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Enoch Choi, MD  
Male, 39
Palo Alto, CA

Specialties: Family Medicine

Interests: sinusitis, Migraine, Low back pain
Palo Alto Medical Foundation
Urgent Care
Palo Alto, CA
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Antidepressants may not be much better than placebo

Feb 26, 2008 - 51 comments
Tags:

antidepressant

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treatment

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depressed

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prozac

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Effexor

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serzone

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paxil

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placebo

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Depression



A fascinating research study was published today by Irving Kirsch of the University of Hull, questioning whether or not 4 popular antidepressants are any better than placebo, and found that they weren't any better.  Here's the study:

http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0050045&ct=1

Both published and unpublished data on fluoxetine (Prozac), venlafaxine (Effexor), nefazodone (Serzone), and paroxetine (Paxil) were combined in a technique called meta-analysis, which brings together the data from many different research studies to see if they agree.

The researchers concluded that the antidepressants were not any better than placebo for mildly depressed patients.  They found that although there was a benefit from antidepressants, it was not significantly better than what a placebo (pill without any medicine in it) did.  The placebo treatments had a great deal of benefit, almost 80% improvement in depression symptoms.  The antidepressants didn't do any better than placebo.

They further concluded that the benefit that these antidepressants had on severely depressed patients was from these patient's lack of benefit from placebo treatment.  That is to say, severely depressed patients didn't get better from a placebo (pill without any medicine in it).  Since severely depressed patients got better at about the same rate as the mildly depressed patients, by comparing this benefit to the lower benefit from placebo, overall they showed a benefit.  Another way to think of it is that really depressed patients get better from antidepressants at about the same rate as mildly depressed patients get better, but since severely depressed patients don't get better from placebo, by comparing treatment versus placebo, the difference is greater.

It's important that patients on these medicines don't stop taking their medicines because serious side effects can occur, such as worsening of the depressive symptoms that they initially took them for, including thoughts of suicide for some patients.

This is just one study that will be further examined.  The great thing is that it's been published in the Public Library of Science online journal.  This is a place where the data and paper are publicly available, without any advertising or corporate support.

Reasons to think twice about the results of this study, is that the technique of meta-analysis is only as good as how well the 47 different data sets they've combined match.  These data sets have to be combined in a valid way, controlling for different factors in each study.  Some researchers disagree with this kind of process, saying that it's very difficult to control for confounding factors in the separate data sets, calling into question the validity of the results.  I'm expecting the drug companies to be fighting these studies powerfully, and be curious to see how they try to disprove the results.

Tips on telling a cold from a bacterial infection: sinusitis, pharyngitis, bronchitis

Jan 30, 2008 - 104 comments
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bacterial

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sinusitis

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pharyngitis

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cough

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sore throat

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Bronchitis

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Infection

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Cold



The flu has passed epidemic rates in much of the country, and if you don't have a cold, I'm sure you have a friend who has the sniffles, fever, chills, aches and pains of a viral upper respiratory infection.  This is different from a bacterial infection such as sinusitis, bronchitis, or pneumonia.  A viral infection doesn't improve with antibiotics as these infections do.  A virus hijacks your own body's healthy cells and uses it to reproduce and spread.  A bacteria is its own living cell and multiplies and spreads on its own and is easier to destroy in that process.  

Speaking of outbreaks, influenza is finally reaching Palo Alto right around now. If your doctor knows that your own area is experiencing an outbreak of influenza, it may be reasonable to treat with antiviral drugs, especially if your temperature is more than 100 degrees and your symptoms have lasted less than 48 hours, and you don't have pneumonia. This is because antivirals won't help if given after 2 days of symptoms. They work by stopping the spread of the virus and if you take the antiviral too late, it's too late to stop the spread, it's already happened.

Here are some guidelines on helping differentiate between run of the mill colds and more serious bacterial infections:




When do I need antibiotics for a cold, as an adult?

Never.

Are you sick with a runny nose, sore throat, cough, possibly even goey green and brown stuff coming out? Well, you're not alone, you've got a cold like millions of other adults right now around the world. Colds are upper respiratory infections that are almost always caused by viruses in adults. They typically get better after a week to ten days.

Viruses can even cause colored mucous, that thick discharge you can't see through, which many people believe only can come from a bacterial infection. Colds can even cause pressure in sinuses, when viruses affect the sinuses .
Antibiotics don't help in these viral infections. Treatments aimed at reducing symptoms can help. A recent review in the American Family Physician journal on Feb 15, 2007 highlights some of the treatments that are helpful in the common cold and how to tell if you're getting worse than just a viral infection:

http://www.aafp.org/afp/20070215/515.html

http://www.aafp.org/afp/20070215/522ph.html

symptoms that are worse than those of a normal cold or that haven't gotten better in 10 days

• a high fever

• an earache that gets worse

• a pain in your face, especially on one side

• shortness of breath

• a health problem that makes it more likely that you will have problems with a cold (for example: asthma and other lung diseases or a disease that affects how your body fights infection)

These are general guidelines, meant to be taken in the whole context of your health history by your doctor.

Conditions that increase the risk of bacterial infection including the complication of pneumonia include the elderly or those with heart and lung disease. Another helpful reference includes the American College of Physicians, Annals of Internal Medicine, 20 March 2001, Volume 134, Number 6. http://www.annals.org/cgi/content/abstract/134/6/479





When do I need antibiotics for sinusitis, as an adult?

Doc! My face hurts on one side and colored mucous is coming out! These are common complaints from adult patients who think they have acute bacterial sinusitis. What people don't know is that it's not common before 7 days of illness, and it's usually best to hold off on antibiotics until symptoms have stuck around for more than a week. Sinusitis is different from the first few days of stuffiness and pressure from viral illness. Clues that you may have a bacterial infection include

- pus coming out of your nose,

- upper tooth pain or pain in your face,

- sinus pain on one side,

- new or worse symptoms after initially improving after a cold

Instead of antibiotics, reach for over the counter painkillers, fever reducers, and decongestants. When it's more clear to your doctor that you do in fact have a bacterial sinusitis, your symptoms will be more moderate to severe, and can be treated with antibiotics that are more narrow-spectrum such as amoxicillin as a first choice. Later generation antibiotics that have broader coverage across more kinds of bacteria should be reserved for complicated infections.

These are general guidelines, meant to be taken in the whole context of your health history by your doctor. Another helpful reference includes the American College of Physicians, Annals of Internal Medicine, 20 March 2001, Volume 134, Number 6.

http://www.annals.org/cgi/content/abstract/134/6/479






When do I need antibiotics for sore throat?

Rarely.

Doc, I'm sure I have strep throat, it's killing me! Well, you may have it but it's pretty unlikely. Only 5 to 15 per cent of people with sore throat have Group A beta-hemolytic Strepococcus bacterial infections. Most cases are viral. Your doctor may consider treating for strep if you have at least 3 of the 4 following signs: fever, pus on tonsils (exudate), tender lymph nodes in front of your neck (anterior cervical lymphadenopathy), and lack of cough (no coughing). If so, treat with antibiotics that are more narrow-spectrum such as penicillin since there's virtually no resistance to penicillin by strep in the community. If less than 3 of 4 of these signs are positive, then wait for your strep test or throat culture to show a bacterial infection before taking antibiotics.

These are general guidelines, meant to be taken in the whole context of your health history by your doctor. Another helpful reference includes the American College of Physicians, Annals of Internal Medicine, 20 March 2001, Volume 134, Number 6.

http://www.annals.org/cgi/content/abstract/134/6/479



When do I need antibiotics for bronchitis?

Almost never.

Doc, I can't stop coughing and am bringing up pus. Well, you're not alone. Millions of other people are in your shoes right now, and over 90 per cent of them have viral infections with coughs productive of colored phlegm.

You should watch out for symptoms of pneumonia but if you have a fever under 100 degrees, pulse rate less than 100, less than 24 breaths per minute, and your doctor doesn't hear anything in your lungs, you can be reassured that pneumonia is unlikely. If your doctor is worried that you might have pneumonia, a chest x-ray can look to see if there's an infection, especially for those who have coughed for more than 3 weeks.

With a viral bronchitis, you should avoid antibiotics especially zpacks (Zithromax / azithromycin) which are overprescribed for these symptoms , and can lead to side effects and adverse drug reaction such as rash, antibiotic drug resistance and yeast infections. Instead, helpful treatments include cough suppressants, bronchodilators (albuterol inhalers), and antihistamine-decongestants.

One possible exception is that you might need antibiotics in an exacerbation of COPD (emphysema or chronic obstructive bronchitis) expecially if you have worse shortness of breath and productive cough of pus.

Another possible exception is that you might need antibiotics in case of an infection with pertussis, where you cough for more than 2 weeks AND have an uncontrollable cough which can cause vomiting, or a whoop sound when you breathe in. In this case, your doctor may swab to look for pertussis, and may choose to start treating you with erythromycin or azithromycin (zithromax) especially if there's an outbreak of it locally in your community, just as we've had here locall in Santa Clara County.

These are general guidelines, meant to be taken in the whole context of your health history by your doctor. Another helpful reference includes the American College of Physicians, Annals of Internal Medicine, 20 March 2001, Volume 134, Number 6.

http://www.annals.org/cgi/content/abstract/134/6/479





How to care for a newly sutured wound

Jan 17, 2008 - 0 comments
Tags:

sutured

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suture

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cut

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Healing

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laceration

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Infection

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scar



You don't have to worry so much if you carefully follow your ER doc's instructions which they gave you before leaving, that sheet should have instructions that are similar to those that I give to patients who are stitched by me:
- no further cleaning, no peroxide, alcohol
- keep covered for 1st two days
- don't vigorously clean the wound since the body lays down cells to heal the wound
- sun protection is important not only for scarring but for coloration
- watching for infection (red, warm, tender, pink streaking away from wound) and coming in for treatment right away if an infection happens, can reduce the risk of scarring

If a scar happens, then a plastic surgeon sometimes is able to help.  Unfortunately, some people are more prone to develop large scars from relatively small injuries, and these people would not be good candidates for surgical revision since the result would be worse than before.

Scarring is possible with all wounds, but with care, the risk can be reduced.  Many patients ask me about aloe vera or Vitamin E and I haven't found good evidence for their use.


ENHANCE trial does not prove lipid lowering agents fail the general population

Jan 16, 2008 - 5 comments
Tags:

ultrasound

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cardiac

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artery

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lipid

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statin

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efficacy



The FDA has not issued an official advisory, but media is hyping and misleading the public regarding results from the ENHANCE trial (Effect of Combination Ezetimibe and High-Dose Simvastatin vs. Simvastatin Alone on the Atherosclerotic Process in Patients with Heterozygous Familial Hypercholesterolemia).  Merck and Schering-Plough submitted this for presentation as an pre-publication abstract at the American College of Cardiology meeting in March 2008.

Can you confirm these that I could dig up:

    * No difference between patients treated with ezetimibe/simvastatin 10/80 mg (Vytorin) versus patients treated with simvastatin 80 mg alone, over a two year period, for the primary endpoint of the mean change in intima-media thickness (IMT) measured at three sites in the carotid arteries. Carotid ultrasound studies are seen as reliable surrogate markers and predictive of future cardiac events.  There was a NON-statistically significant difference in wall thickness (p=0.29).

    * The Heterozygous Familial Hypercholesterolemia (HFH) population studied had baseline LDL measurements > 300 mg/dL. These patients make up 0.2% of the general population and are NOT representative of the typical patient receiving medication for hyperlipidemia.

    * Sinc conclusive evidence of ezetimibe's true effect is not available until studies on the general population with more power are published, maximizing statin dosing whenever possible is warranted for many patients with hypercholesterolemia.  Niacin or colesevelam (Welchol) are  alternatives to consider for statin intolerant patients.

http://www.merck.com/newsroom/press_releases/product/2008_0114.html