Monday, July 28, 2014

Vitamin D Is More Than Just Bones

Since someone close to me was recently diagnosed with Systemic Lupus Erythematosus aka Lupus aka SLE, I started thinking about the effect that being told to avoid the sun might have on both vitamin D levels and the impact on lupus.

Since the root cause of many diseases such as SLE remains elusive, I was intrigued to find that specialists in the field were asking similar questions. Abou-Raya and colleagues conducted a placebo-controlled trial of vitamin D supplementation in patients with lupus.

Their findings were interesting. First, the lupus patients tended to have lower baseline vitamin D levels when compared with the control group. Second, and more importantly, vitamin D supplementation for 12 months led to significant improvements in both markers of disease activity and in clinical disease activity as well.

From the discussion: ... The overall effect of vitamin D is enhancement of protective innate immune response, while maintaining self-tolerance by dampening overactive adaptive immune responses30. Amelioration of proinflammatory cytokines by vitamin D supplementation may be attributed to the antiinflammatory and immunomodulation effect of vitamin D.

Finally, they conclude: Vitamin D, a safe, inexpensive, and widely available agent, may be effective as a disease-suppressing intervention for patients with SLE. In addition to the potential benefit of vitamin D replacement on improvement of SLE activity, vitamin D seems to have an immune-inflammatory-modulatory role that may benefit musculoskeletal and cardiovascular manifestations of SLE. This role could also help maintain immune health, thus avoiding the excess morbidity and mortality associated with vitamin D deficiency. We recommend routine assessment of vitamin D levels and adequate supplementation of the vitamin in patients with SLE.

When it comes to knowledge about vitamin D, let the sunshine in.

I know this has little to do with ultrasound but a lot to do with our health and that of our loved ones. If you do need an appointment for an ultrasound, feel free to call (718) 925-6277.

Monday, July 14, 2014

Pelvic Exam for the 21st Century

The American College of Physicians (ACP) certainly stirred up a hornets' nest with their pronouncement on the value of pelvic exams.

...“Routine pelvic examination has not been shown to benefit asymptomatic, average risk, non-pregnant women. It rarely detects important disease and does not reduce mortality and is associated with discomfort for many women, false positive and negative examinations, and extra cost,” said Dr. Linda Humphrey, a co-author of the guideline and a member of ACP’s Clinical Practice Guidelines Committee.

As I have posted previously, perhaps it's time to think about replacing the pelvic exam with ultrasound.

...So how would ultrasound stack up? Tayal et al conducted a study of emergency patients who were being evaluated for pain. Patients underwent both a transvaginal sonogram and the clinical pelvic examination. The order of examinations was randomized. The group found the sonographic pelvic exam superior to the digital pelvic exam across all BMI classes. And remember, these were patients already in pain.

When it comes to the issue of screening for ovarian cancer, the pelvic exam has failed miserably. Dr. Nick Summerton writes in the Spectator :

In seeking to pick up ovarian cancer at an early stage — with an improved chance of cure — much better alternatives to the vaginal examination are trans-vaginal ultrasound and CA125 testing. CA125 is a chemical given off by cancer cells that circulates in the bloodstream and women with ovarian cancer tend to have higher levels.

In 2015, the UKCTOCS screening trial for ovarian cancer will publish its results. Preliminary findings look very promising but, of course, "it ain't over 'til it's over."

Stay tuned.

For more information or to schedule an ultrasound, please call (718) 925-6277.

Tuesday, July 8, 2014

Where's Waldo?

We've all seen Waldo, the guy with the striped shirt and matching cap.

Seems pretty easy to spot, right?

But what if Waldo is in a large, busy crowd - is he still easy to spot?

Sometimes, an early pregnancy is harder to spot than Waldo. Because pregnancy tests are so sensitive, women are getting that first ultrasound quite early on in gestation. There is a window of about 2 - 3 weeks after conception when an early intrauterine pregnancy might not be visualized. This creates a quandary - is she really pregnant, is there a problem with the pregnancy or a problem with the dates, and, worst case scenario, is the pregnancy ectopic. Doctors refer to this clinical situation as "Pregnancy of Uncertain Location" or PUL. The usual management consists of serial measurements of the blood pregnancy hormone or Beta HCG and repeating the ultrasound until the situation is resolved. The protocol had been that failure to see a normally-situated pregnancy on ultrasound at a critical level of Beta HCG was highly suspicious for an ectopic pregnancy or a failed intrauterine pregnancy. Unfortunately, as we all are aware, life is not always so neat.

Doubilet et al, writing in the New England Journal of Medicine reviewed the diagnostic criteria of pregnancy of uncertain location and failed pregnancy and found that previously utilized criteria were a set up for diagnostic error, resulting in administration of a powerful teratogenic drug, Methotrexate, in cases subsequently found to be normal pregnancy. Nurmohamed et al found 8 cases of intrauterine pregnancy in which methotrexate was administered for suspected ectopic. None of these cases had a happy outcome.

Doubilet's review offered new consensus guidelines for the diagnosis of both early pregnancy failure and pregnancy of uncertain location, nicely summarized Here.

So if you find yourself in this situation, please review this post again and perhaps ask your doctor to review it as well.

For more information or to schedule an ultrasound, please call (718) 925-6277.