Volume 111, Issue 3

Context: High levels of human secretory immunoglobulin A (sIgA) have been shown to decrease the incidence of acquiring upper respiratory tract infections. Osteopathic manipulative treatment (OMT) has been shown to improve cardiac indices, increase lymph flow rates through the thoracic duct, and decrease sympathetic tone in postoperative patients and those in intensive care. Therefore, we hypothesized that OMT may also increase sIgA levels in people under high levels of emotional and psychological stress, thereby enhancing immunity and potentially preventing subsequent infections. Objective: To determine if OMT increases sIgA levels in highly stressed individuals. Methods: Twenty-five second-year osteopathic medical students were randomly assigned to an experimental group (n=12) or a control group (n=13). All participants were scheduled to take their national board examination (Comprehensive Osteopathic Medical Licensing Examination-USA) within 2 to 3 weeks after the experiment. After each participant submitted a saliva sample for a baseline sIgA level assessment, the experimental group received 20 minutes of OMT while the control group sat quietly and relaxed in a separate area for 20 minutes. Participants in both groups rested quietly for 1 hour after the 20-minute session and then submitted a second saliva sample. Results: A 2 × 2 repeated measures analysis of variance revealed that the experimental group displayed a statistically significant greater increase in postintervention sIgA levels than the control group (F 1,23 , 5.92; P <.025). Conclusion: This study demonstrates the positive effect of OMT on sIgA levels in persons experiencing high stress. Results suggest that OMT may then have therapeutic preventive and protective effects on both healthy and hospitalized patients, especially those experiencing high levels of emotional or physiological stress and those at higher risk of acquiring upper respiratory tract infections.

Context: The effects of maternal hypoglycemia on birth weight, placental weight, and placental ratio are unclear. A reliable indicator for increased risk of low birth weight or associated low placental weight could prove invaluable in caring for newborns who are small for gestational age. Objective: To retrospectively review 2 years of hospital obstetric records for evidence of an association between maternal hypoglycemia (< fifth percentile at 24-week 1-hour glucose challenge test) and birth weight, placental weight, or placental ratio. Methods: Medical center records were reviewed for women who delivered a term newborn between July 1, 2005, and July 31, 2007. Women included in the study were younger than 35 years and had completed a 1-hour glucose challenge test during pregnancy. Excluded were women with comorbid conditions that may be associated with abnormal birth weight and women with serum glucose levels greater than 135 mg/dL. Results: Newborns of women with hypoglycemia weighed, on average, significantly less than newborns of women with normal blood glucose levels ( t test P =.011). Relative risk was 5.81 (95% confidence interval, 1.25-27.03). Placentas of women with hypoglycemia were also lighter than those of the women in the control group, but the difference was not significant ( t test P =.1089). Differences in placental ratios between the 2 groups were not statistically significant ( P =.8171). Conclusion: Lower serum glucose levels during pregnancy might be a causative factor, rather than merely a risk factor, for lower birth weights. (ClinicalTrials.gov number NCT00614094)

Context: Since 2002, when the US Food and Drug Administration (FDA) placed a black box warning on women's hormone replacement products, women and their providers have been struggling with whether to proceed with hormone replacement therapy. Out of the controversy has grown a popular movement promoting the use of bioidentical hormones. Many providers are still unsure if they want to recommend these products and, if so, how to use them appropriately. Objective: To inform primary care providers (eg, physicians, physician assistants, nurse practitioners) about current data on the safety and efficacy of bioidentical hormone replacement therapy and to provide a context for patient perceptions. Methods: Literature published between 1999 and 2009 was reviewed through MD Consult's Medline and Ovid search engines. A Google search of popular media was also performed using the same terms. Results: Randomized clinical trial data are sufficient to support the prescription of only estropipate, estradiol, and progesterone for the relief of menopausal symptoms. Estropipate is approved by the FDA for the management of menopausal symptoms. 17β-Estradiol is FDA approved for menopausal symptoms, may have cardioprotective effects, and may have fewer adverse effects on blood pressure than conjugated equine estrogens. Estriol is not FDA approved but is widely used in Europe and is effective for relieving menopausal symptoms. Progesterone is approved by the FDA for the management of menopausal symptoms and for the prevention of endometrial hyperplasia; it should be used orally to oppose estrogen. Testosterone is FDA approved in combination with estrogen for the management of vasomotor symptoms. Dehydroepiandrosterone is not FDA approved, but small-scale studies indicate it may improve bone mineral density. Data are conflicting about efficacy in improving sexual dysfunction. There is an abundance of misleading information available in the media and on the Internet for our patients. Compounded bioidenticals and salivary hormone testing are unnecessary, are not standardized, and should be avoided. Conclusion: Bioidentical hormones that are approved by the FDA may be preferred over standard hormone replacement because of their physiologic benefits and safety profile.

Recently, reports have suggested that chronic cannabis abuse can result in cyclical vomiting, or cannabinoid hyperemesis syndrome. With the increasing prevalence of cannabis use in the United States, this syndrome may be encountered in the emergency department. The authors describe a case of a 30-year-old man who presented to the emergency department with diffuse abdominal pain, nausea, and intractable vomiting. He reported symptomatic relief with prolonged hot showers. Results of a urine drug screen were positive for cannabis, and the patient admitted to chronic cannabis use for years. Results of the drug screen, combined with the patient's symptomatic relief with hot showers, led to the diagnosis of cannabinoid hyperemesis syndrome. The patient was admitted to the hospital and underwent pharmaceutical treatment. However, hot showers continued to be the mainstay of the patient's symptomatic relief. Four days after presentation, the patient's symptoms resolved and he was discharged from the hospital.

Balò disease, also called concentric sclerosis , is a rare variant of multiple sclerosis that has been historically characterized as a monophasic, rapidly progressive, often fatal demyelinating disease. The diagnosis of Balò disease is based on the pathognomonic concentric ring pattern seen on magnetic resonance images. The authors describe the case of a 30-year-old woman with Balò disease who was initially treated with an unconventionally high dose of steroids and had a positive long-term clinical outcome with near-complete resolution of her neurologic symptoms. The authors also report MRI findings of concentric lesions before steroid treatment and resolution of the lesions shortly after and several months after steroid treatment. Given the outcome in this patient, we propose using high doses of steroids in the early treatment of patients with Balò disease. However, further studies are needed.