From the publishers of the New England Journal of Medicine

Clinical Medicine
A collection of key research summaries with important implications for clinical practice.

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Clinical Medicine
Dear Reader, Our Journal Watch mission is to capture the studies and research most relevant for your practice, summarize the signifi cant data, and contextualize the findings in pertinent commentary. Our 140 Journal Watch physicianeditors regularly survey more than 250 medical journals and deliver only the most important clinical research discoveries in a quick, manageable format. Weve compiled this collection of recent Journal Watch summaries with important implications for clinical prac tice.We hope you enjoy this compilation and invite you to interact with us at JWatch.org, where youll find blogs, pod casts, reader perspectives, and expert interviews in addition to the medical research we survey daily. The Journal Watch Editors

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CONTENTS
Measuring Blood Pressure: Once Is Not Enough ................................................1 Risk for Diabetes Increases with Statin Dose ......1 Intensified Early Treatment of Subclinical Diabetes: No Benefit at 5 Years ......2 Nonadherence to Gastroprotective Therapy Among NSAID Users ..............................................3 Percutaneous Coronary Intervention at U.S. Hospitals: A Report Card ..........................3 Mammography Screening and Breast Cancer Mortality: Long-Term Advantages.......................4 Breast Cancer and OCs: Still Worried After All These Years? ....................5 Cephalosporin-Resistant Gonococci on the Rise ................................................................5 Cumulative Antibiotic Exposure Is Associated with Risk for C. difficile Infection .........................6 For Dermatologic Surgery, Clean Rather Than Sterile Technique May Be Sufficient ........7 Salicylic Acid Is as Effective as Cryotherapy for Plantar Warts .............................8 Why Do Children Drink Bottled Water? .................8 Nitrous Oxide Provides Sedation and Pain Control for Pediatric Procedures................9 Long-Acting Reversible Contraceptives Are Suitable for Adolescents ...............................9 Multifaceted Podiatry Treatment of Foot Pain Prevents Falls in Elders .................10 Low Dietary Calcium Intake Raises Risk for Fracture and Osteoporosis ...........................11 Surgery Doesnt Trump Rehabilitation in Patients with Degenerative Disk Disease ...11

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Measuring Blood Pressure: Once Is Not Enough

The optimal number of readings was four or five.

demonstrate that a single BP measurement is inadequate.

Jamaluddin Moloo, MD, MPH
Originally published in Journal Watch General Medicine

Although patients often use home blood pressure (BP) monitors, hypertension treat ment decisions generally are based on BP measurements obtained in our offices. One goal of this study was to determine the opti mal setting for, and optimal number of, BP measurements for clinical decision making. Researchers compared systolic BP measure ments obtained repeatedly during 18 months for 444 patients (92% men) at a Veterans Af fairs medical center; readings were obtained concurrently in three ways: during routine outpatient clinic visits, from electronic home monitors, and as part of a research protocol (obtained by research staff) at 6month in tervals. Systolic BP was deemed controlled if clinic or researchbased readings were <140 mm Hg and if homebased readings were <135 mm Hg. The proportion of patients whose sys tolic BP was identified as controlled in the first 30 days varied by measurement type: 28% for clinic readings, 47% for home readings, and 68% for researchbased read ings. Regardless of the setting, averaging the measurements from multiple readings decreased withinpatient variability; the optimal number of readings was approxi mately four to five. The intervals between readings differed for each group: three times weekly for home monitoring readings, two readings every 6 months for the re search readings, and variable intervals for outpatient routine clinic visits.
COMMENT

Powers BJ et al. Measuring blood pressure for decision making and quality reporting: Where and how many measures? Ann Intern Med 2011 Jun 21; 154:781.

Risk for Diabetes Increases with Statin Dose

Risk was highest with intensive-dose therapy.

Small trials and a metaanalysis have sug gested that intensive versus moderatedose statin therapy is associated with elevated risk for developing insulin resistance and type 2 diabetes (Lancet 2010; 375:735). Researchers explored this association in a metaanalysis of five randomized statin trials with nearly 33,000 participants who did not have diabetes at baseline. During a mean followup of 4.9 years, 8.4% of participants developed diabetes, and 20.4% experienced major adverse cardio vascular (CV) events. Intensivedose therapy (daily atorvastatin [Lipitor; 80 mg] or simva statin [80 mg]) was compared with moderate dose therapy (daily atorvastatin [10 mg], simvastatin [20 mg], or pravastatin [40 mg]). Risk for diabetes was higher by 12% in the intensivedose group, with a number needed to treat [NNT] of 498 patients treated for 1 year for 1 patient to develop diabetes. Risk for CV events was lowered by 16% with an NNT of 155 for 1 patient to benefit.
COMMENT

In this study, BP readings varied substan tially when measured at home, in a clinic, or as part of a research protocol. Although we dont clearly know which approach to measuring BP correlates best with cardio vascular outcomes, the data convincingly

These somewhat counterintuitive results have no obvious biological explanation. The excess risk for developing type 2 diabetes is less than the lower risk for a CV event. Closerthan usual monitoring might be appropriate for these patients, but they likely are monitored closely already because they are usually at elevated risk. Thomas L. Schwenk, MD
Originally published in Journal Watch General Medicine

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CONTRIBUTING AUTHORS Murad Alam, MD, MSCI, Associate Professor of Dermatology, Otolaryngology, and Surgery, Chief of Cutaneous and Aesthetic Surgery, Feinberg School of Medicine, Northwestern University, Chicago Neil M. Ampel, MD, Professor of Medicine and Public Health, University of Arizona College of Medicine; Staff Physician, Southern Arizona VA Health Care System, Tucson Katherine Bakes, MD, Assistant Professor, University of Colorado Health Sciences Center; Division Head and Pediatric Emergency Medicine Director, Denver Emergency Center for Children; Clinical Instructor, The Childrens Hospital of Denver Stephen G. Baum, MD, Senior Associate Dean for Students and Professor of Medicine, Albert Einstein College of Medicine, Bronx, New York David J. Bjorkman, MD, MSPH (HSA), SM (Epid.), Dean, University of Utah School of Medicine; Executive Medical Director, University of Utah Medical Group, Salt Lake City Alain Joffe, MD, MPH, FAAP, Director, Student Health and Wellness Center, Johns Hopkins University, Associate Professor of Pediatrics, Johns Hopkins School of Medicine, Baltimore Andrew M. Kaunitz, MD, Professor and Associate Chair, Department of Obstetrics and Gynecology, University of Florida Health Science Center Jacksonville Beat J. Meyer, MD, Associate Professor of Cardiology, University of Bern; Chief, Division of Cardiology, Lindenhofspital, Bern, Switzerland Jamaluddin Moloo, MD, MPH, Assistant Professor of Medicine, Department of Medicine and Radiology, University of Colorado Health Sciences Center, Aurora, Colorado Paul S. Mueller, MD, MPH, FACP, Chair of the Division of General Internal Medicine, Associate Professor of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota Eleanor Bimla Schwarz, MD, MS, Associate Professor of Medicine, Epidemiology, Obstetrics, Gynecology, and Reproductive Sciences, Clinical and Translational Sciences, Center for Research on Health Care, University of Pittsburgh Thomas L. Schwenk, MD, Professor and Chair, Department of Family Medicine, University of Michigan Medical Center, Ann Arbor Bruce Soloway, MD, Associate Professor and Vice Chair, Department of Family and Social Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York Cornelius W. Van Niel, MD, Pediatrician, Sea Mar Community Health Centers; Clinical Professor, Department of Pediatrics, University of Washington School of Medicine, Seattle MASSACHUSETTS MEDICAL SOCIETY Christopher R. Lynch, Vice President for Publishing; Alberta L. Fitzpatrick, Publisher Sharon Salinger, Staff Editor; Kara OHalloran, Copy Editor; Sioux Waks, Layout; Robert Dall, Editorial Director; Art Wilschek, Christine Miller, Lew Wetzel, Advertising Sales; William Paige, Publishing Services; Bette Clancy, Customer Service

Preiss D et al. Risk of incident diabetes with intensivedose compared with moderate-dose statin therapy: A meta-analysis. JAMA 2011 Jun 22/29; 305:2556.

Intensified Early Treatment of Subclinical Diabetes: No Benefit at 5 Years

Longer follow-up might reveal benefit.

Clinicians often diagnose type 2 diabetes by screening asymptomatic patients, but how intensively patients should be managed at this early stage of disease is unclear. Researchers in the U.K., Denmark, and the Netherlands randomized 343 primary care practices to provide either routine care or in tensive multifactorial treatment to 3057 pa tients with early diabetes that was diagnosed through routine screening. Physicians and nurses in the intensive intervention received education on targets, algorithms, and lifestyle advice for managing hyperglycemia, blood pressure, and lipids; in some areas, patients also met periodically with diabetes nurses. After a mean followup of 5.3 years, mean declines in levels of glycosylated hemo globin (HbA1c), total and LDL cholesterol, and blood pressure were slightly but signifi cantly greater in patients in the intensive treatment practices than in those receiving routine care. The incidence of the primary composite endpoint (cardiovascular death, nonfatal myocardial infarction or stroke, or revascularization), each of its components, and allcause death was lower in the intensive treatment group. However, none of these dif ferences in clinical outcomes reached signifi cance (hazard ratio for composite endpoint, 0.83; P=0.12).
COMMENT

Although this trial had the virtue of a prag matic setting, it took place against the back ground of improving evidence and guide linedriven general diabetes care, which might have lessened the relative effect of the

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intensive intervention. The cumulative inci dence curves for the primary endpoint began to diverge after 4 years; longer followup might reveal an important clinical benefit.
Bruce Soloway, MD
Originally published in Journal Watch General Medicine

COMMENT

Griffin SJ et al. Effect of early intensive multifactorial therapy on 5-year cardiovascular outcomes in individuals with type 2 diabetes detected by screening (ADDITION-Europe): A cluster-randomised trial. Lancet 2011 Jul 9; 378:156. Preiss D and Sattar N. The case for diabetes screening: ADDITION-Europe. Lancet 2011 Jul 9; 378:106.

Nonadherence to Gastroprotective Therapy Among NSAID Users

Low adherence increased risk for upper gastrointestinal bleeding.

The risk for upper gastrointestinal (UGI) bleeding in patients taking nonselective non steroidal antiinflammatory drugs (NSAIDs) can be reduced by concomitant gastroprotec tive therapy. However, many patients do not comply with this approach. To evaluate adherence to gastroprotective therapy and its effect on UGI events, investi gators conducted a nested casecontrol study using three large national databases from the UK, the Netherlands, and Italy. Among a co hort of NSAID users aged 50 years who took gastroprotective agents, patients with UGI events were identified. Adherence to gastro protective therapy was determined using pharmacy data and compared between patients with and without UGI events. Investigators documented 117,307 epi sodes of NSAID use with gastroprotective cotherapy. Patient adherence was rated as low (<20%) among 4.9% of the group and high (>80%) among 68.1%. A total of 339 UGI events occurred. The risk for such events was greater in those with low versus high adher ence (odds ratio, 2.39 for all events; and OR, 1.89 for bleeding).

The authors conclude that nonadherence to gastroprotective therapy is associated with an increased risk for upper gastrointestinal events and bleeding and that strategies to improve adherence should be developed. Despite the limitations of retrospective data base studies, this studys notable strengths were inclusion of patient databases from three European countries (each of which showed the same result) and use of a cohort taking both NSAIDs and gastroprotective agents, which eliminated the possibility of confound ing through channeling of patients with higher risk of incident symptoms. However, the results compare only the patients with lowest (<20%) and highest (>80%) adherent, whereas many patients are occasionally ad herent. We cannot conclude from this study if a threshold adherence rate lower than 80% exists that should be targeted clinically.
David J. Bjorkman, MD, MSPH (HSA), SM (Epid.)
Originally published in Journal Watch Gastroenterology

van Soest EM et al. Suboptimal gastroprotective coverage of NSAID use and the risk of upper gastrointestinal bleeding and ulcers: An observational study using three European databases. Gut 2011 Jun 2; [e-pub ahead of print]. (http://dx.doi.org/10.1136/gut.2011.239848)

Percutaneous Coronary Intervention at U.S. Hospitals: A Report Card

An analysis of national registry data showed nearly all acute PCIs to be appropriate but 12% of nonacute PCIs to be inappropriate, with substantial hospital-level variation.

Inappropriate use of percutaneous coronary intervention (PCI) generates unnecessary costs and risks for procedural and stent related complications. Moreover, in stable patients without acute coronary syndromes, PCI provides only a small advantage over medical therapy for symptom relief (N Engl J Med 2008; 359:677). However, a lack of

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standards for defining appropriateness of PCI has hindered past attempts to improve pa tient selection. Recently, six U.S. professional organizations jointly developed appropriate use criteria for the use of PCI. Now, investi gators have used prospective data from the National Cardiovascular Data Registry of pa tients undergoing PCI at 1091 U.S. hospitals from July 2009 through September 2010 to classify the indications for PCI as appropriate, of uncertain appropriateness, or inappropriate. Of 500,154 PCIs, 71.1% were for acute in dications (STsegmentelevation myocardial infarction [STEMI], 20.6%; nonSTEMI, 21.1%; highrisk unstable angina, 29.3%), and 28.9% were for nonacute indications. Appropriateness findings were as follows: Acute: appropriate, 98.6%; uncertain, 0.3%; inappropriate, 1.1% Nonacute: appropriate, 50.4%; uncertain, 38.0%; inappropriate, 11.6%

the many reasons for procedural overuse. To improve patient selection, quality, and cost effectiveness, we need stronger efforts to edu cate physicians and patients about procedural appropriateness. Beat J. Meyer, MD
Originally published in Journal Watch Cardiology

Chan PS et al. Appropriateness of percutaneous coronary intervention. JAMA 2011 Jul 6; 306:53.

Mammography Screening and Breast Cancer Mortality: Long-Term Advantages

Swedish data based on 3 decades of follow-up show major benefits of screening.

Most inappropriate nonacute PCIs were per formed in patients with no angina (53.8%), lowrisk ischemia on noninvasive stress test ing (71.6%), or suboptimal antianginal ther apy (1 medication; 95.8%). For acute indica tions, variation in the rate of inappropriate PCI among hospitals was minimal; however, for nonacute indications, the rate of inappro priate PCI varied considerably (median, 10.8%; interquartile range, 6.0%16.7%). At 25% of hospitals, at least 1 in 6 of nonacute pro cedures were classified as inappropriate.
COMMENT

The 2009 U.S. Preventive Services Task Force guidelines on screening mammography re kindled controversy about routine breast im aging (Ann Intern Med 2009; 151:716). In a Swedish trial, >133,000 women without his tories of breast cancer were randomized in the late 1970s to usual care or singleview mammography (every 24 months if age 40 49 at entry; every 33 months if age 5074) for 7 years. Now, researchers have assessed the effects of screening on breast cancer mortal ity at a maximum 29year followup. In the screening group (77,080 women), 351 deaths from breast cancer occurred; in the usualcare group (55,985 women), 367 such deaths occurred. Risk for breast cancer death was 31% lower in the screening group (P<0.0001). The number of women needed to screen for 7 years to prevent 1 breast can cer death was 414.
COMMENT

The development of appropriateness criteria for percutaneous coronary intervention is a major step forward for quality improvement and cost savings. From my European per spective, current financial incentives for hospitals, decisions to perform ad hoc PCI (immediately after diagnostic angiography) without the opportunity for informed discus sion, and patients and physicians overesti mation of PCIs benefits are foremost among

Most breast cancer deaths that could have been prevented by screening would have oc curred >10 years after initial mammography; therefore, this trials lengthy followup facili tates comprehensive assessment of screen ings effect on mortality. The authors note that nonadherence in the mammography group and screening contamination in the usualcare group lead to conservative

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estimates of mortality benefits associated with screening. Furthermore, twoview screening the current standard is more sensitive than the singleview approach used in this trial, again suggesting that screening benefits were underestimated. However, un like the authors of a 2010 Norwegian study, (N Engl J Med 2010; 363:1203), these Swedish authors do not consider major advances in breast cancer treatment during recent de cades (some experts suggest that such ad vances make early diagnosis of breast cancer less critical to good outcomes than was previ ously thought), nor do they assess the harms associated with screening mammography. In my practice, I encourage regular screening for highrisk women in their 40s and all women 50 or older. I do not dissuade lowrisk women in their 40s who request screening. For all women who undergo screening mammography, I am flexible about recom mending annual versus biennial screens.
Andrew M. Kaunitz, MD
Originally published in Journal Watch Womens Health

No associations were observed between OC use and breast cancerspecific mortality in the CARE study (828 breast cancer deaths; median followup, 8.6 years) or the CTS (261 breast cancer deaths; median followup, 6.1 years). In addition, no association was observed between OC use and allcause mor tality (CARE relative risk, 1.01; CTS RR, 0.84). Lower risk for allcause death (but not breast cancerrelated death) was observed in those CTS participants who used OCs for 10 years (RR, 0.67); however, no trend for de creasing risk with increasing OC duration was observed (P for trend, 0.22).
COMMENT

Tabr L et al. Swedish Two-County Trial: Impact of mammographic screening on breast cancer mortalityduring 3 decades. Radiology 2011 Sep; 260:658.

Although the authors adjusted for many po tential confounders (e.g., bodymass index, age at menarche, race, tobacco and alcohol use), they did not adjust for parity or lacta tion, both of which have been associated with lower risk for breast cancer. Nonetheless, these studies add to the evidence showing that the millions of women who opt to use oral contraceptives face no higher risk for developing breast cancer and might even live longer than women who dont use OCs (BMJ 2010; 340:c927).
Eleanor Bimla Schwarz, MD, MS
Originally published in Journal Watch Womens Health

Breast Cancer and OCs: Still Worried After All These Years?
Two studies confirm that oral contraceptives are not associated with breast cancerspecific or all-cause mortality.

Lu Y et al. Oral contraceptive use and survival in women with invasive breast cancer. Cancer Epidemiol Biomarkers Prev 2011 Jul; 20:1391.

Epidemiologic studies have yielded reassuring findings that oral contraceptives (OCs) do not raise risk for developing breast cancer (N Engl J Med 2002; 346:2025). To evaluate risk for allcause or breast cancerrelated death in women with invasive breast cancer who used OCs, investigators assessed mortality of 4565 participants in the Womens Contraceptive and Reproductive Experiences (CARE) Study (a populationbased casecontrol study) and 3929 participants in the California Teachers Study (CTS; a cohort study).

Cephalosporin-Resistant Gonococci on the Rise

The proportion of Neisseria gonorrhoeae isolates with decreased cephalosporin susceptibility increased significantly in the U.S. between 2000 and 2010; men who have sex with men accounted for most of the increase.

Current recommendations for treating Neisseria gonorrhoeae infection involve the use of a cephalosporin plus either azithromycin or doxycycline. In May 2011, the CDC re ported the isolation of azithromycinresistant

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gonococci from five male patients at a sexual ly transmitted disease (STD) clinic in Califor nia (MMWR Morb Mortal Wkly Rep 2011; 60:579). Now, using data from the Gonococcal Isolate Surveillance Project, the CDC has de scribed trends in cephalosporin susceptibility among N. gonorrhoeae isolates in the U.S. from 2000 to 2010. This project involves test ing isolates from men attending publicly funded STD clinics and each year includes about 4% of reported gonorrhea cases among men nationwide. During the study period, the proportion of isolates with elevated minimum inhibitory concentrations (MICs) to the two most com monly used antigonococcal cephalosporins increased, indicating decreased susceptibility to these drugs. Overall, the proportion of iso lates with cefixime MICs 0.25 g/mL rose from 0.2% to 1.4% (P<0.001), and the pro portion with ceftriaxone MICs 0.125 g/mL went from 0.1% to 0.3% (P=0.047). Signifi cant increases were seen only in isolates from men who have sex with men (MSM).
COMMENT

treatment failure, an infectious diseases ex pert and the CDC should be consulted. All isolates with decreased cefixime or ceftriax one susceptibility should be reported to local or state health departments and, ultimately, to the CDC (gipsinfo@cdc.gov).
Stephen G. Baum, MD
Originally published in Journal Watch Infectious Diseases

Centers for Disease Control and Prevention (CDC). Cephalosporin susceptibility among Neisseria gonor rhoeae isolates United States, 20002010. MMWR Morb Mortal Wkly Rep 2011 Jul 8; 60:873. Ohnishi M et al. The new superbug Neisseria gonor rhoeae makes gonorrhoea untreatable? First highlevel ceftriaxone resistance worldwide and public health importance. 19th Biennial Conference of the International Society for Sexually Transmitted Diseases Research, Quebec City, Canada, July 2011. Abstract O3-S4.01.

Cumulative Antibiotic Exposure Is Associated with Risk for C. difficile Infection

In a retrospective study among hospitalized patients, higher cumulative dose, number, and duration of antibiotics were independently associated with greater risk.

Over the last 40 years, the gonococcus has shown a remarkable ability to develop resis tance to each new antimicrobial agent used against it. Although the overall proportion of isolates resistant to cephalosporins is still small, the negative portent of this new find ing is large. As if to highlight the warning, researchers in Japan just reported the first N. gonorrhoeae strain that is highly resistant to ceftriaxone. They noted that we may have entered the era of untreatable gonorrhea. The CDC urges confirmation of treat ment success, especially in MSM in the western U.S., by having patients return for testing (preferably with culture) 1 week after treatment. Patients with cefixime treatment failure should be retreated with 250 mg of ceftriaxone intramuscularly and 2 g of azith romycin orally. In cases involving ceftriaxone

Antibiotic therapy is a major risk factor for Clostridium difficile infection (CDI), but little is known about the effect of cumulative exposure. To explore this issue, researchers performed a retrospective cohort study involving adults who were hospitalized at a Rochester, New York, medical center in 2005 and received antibiotics for 2 consecutive days during their stay. For each day of antibiotic exposure, the total dose of each agent was calculated. Daily doses were standardized according to the WHO Defined Daily Dose system. The number of different antibiotics and the duration of exposure were also calculated. A total of 10,154 hospitalizations involv ing 7792 unique patients met study criteria. The incidence of CDI in this group was 4.3 per 10,000 patientdays. Factors significantly

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associated with increased CDI risk included older age, gastrointestinal procedures, HIV infection, history of CDI, higher chronic dis ease score, longer length of stay, and receipt of antacid therapy, including protonpump or histamine2 inhibitors. In addition, CDI risk rose, in a dosedependent manner, with increases in cumulative dose, number, and days of antibiotics. Risk was 7.8fold higher in patients with >18 antibiotic days than in those with <4 days and 9.6fold higher in pa tients who received five or more antibiotics than in those who received only one. Intra venous cephalosporins, lactamase inhibitor combinations, sulfa drugs, fluoroquinolones, and vancomycin were all associated with an increased risk for CDI.
COMMENT

showed undetected microperforations in gloves; when sterile gloves are appropri ate, double gloving may be preferable. Masks and head coverings do not appear to reduce surgical site infections; surgical personnel with scalp Staphylococcus colo nization can cause widespread infection in patients despite use of head coverings. Gown materials and construction vary, so conclusions about protective benefits, if any, are difficult to establish. Street shoes have been shown to harbor and transfer more bacteria than operat ing room (OR)only shoes, but studies showing that this increased colonization results in patient infection are lacking. Shoe covers are not particularly helpful and may increase hand contamination.

These findings suggest that longer durations of therapy and increasing numbers of antibi otics are associated with heightened risk for CDI. One surprising outcome is that vanco mycin a therapy for CDI when given orally is a risk factor when administered intravenously. Neil M. Ampel, MD
Originally published in Journal Watch Infectious Diseases

COMMENT

Stevens V et al. Cumulative antibiotic exposures over time and the risk of Clostridium difficile infection. Clin Infect Dis 2011 Jul 1; 53:42.

For Dermatologic Surgery, Clean Rather Than Sterile Technique May Be Sufficient
However, it may not be prudent to dispense with current protective measures.

The author of this literature review on surgi cal garb systematically evaluated evidence regarding the effectiveness of specific protec tive measures to minimize patient infection. Among the findings: No randomized, controlled trials of the utility of sterile gloves are available. Clean gloves may be as protective as sterile gloves. Moreover, many studies

This exhaustive and, I am sure, exhausting review yielded surprising results. Eisen re viewed many tangentially relevant studies to extract the data useful for dermatologic sur geons (including 5 studies of masks, 8 studies of gloves, 7 studies of gowns, in >26,000 sub jects). Much of the received dogma regarding operating room sterility is unsupported by clinical studies. For dermatologic surgical procedures, clean rather than sterile tech nique (e.g., clean gloves) may be sufficient. Double gloving may be useful during pro longed reconstructive procedures or major cosmetic procedures, like liposuction or face lifts. Similarly, ORonly shoes may be a good idea, although the evidence is inconclusive. Surprisingly, masks and head coverings ap pear to be of little benefit. Nonetheless, it may be prudent not to dispense with current pro tective measures, as they are reassuring to our patients, are considered standard of care, and are all that we have. Although sterility is not crucial for some dermatologic proce dures, it does not follow that cleanliness is unimportant. Very clean operating rooms with very clean gloves and trays may be as

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good as fully sterile set ups, but contaminated or dirty surfaces are certainly likely to foster surgical infections. Indeed, recurrent infec tions in a dermatology office should stimu late the search for a contaminant and insti gate cleaning of all procedure rooms.
Murad Alam, MD, MSCI
Originally published in Journal Watch Dermatology

cryotherapeutic treatments for plantar warts would be welcome.

Paul S. Mueller, MD, MPH, FACP
Originally published in Journal Watch General Medicine

Cockayne S et al. Cryotherapy versus salicylic acid for the treatment of plantar warts (verrucae): A randomised controlled trial. BMJ 2011 Jun 7; 342:d3271. (http://dx.doi.org/10.1136/bmj.d3271)

Eisen DB. Surgeons garb and infection control: Whats the evidence? J Am Acad Dermatol 2011 May; 64:960.

Why Do Children Drink Bottled Water?

Beliefs that bottled water tastes better and is safer, cleaner, and more convenient were more common among black and Latino parents.

Salicylic Acid Is as Effective as Cryotherapy for Plantar Warts

And costs were lower for home-administered salicylic acid treatment.

In this multicenter trial, U.K. investigators compared the effectiveness of selftreatment with 50% salicylic acid versus clinician delivered cryotherapy with liquid nitrogen for treating plantar warts. The 240 study participants (age, 12) were randomized to daily selftreatment with salicylic acid for a maximum of 8 weeks or to as many as four cryotherapy treatments 2 to 3 weeks apart. At 12 weeks, 14% of patients in each group exhibited complete clearance of plantar warts. At 6 months, 31% of patients in the salicylicacid group and 34% in the cryotherapy group had complete clearance of plantar warts an insignificant difference. Time to clearance did not differ between groups.
COMMENT

Many parents choose bottled water over tap water for their children. To determine what factors affect this choice, researchers surveyed 639 parents (33% black, 33% Latino, and 33% nonLatino white) during visits to a pediatric emergency department in Wisconsin. Black and Latino parents were signifi cantly more likely than nonLatino white parents to give their children bottled water most or all of the time (52%, 46%, and 37% respectively). Beliefs that bottled water tastes better and is safer, cleaner, and more conve nient than tap water were significantly asso ciated with bottled water use; these beliefs were significantly more common among black and Latino parents. After adjusting for these beliefs and sources of information about water, race and ethnicity were no longer sig nificantly associated with bottled water use. Parents who reported buying any bottled water spent an average of US$23 monthly on the product. Physicians were an information source regarding water for 30% of parents.
COMMENT

Although most plantar warts clear spontane ously, many patients understandably want to expedite clearance. Salicylic acid and cryo therapy are equally effective treatments. The authors cite the higher cost of clinician administered cryotherapy as a reason to favor homeadministered salicylic acid. A compar ison of salicylic acid with overthecounter

Parental beliefs about the differences between bottled water and tap water drove the dispar ity in bottled water use in children from three racial and ethnic groups. Excess cost and water bottle waste aside, the main reason for

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children to drink tap water is that it usually is fluoridated (unlike bottled water), which promotes pediatric oral health. Pediatricians should ask what kind of water patients drink and be prepared to address parental beliefs about bottled water and the benefits of tap water. Cornelius W. Van Niel, MD
Originally published in Journal Watch Pediatrics and Adolescent Medicine

analgesia (15% vs. 35%). Nurse ratings of patient cooperation during the procedure were twice as high in the EMONO group. Two patients (both in the EMONO arm) experienced unpleasant feelings of malaise.
COMMENT

Gorelick MH et al. Perceptions about water and increased use of bottled water in minority children. Arch Pediatr Adolesc Med 2011 Jun 6; [e-pub ahead of print]. (http://dx.doi.org/10.1001/ archpediatrics.2011.83)

The finding that nitrous oxide was more effective than no sedation is not surprising. Nitrous oxide particularly given its anxio lytic effects might be a good choice for simple and short procedures that would not otherwise warrant deep sedation.
Katherine Bakes, MD
Originally published in Journal Watch Emergency Medicine

Nitrous Oxide Provides Sedation and Pain Control for Pediatric Procedures
Children who received inhaled nitrous oxide had significantly less pain and anxiety during painful diagnostic or therapeutic procedures than those who received placebo.

Reinoso-Barbero F et al. Equimolar nitrous oxide/ oxygen versus placebo for procedural pain in children: A randomized trial. Pediatrics 2011 Jun; 127:e1464.

Investigators assessed quality of sedation and pain control of inhaled nitrous oxide in a randomized, controlled, doubleblind study involving 100 children (age range, 118 years) undergoing short diagnostic or therapeutic procedures in a pediatric pain unit or emer gency department of an academic hospital in Spain. Patients received an equimolar mixture of 50% oxygen and nitrous oxide (EMONO) or placebo (premixed 50% nitro gen and oxygen) administered by pediatric anesthesiologists or critical care pediatricians. Propofol or sevoflurane was available for res cue analgesia in both groups. The EMONO group was significantly older (mean age, 8.0 vs. 6.2 years). Mean scores on standardized pain scales were nearly 50% lower in the EMONO group than in the placebo group and nearly 80% lower among patients who received EMONO in addition to an eutectic mixture of local anesthetic (EMLA) than in those who received placebo without EMLA. Significantly fewer EMONO patients than placebo patients required rescue

Long-Acting Reversible Contraceptives Are Suitable for Adolescents

IUDs and the subdermal implant can be offered to most women, including nulliparous women and adolescents.

The American College of Obstetricians and Gynecologists has updated its practice bulletin on the use and clinical management of long acting reversible contraceptives. Based primar ily on consensus and expert opinion, it con cludes that intrauterine devices (IUDs) and contraceptive implants have few contraindica tions and can be considered for most women. Highlights of the bulletin are as follows: Longacting reversible contraceptives are extremely effective; firstyear failure rates for typical use and perfect use are the same (<0.8%). Two IUDs (1 containing copper and the other levonorgestrel) and one sub dermal implant (containing etonogestrel, the metabolite of the progestin desogestrel) are approved for use in the U.S. The copper and levonorgestrel IUDs can be left in place for 10 and 5 years, respectively. The subdermal implant is effective for 3 years.

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Concerns about IUD placement in ado lescents have focused on a possible increased risk for pelvic inflammatory disease (PID) and expulsion. However, current research does not support a link between IUD use and PID. A recent systematic review reported ex pulsion rates in adolescents of 5% to 22%, with two of the studies suggesting an inverse relation between age and expulsion rate. For women at high risk for sexually transmitted infections (including adolescents and adults aged 25), screening for such infections, especially chlamydia, can be performed on the same day as IUD placement. Between 6% and 12% of implant users report weight gain, but only 3% to 7% of all users have the implant removed for this rea son. Extrapolation of data from pharmaco kinetic studies in etonogestrel implant users and data from bone mineral density (BMD) assessments in women aged 18 and older suggest that the subdermal implant should not affect estrogen production or BMD in adolescents.
COMMENT

Multifaceted Podiatry Treatment of Foot Pain Prevents Falls in Elders

Intervention patients received appropriate footwear and a home-based foot and ankle exercise program.

Among elders, foot problems are associated with falling, which is a major risk factor for fracture. In this randomized controlled trial, Australian investigators compared the effec tiveness of a multifaceted podiatry interven tion versus routine podiatric care in prevent ing falls in 305 communitydwelling elders (mean age, 74; 69% women) who had chronic foot pain, were receiving podiatric care, and were at elevated risk for falls. Both control and intervention groups continued with the podiatric care they were currently receiving. The intervention group also received a multifaceted treatment pack age consisting of prefabricated fulllength foot orthotics, advice on and provision of ap propriate footwear, a homebased foot and ankle exercise program, and education in fall prevention. The control group received podi atric care only. At 1year followup, number of falls was significantly lower in the inter vention group than in the control group (103 vs. 161 falls). The intervention group experi enced one fracture, and the control group suffered seven fractures a notquitesig nificant result (P=0.07) that likely reflected an underpowered study.
COMMENT

The best contraceptive for an adolescent is the one she will use consistently and that her insurance plan will cover. The IUD and im plant are safe and may be ideal methods for adolescents who might have trouble taking pills daily, cannot use estrogencontaining products, or might not be able to adhere to the 3month schedule for injectable contra ceptives (or might fear the associated weight gain). Longacting reversible contraceptives may be particularly suitable for teenage mothers after the birth of their first child.
Alain Joffe, MD, MPH, FAAP
Originally published in Journal Watch Pediatrics and Adolescent Medicine

Practice bulletin no. 121: Long-acting reversible contraception: Implants and intrauterine devices. Obstet Gynecol 2011 Jul; 118:184.

This study has a number of limitations: The investigators could not blind the participants to their group allocation and do not define or describe the podiatric care the participants received before and continued throughout the trial. Nevertheless, the results suggest that a relatively simple multifaceted podiatry intervention can prevent falls in elders with foot pain and at elevated risk for falls. Com bined with other simple measures to prevent falls (e.g., avoidance of medications that

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promote falls, maximizing vision, home hazard assessment and modification), this intervention might substantially lower mor bidity and costs (which, according to the CDC, were about US$24 billion in 2005) associated with falls among U.S. elders.
Paul S. Mueller, MD, MPH, FACP
Originally published in Journal Watch General Medicine

(>1137 mg/day) quintiles had similar risks for fracture of any type and similar risks for osteoporosis, but those in the highest quintile exhibited excess risk for hip fracture (HR, 1.2). Of note, results were similar when total cal cium intake (i.e., including supplements) in stead of dietary calcium intake was evaluated.
COMMENT

Spink MJ et al. Effectiveness of a multifaceted podiatry intervention to prevent falls in community dwelling older people with disabling foot pain: Randomised controlled trial. BMJ 2011 Jun 16; 342:d3411. (http://dx.doi.org/10.1136/bmj.d3411)

Low Dietary Calcium Intake Raises Risk for Fracture and Osteoporosis
During 19 years, first fracture of any type was significantly more common among women with low daily dietary calcium intake (750 mg).

Observational studies and randomized trials of dietary or supplemental calcium to prevent fractures have yielded inconsistent results. In this prospective observational study, investi gators determined the associations between dietary calcium intake and risk for any frac ture among a populationbased cohort of 61,000 Swedish women; risk for osteoporosis was evaluated in a randomly selected subco hort of 5000 women. During a median 19year followup, 24% of women experienced first fractures of any type, 6% suffered first hip fractures, and 20% developed osteoporosis. After adjustment for multiple variables, risk for first fracture of any type was significantly higher among women in the lowest dietary calciumintake quintile (750 mg/day; hazard ratio, 1.2) than among women in the third (middle) quintile (882996 mg/day). Similar results for the lowest versus the middle quintile were found for first hip fracture (HR, 1.3) and os teoporosis (HR, 1.5). Low vitamin D intake was associated with excess fracture risk. In contrast, women in the middle and highest

In this study, higherthanmedian intake of calcium did not lower risk for any fracture, hip fracture, or osteoporosis, which casts further doubt on the role of supplemental calcium in preventing these outcomes. Perhaps the most relevant finding was that low dietary calcium intake indeed was associated with excess risk for fracture and osteoporosis. The authors conclude that in the prevention of osteopo rotic fractures emphasis should be placed on individuals with a low intake of calcium rather than increasing the intake of those already consuming satisfactory amounts.
Paul S. Mueller, MD, MPH, FACP
Originally published in Journal Watch General Medicine

Warensj E et al. Dietary calcium intake and risk of fracture and osteoporosis: Prospective longitudinal cohort study. BMJ 2011 May 24; 342:d1473. (http://dx.doi.org/10.1136/bmj.d1473)

Surgery Doesnt Trump Rehabilitation in Patients with Degenerative Disk Disease

Disk prosthesis surgery and nonsurgical rehabilitation led to clinically similar results.

Two surgical procedures are performed com monly in patients afflicted with chronic low back pain and degenerated disks: spinal fu sion surgery and prosthetic disk replacement surgery. However, in a previous trial, spinal fusion surgery was not better than disk re placement or nonsurgical rehabilitation (BMJ 2005; 330:1233); whether disk replacement is superior to rehabilitation is unknown. In a multicenter randomized controlled trial, investigators in Norway compared disk

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COMMENT

replacement surgery with nonsurgical multi disciplinary treatment (i.e., cognitive and rehabilitation therapy that involved physiat rists, therapists, nurses, and social workers). The 173 enrolled patients (age range, 2555) suffered from low back pain for 1 year, had undergone physical therapy or chiropractic care for 6 months, and exhibited degenera tive intervertebral disk changes at L4/L5, L5/ S1, or both. Patients with nerve root compres sion from herniated disks were excluded. At 2 years, a small significant difference in mean scores on the Oswestry disability index favored surgery; however, the differ ence did not reach a prespecified threshold for clinical importance. Several secondary outcomes favored surgery, but no differences were noted between groups in return to work, life satisfaction, fear avoidance beliefs, drug use, or scores on a back performance scale.

Surgery with disk prosthesis was not clearly superior to nonsurgical multidisciplinary treatment in patients with chronic low back pain attributed to degenerative disk disease. As an editorialist stated, the nonsurgical ap proach is cheaper, safer, and less disruptive to peoples lifestyle than surgery, and it gives a long term benefit. However, note that these results do not apply to people with nerve root compression from herniated disks or spinal stenosis. Paul S. Mueller, MD, MPH, FACP
Originally published in Journal Watch General Medicine

Hellum C et al. Surgery with disc prosthesis versus rehabilitation in patients with low back pain and degenerative disc: Two year follow-up of randomised study. BMJ 2011 May 19; 342:d2786. (http://dx.doi.org/ 10.1136/bmj.d2786) Fairbank J. Total disc replacement for chronic low back pain. BMJ 2011 May 19; 342:d2745. (http://dx.doi.org/ 10.1136/bmj.d2745)

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