherichia coli Nissle 1917, and Saccharomyces boulardii (yeast).

Dr. Coyle discussed the potential benefits of several probiotics on the market:

– VSL #3. This product contains four lactobacilli organisms (L. plantarum, casei, acidopholus, and delbrueckii), three bifidobacteria organisms (B. infantis, breve, and longum), and one streptococcus organism (Streptococcus salivarius subsp. thermophilus). "It’s fairly expensive and has to be kept refrigerated," Dr. Coyle said. "Randomized placebo-controlled trials have shown it’s very good for pouchitis." A more recent study of its use in ulcerative colitis patients found that it was superior to placebo in mild to moderate activity (Am. J. Gastroenterol. 2010; 105:2218-27). "It’s not one of my first-line therapies for inflammatory bowel disease, but it is out there as an alternative," he said.

– Digestive Advantage for IBS. This product contains Ganeden BC³⁰, a patented bacteria strain of Bacillus coagulans, erythritol, cellulose, and other minor ingredients. One small, randomized, double-blind, placebo-controlled trial found it to be an effective treatment of abdominal pain and bloating in patients with irritable bowel syndrome (Postgrad. Med. 2009;121 [doi: 10.3810/pgm.2009.03.1984]). "I’ll try it if the patients fail to have symptom improvement with other therapies, but there are no really well done randomized, placebo-controlled trials, which is the problem with most probiotics," Dr. Coyle said.

– Align. This product contains a patented strain of Bifidobacterium infantis 35624. In two large trials, it demonstrated decreased symptoms in IBS patients, "mostly in bloating and a little bit on flatulence," he said. This probiotic was also shown in trials to decrease the mucosal levels of IL-6, a known inflammatory cytokine. (See Gastroenterol. 2005;128:541-51 and Am. J. Gastroenterol. 2006;101:1581-90.) "I often try Align for my irritable bowel patients," he said.

– Florastor (Saccharomyces boulardii). This product has been shown to help prevent recurrent Clostridium difficile infections and to decrease diarrhea associated with antibiotic use. The dosing in one randomized, placebo-controlled study (JAMA 1994;271:1913-8) was two tablets twice per day, "which is expensive," Dr. Coyle said. "I typically recommend one tablet twice a day. However, for those patients who have had multiple recurrences of C. difficile, I do use the higher dose of two tablets twice per day."

– Actimel. This yogurt-type drink contains the patented yogurt culture known as Lactobacillus casei Immunitas. In a 2007 randomized, placebo-controlled trial of 135 hospitalized patients on antibiotics, those who received an Actimel-like product were significantly less likely to develop hospital-acquired diarrhea, compared with those who received placebo (12% vs. 34%, respectively). A similar association was seen in the prevention of hospital-acquired C. difficile (BMJ 2007;335:80 [doi: 10.1136/bmj.39231.599815.55]).

In this trial, "you only needed to treat five patients to prevent one case of hospital-acquired diarrhea, and you only needed to treat six patients to prevent one case of hospital-acquired C. difficile," Dr. Coyle said. "Why are we not doing this in the hospital?"

– Activia. This yogurt product contains Bifidus regularis and Bifidobacterium animus, and has been shown in scientific studies to increase transit time in women and in older adults. "If you like the taste of Activia, take it," he commented. "I don’t think I’d take it for making your gut healthier. It may, but we don’t have the data. It does help in patients who are often constipated. I’m fine with that, but I’m not sure I would classify it as a medical food."

– Culturelle. This product contains Lactobacillus rhamnosus GG and has been shown in scientific studies to be superior to placebo for diarrheal illnesses. "It’s proven to survive transit through the stomach and small intestine, and binds to human colonocytes," Dr. Coyle said. "It’s a reasonable choice for diarrhea patients and it’s been around for a long time."

He noted that current studies of prebiotics – ingested substances that selectively stimulate the proliferation or activity of desirable bacterial populations present in the host intestinal tract – have the potential for significant impact in the field of gastroenterology. "Is it possible to design a food, sugar, protein, or fat that would alter your gut flora to promote weight loss? That concept is exciting," he said. "I think you’re going to see a lot coming down the line on this."

Dr. Coyle said that he had no relevant financial disclosures.

SAN DIEGO – With consumers buzzing about the advertised benefits of probiotics for a healthy gut, what’s a primary care physician to recommend?

At a meeting on primary care medicine sponsored by the Scripps Clinic, Dr. Walter J. Coyle emphasized that while probiotics may play a role in the treatment and management of certain gastroenterological conditions, "there are not a lot of well-done randomized, placebo-controlled trials of these drugs. Most GI physicians use probiotics regularly, but our understanding of how these products work and interact with our immune systems and gut lining is still in its infancy."

The majority of probiotics are gram-positive lactic acid producers such as Bifidobacterium and Lactobacillus species, "which survive in transit through the stomach and duodenum," said Dr. Coyle, a gastroenterologist who directs the Scripps Clinic Gastroenterology Fellowship Program. Others include nonpathogenic streptococci, enterococci, Escherichia coli Nissle 1917, and Saccharomyces boulardii (yeast).

Dr. Coyle discussed the potential benefits of several probiotics on the market:

– VSL #3. This product contains four lactobacilli organisms (L. plantarum, casei, acidopholus, and delbrueckii), three bifidobacteria organisms (B. infantis, breve, and longum), and one streptococcus organism (Streptococcus salivarius subsp. thermophilus). "It’s fairly expensive and has to be kept refrigerated," Dr. Coyle said. "Randomized placebo-controlled trials have shown it’s very good for pouchitis." A more recent study of its use in ulcerative colitis patients found that it was superior to placebo in mild to moderate activity (Am. J. Gastroenterol. 2010; 105:2218-27). "It’s not one of my first-line therapies for inflammatory bowel disease, but it is out there as an alternative," he said.

– Digestive Advantage for IBS. This product contains Ganeden BC³⁰, a patented bacteria strain of Bacillus coagulans, erythritol, cellulose, and other minor ingredients. One small, randomized, double-blind, placebo-controlled trial found it to be an effective treatment of abdominal pain and bloating in patients with irritable bowel syndrome (Postgrad. Med. 2009;121 [doi: 10.3810/pgm.2009.03.1984]). "I’ll try it if the patients fail to have symptom improvement with other therapies, but there are no really well done randomized, placebo-controlled trials, which is the problem with most probiotics," Dr. Coyle said.

– Align. This product contains a patented strain of Bifidobacterium infantis 35624. In two large trials, it demonstrated decreased symptoms in IBS patients, "mostly in bloating and a little bit on flatulence," he said. This probiotic was also shown in trials to decrease the mucosal levels of IL-6, a known inflammatory cytokine. (See Gastroenterol. 2005;128:541-51 and Am. J. Gastroenterol. 2006;101:1581-90.) "I often try Align for my irritable bowel patients," he said.

– Florastor (Saccharomyces boulardii). This product has been shown to help prevent recurrent Clostridium difficile infections and to decrease diarrhea associated with antibiotic use. The dosing in one randomized, placebo-controlled study (JAMA 1994;271:1913-8) was two tablets twice per day, "which is expensive," Dr. Coyle said. "I typically recommend one tablet twice a day. However, for those patients who have had multiple recurrences of C. difficile, I do use the higher dose of two tablets twice per day."

– Actimel. This yogurt-type drink contains the patented yogurt culture known as Lactobacillus casei Immunitas. In a 2007 randomized, placebo-controlled trial of 135 hospitalized patients on antibiotics, those who received an Actimel-like product were significantly less likely to develop hospital-acquired diarrhea, compared with those who received placebo (12% vs. 34%, respectively). A similar association was seen in the prevention of hospital-acquired C. difficile (BMJ 2007;335:80 [doi: 10.1136/bmj.39231.599815.55]).

In this trial, "you only needed to treat five patients to prevent one case of hospital-acquired diarrhea, and you only needed to treat six patients to prevent one case of hospital-acquired C. difficile," Dr. Coyle said. "Why are we not doing this in the hospital?"

– Activia. This yogurt product contains Bifidus regularis and Bifidobacterium animus, and has been shown in scientific studies to increase transit time in women and in older adults. "If you like the taste of Activia, take it," he commented. "I don’t think I’d take it for making your gut healthier. It may, but we don’t have the data. It does help in patients who are often constipated. I’m fine with that, but I’m not sure I would classify it as a medical food."

– Culturelle. This product contains Lactobacillus rhamnosus GG and has been shown in scientific studies to be superior to placebo for diarrheal illnesses. "It’s proven to survive transit through the stomach and small intestine, and binds to human colonocytes," Dr. Coyle said. "It’s a reasonable choice for diarrhea patients and it’s been around for a long time."

He noted that current studies of prebiotics – ingested substances that selectively stimulate the proliferation or activity of desirable bacterial populations present in the host intestinal tract – have the potential for significant impact in the field of gastroenterology. "Is it possible to design a food, sugar, protein, or fat that would alter your gut flora to promote weight loss? That concept is exciting," he said. "I think you’re going to see a lot coming down the line on this."

Dr. Coyle said that he had no relevant financial disclosures.

SAN DIEGO – With consumers buzzing about the advertised benefits of probiotics for a healthy gut, what’s a primary care physician to recommend?

At a meeting on primary care medicine sponsored by the Scripps Clinic, Dr. Walter J. Coyle emphasized that while probiotics may play a role in the treatment and management of certain gastroenterological conditions, "there are not a lot of well-done randomized, placebo-controlled trials of these drugs. Most GI physicians use probiotics regularly, but our understanding of how these products work and interact with our immune systems and gut lining is still in its infancy."

The majority of probiotics are gram-positive lactic acid producers such as Bifidobacterium and Lactobacillus species, "which survive in transit through the stomach and duodenum," said Dr. Coyle, a gastroenterologist who directs the Scripps Clinic Gastroenterology Fellowship Program. Others include nonpathogenic streptococci, enterococci, Escherichia coli Nissle 1917, and Saccharomyces boulardii (yeast).

Dr. Coyle discussed the potential benefits of several probiotics on the market:

– VSL #3. This product contains four lactobacilli organisms (L. plantarum, casei, acidopholus, and delbrueckii), three bifidobacteria organisms (B. infantis, breve, and longum), and one streptococcus organism (Streptococcus salivarius subsp. thermophilus). "It’s fairly expensive and has to be kept refrigerated," Dr. Coyle said. "Randomized placebo-controlled trials have shown it’s very good for pouchitis." A more recent study of its use in ulcerative colitis patients found that it was superior to placebo in mild to moderate activity (Am. J. Gastroenterol. 2010; 105:2218-27). "It’s not one of my first-line therapies for inflammatory bowel disease, but it is out there as an alternative," he said.

– Digestive Advantage for IBS. This product contains Ganeden BC³⁰, a patented bacteria strain of Bacillus coagulans, erythritol, cellulose, and other minor ingredients. One small, randomized, double-blind, placebo-controlled trial found it to be an effective treatment of abdominal pain and bloating in patients with irritable bowel syndrome (Postgrad. Med. 2009;121 [doi: 10.3810/pgm.2009.03.1984]). "I’ll try it if the patients fail to have symptom improvement with other therapies, but there are no really well done randomized, placebo-controlled trials, which is the problem with most probiotics," Dr. Coyle said.

– Align. This product contains a patented strain of Bifidobacterium infantis 35624. In two large trials, it demonstrated decreased symptoms in IBS patients, "mostly in bloating and a little bit on flatulence," he said. This probiotic was also shown in trials to decrease the mucosal levels of IL-6, a known inflammatory cytokine. (See Gastroenterol. 2005;128:541-51 and Am. J. Gastroenterol. 2006;101:1581-90.) "I often try Align for my irritable bowel patients," he said.

– Florastor (Saccharomyces boulardii). This product has been shown to help prevent recurrent Clostridium difficile infections and to decrease diarrhea associated with antibiotic use. The dosing in one randomized, placebo-controlled study (JAMA 1994;271:1913-8) was two tablets twice per day, "which is expensive," Dr. Coyle said. "I typically recommend one tablet twice a day. However, for those patients who have had multiple recurrences of C. difficile, I do use the higher dose of two tablets twice per day."

– Actimel. This yogurt-type drink contains the patented yogurt culture known as Lactobacillus casei Immunitas. In a 2007 randomized, placebo-controlled trial of 135 hospitalized patients on antibiotics, those who received an Actimel-like product were significantly less likely to develop hospital-acquired diarrhea, compared with those who received placebo (12% vs. 34%, respectively). A similar association was seen in the prevention of hospital-acquired C. difficile (BMJ 2007;335:80 [doi: 10.1136/bmj.39231.599815.55]).

In this trial, "you only needed to treat five patients to prevent one case of hospital-acquired diarrhea, and you only needed to treat six patients to prevent one case of hospital-acquired C. difficile," Dr. Coyle said. "Why are we not doing this in the hospital?"

– Activia. This yogurt product contains Bifidus regularis and Bifidobacterium animus, and has been shown in scientific studies to increase transit time in women and in older adults. "If you like the taste of Activia, take it," he commented. "I don’t think I’d take it for making your gut healthier. It may, but we don’t have the data. It does help in patients who are often constipated. I’m fine with that, but I’m not sure I would classify it as a medical food."

– Culturelle. This product contains Lactobacillus rhamnosus GG and has been shown in scientific studies to be superior to placebo for diarrheal illnesses. "It’s proven to survive transit through the stomach and small intestine, and binds to human colonocytes," Dr. Coyle said. "It’s a reasonable choice for diarrhea patients and it’s been around for a long time."

He noted that current studies of prebiotics – ingested substances that selectively stimulate the proliferation or activity of desirable bacterial populations present in the host intestinal tract – have the potential for significant impact in the field of gastroenterology. "Is it possible to design a food, sugar, protein, or fat that would alter your gut flora to promote weight loss? That concept is exciting," he said. "I think you’re going to see a lot coming down the line on this."

Dr. Coyle said that he had no relevant financial disclosures.