AFP Journal Articles

1. AFP Journal Articles April 1, 2009

2. April 1, 2009 Issue • Infant Formula • Diets for CV Disease Prevention • Epididymitis and Orchitis: An Overview • Green Tea: Potential Health Benefits

3. Infant Formula • AAP and the AAFP recommend breast milk for optimal infant nutrition • All formulas classified based on: • caloric density (20-24 kcal/oz) • carbohydrate source (lactose/corn) • protein composition (cow’s milk/soy) • Non-breast fed infants should receive iron-fortified formula to prevent iron deficiency anemia

4. Types of Formulas • Term • Modeled after breast milk, 20kcal/oz, carb source is lactose, contain cow’s milk protein. • All nutritionally interchangeable • Carnation Good Start, Enfamil with Iron, Similac with Iron • Formulas supplemented with AA and DHA show no clinical benefit and not recommended (Enfamil Lipil, Good Start DHA & ARA, Similac Advance)

5. Types of Formulas • Preterm • Contain 24 kcal/ounce, carb source is lactose, cow’s milk protein • Enfamil 24 Premature, Preemie SMA 24, Similac 24 Special Care • Standard of care for infants less than 34 weeks' gestation or weight less than 1,800 g • Enriched • Contain 22 kcal/oz, lactose, cow’s milk protein • Enfacare, Similac Neosure • 34 to 36 weeks' gestation or weight > 1,800 g

6. Specialized Term Formulas • Soy • 20 kcal/oz, corn-based carbohydrate, soy protein • Enfamil Prosobee, Good Start Soy, Similac Isomil • AAP guidelines limit to infants with galactosemia or congenital lactase deficiency • Lack of proven benefit for other conditions including milk protein allergy, generalized colic, and acute gastroenteritis • Should not be used for preterm infants, due to osteopenia of prematurity and less weight gain

7. Specialized Term Formulas • Lactose-Free • Indicated for galactosemia and congenital and primary lactase deficiency • 20 kcal/oz, corn-based, cow’s milk protein • Enfamil Lactofree, Similac Sensitive • At-risk infants might benefit from a switch to lactose-free formula following acute gastroenteritis

8. Specialized Term Formulas • Hypoallergenic and nonallergenic • Indicated for infants with true IgE-mediated milk protein allergy • Contain extensively hydrolyzed proteins that are less likely to stimulate antibody production • 20 kcal/oz, corn or sucrose-based • Similac Alimentum; Enfamil Nutramigen; Enfamil Pregestimil; Elecare; Neocate; Nutramigen AA

10. Specialized Term Formulas • Antireflux • Prethickened with added rice starch • 20 kcal/oz, lactose, cow’s milk protein • Shown to decrease daily episodes of regurgitation and emesis, but not clear whether they improve long-term outcomes, such as growth or development • Enfamil AR; Similac Sensitive RS

11. Infant Formula and Colic • Parents often change formulas in response to infant colic • Most colic improves spontaneously between four and six months of age • Evidence for soy formula in the treatment of colic is limited and based on poor-quality trials • No evidence to support lactose-free formula, but a short trial may be reasonable in infants with colic who also have gastrointestinal symptoms • Two systematic reviews have found some benefit with hypoallergenic formula, but at significantly greater $ • Counseling parents about infant crying appears to reduce symptoms of colic more than any change in formula.

12. Specialized Term Formulas • Toddler • Developed for “picky” infants 9 to 24 months of age • Milk-based formulas contain added iron, vitamin C, vitamin E, zinc, DHA, AA and more calcium than standard infant formulas (but not significantly more than whole milk). • 20 kcal/oz, lactose, cow’s milk protein • No evidence of advantage over whole milk in terms of growth or development, but more expensive • Enfamil Next Step, Good Start 2, Similac Go and Grow

13. Infant Formula

15. Diets for Cardiovascular Disease Prevention • Very low-carbohydrate (Atkins Diet) • No calorie restriction, unlimited fat intake • Severely limited fruit/vegetables • Unlimited saturated and trans-fat, but discouraged • Requires urine ketone monitoring • No patient-oriented outcomes or long-term data; may improve triglyceride and HDL levels; better for short-term weight loss

16. Low-carbohydrate/ low-glycemic index • South Beach Diet, the Zone, Sugar Busters! • No calorie restriction, unlimited fat intake • Limited fruits/vegetables • Limited saturated and trans-fats • Requires knowledge of glycemic index • Offers sound principles without ample patient-oriented data

17. Very low-fat • Ornish diet • No calorie restriction • Limits fat to < than 10% of total calories • Vegetarian-based • No saturated or trans-fat allowed • Requires meditation, vegetarian diet, smoking cessation • Perfusion improvements and symptom reductions; very strict diet; lowers HDL levels

18. Mediterranean diet • No calorie restriction, unlimited fat intake • Unlimited fruits and vegetables • Limited saturated and trans-fat • Costly, limited in some populations because of lack of produce or fatty acid sources • Excellent mortality data, but limited study population

19. Basic Components of the Mediterranean Diet • Plant-based foods (e.g., fruits, vegetables, breads, cereals, potatoes, legumes, nuts) • Locally grown, minimally processed food • Fish and poultry • Infrequent red meat intake • Up to four whole eggs per week • Moderate amount of dairy products • Olive oil as the principal source of fat • Moderate amount of red wine with meals • Desserts primarily of fresh fruits

20. American Heart Association Guidelines • Restricts calories • Unlimited fat and unlimited fruits/vegetables • Limits saturated fat < 7 % and trans-fat < 1 % of total calories • Broad guidelines • Same as TLC Diet, but with a greater emphasis on overall cardiovascular risk reduction and population health improvements

21. American Heart Association Lifestyle Interventions • Count calories to achieve a hypocaloric diet (for weight loss) • Increase aerobic exercise to 30 minutes or more on most days; increase to 60 minutes for weight loss • Increase intake of fresh fruits and vegetables (not juice) • Increase intake of whole grains and other high-fiber foods • Consider plant stanol supplementation • Consume oily fish twice per week • Increase intake of healthful fats (e.g., olive oil, canola oil, nuts) • Supplement with omega-3 fatty acids in persons who do not eat fish • Limit saturated and trans-fatty acids • Limit alcohol intake to two drinks per day in men and one drink per day in women • Limit salt intake to 2 g per day • Minimize sugar intake • Use caution when eating outside of the home

23. Diets for Cardiovascular Disease Prevention

24. Epididymitis and Orchitis: An Overview • Inflammation of the epididymis and testes, with or without infection • Acute epididymitis, symptoms are present for less then six weeks and are characterized by pain and swelling. • Chronic epididymitis is characterized by pain, generally without swelling, that persists for more than three months. • Orchitis usually occurs when the inflammation from the epididymis spreads to the adjacent testicle.

25. Anatomy of the normal testis and spermatic cord

26. Epidemiology • 600,000 cases of epididymitis per year in the US • Most occur in men between 18 and 35 years of age • Epididymitis is more common than orchitis • Isolated orchitis is rare and generally associated with mumps infection in prepubertal boys (13 years or younger).

27. Etiology and Pathophysiology • Retrograde ascent of pathogens • 14 to 35 y/o • N. gonorrhoeae, C. trachomatis • < 14 or > 35 y/o • urinary tract pathogens, E. coli; U. urealyticum,P. mirabilis,K. pneumoniae, and P. aeruginosa less common • Mycobacterium tuberculosis in high risk • Fungal and viral etiologies, including CMV, have been reported in immunocomprised

28. Etiology and Pathophysiology • Noninfectious etiologies - postinfectious inflammatory reaction to pathogens, vasculitides and certain medications (amiodarone) • With the exception of viral diseases, genitourinary tract infections seldom primarily involve the testis • Orchitis usually occurs in patients with concurrent epididymitis, and the causative pathogens are similar. • Risk Factors: sexual activity, strenuous physical activity, bicycle or motorcycle riding, and prolonged periods of sitting; recent urinary tract surgery and anatomic abnormalities

29. Differential Diagnosis Any patient with acute scrotum and any patient in whom testicular torsion is otherwise suspected should receive urgent referral to a urologist for possible surgery. ****

31. Diagnostic Tests • Gram stain and culture of swabbed urethral discharge to detect urethritis and gonococcal infection. • UA and culture, preferably on first-void urine samples. • If epididymitis is suspected, PCR assays for C. trachomatis and N. gonorrhoeae should be performed on urethral swab or urine specimens. • CRP and ESR help to differentiate infection from torsion with sn 96% and sp 94% in one study • Color doppler ultrasonography • Referral should not be delayed pending results of these tests if testicular torsion is clinically suspected!

32. Treatment • Empirically treat based on likely pathogens pending results • Patients 14 to 35 years of age • ceftriaxone (Rocephin), a single 250-mg dose intramuscularly and doxycycline (Vibramycin), 100 mg orally twice daily for 10 days. • Azithromycin (Zithromax), a single 1-g dose orally, may be substituted for doxycycline if treatment compliance is questionable • Patients < 14 years or > 35 years • Ofloxacin 300 mg orally twice daily for 10 days, or levofloxacin (Levaquin), 500 mg orally once daily for 10 days. • Immunocompromised treated same

33. Treatment • Analgesics, scrotal elevation, limitation of activity, and cold packs are helpful • Complications include sepsis, abscess, infertility, and extension of the infection. • Inpatient care is recommended for intractable pain, vomiting (because of the inability to take oral antibiotics), suspicion of abscess, failure of outpatient care, or signs of sepsis. • Orchitis treatment is mostly supportive • Antibacterial medications are not indicated for the treatment of viral orchitis • Epididymo-orchitis requires appropriate antibiotic coverage, as with epididymitis.

34. Follow Up • 3 to 7 days • Pain typically improves within one to three days, but it may take two to four weeks for induration to fully resolve • Prepubescent boys with epididymitis need a urology referral because of the high incidence of urogenital abnormalities. • Men older than 50 years should be evaluated for urethral obstruction secondary to BPH • Screening tests and treatment of co-morbid STDs, for the patient and his sex partners.

35. Epididymitis and Orchitis: An Overview

36. Green Tea: Potential Health Benefits • Leaves come from Camellia sinensis plant • Contains: caffeine, theanine, theaflavins, theobromine, theophylline, and phenolic acids • Polyphenols are potent antioxidants with antimutagenic, antidiabetic, antibacterial, anti-inflammatory, and hypocholesterolemic properties • Epigallocatechin gallate (EGCG) is the most prevalent catechin in tea, and the most researched

37. B evidence rating

38. Quiz • A woman brings in her infant for his one-month well-child examination. She has been feeding him a generic (store-brand) basic term formula with iron. The infant is at the 50th percentile for weight and 60th percentile for head circumference. The woman is concerned about his continuous crying (colic) and is wondering if she should change to a different formula. Which one of the following is the most appropriate recommendation? A. Switch to formula supplemented with docosahexaenoic acid or arachidonic acid. B. Switch to antireflux formula. C. Do not switch formula; reassure her and counsel her about infant crying. D. Switch to low-iron formula

39. A mother brings her five-month-old infant to your office because, while transitioning from breastfeeding to formula, the infant has developed red patches on her face and chest. Of note, the mother rarely drinks milk herself. Which one of the following would best explain the infant's symptoms? A. Cow's-milk protein allergy. B. Primary lactase deficiency. C. Congenital lactase deficiency. D. Secondary lactase deficiency.

40. Which of the following interventions for infant feeding is/are supported by current evidence? A. Preterm and enriched formulas to improve short-term growth in premature infants. B. Supplementation of infant formula with docosahexaenoic acid or arachidonic acid in term infants. C. Antireflux formulas to reduce daily emesis and regurgitation. D. Hypoallergenic formula for treatment of milk protein allergy.

41. Which one of the following statements about commercial diet plans is correct? A. Very low-carbohydrate diets (e.g., the Atkins diet) decrease levels of high-density lipoprotein. B. Very low-fat diets (e.g., the Ornish diet) increase body mass index. C. The Mediterranean diet may improve patient-oriented outcomes without weight loss. D. Low-carbohydrate diets (e.g., the Zone diet) increase levels of low-density lipoprotein

42. Which of the following strategies is/are recommended in the 2006 American Heart Association dietary guidelines? A. Increasing juice intake. B. Supplementing with plant stanols. C. Counting calories. D. Exercising aerobically for 60 minutes on most days of the week to lose weight

43. Which one of the following organisms is the most common cause of epididymitis in patients younger than 14 years and older than 35 years? A. Escherichia coli. B. Ureaplasma urealyticum. C. Klebsiella pneumoniae. D. Chlamydia trachomatis

44. Which one of the following findings is more consistent with epididymitis than with testicular torsion? A. Urinary tract symptoms. B. Abrupt onset of pain. C. Recurrent episodes of pain. D. Abnormal cremasteric reflex.

45. Typical treatment options for epididymitis include which of the following? A. Doxycycline (Vibramycin) in men 14 to 35 years of age. B. Levofloxacin (Levaquin) in men older than 35 years. C. Ofloxacin (Floxin; brand no longer available in the United States) in children younger than 14 years. D. Doxycycline in men older than 65 years.

46. References • O’Connor, N. Infant Formula. American Family Physician. Apr 2009; 79 (7): 565-570. • Walker C, Reamy B. Diets for Cardiovascular Disease Prevention: What Is the Evidence? American Family Physician. Apr 2009; 79 (7): 571-578. • Trojian T, Lishnak T, Heiman D. Epididymitis and Orchitis: An Overview. American Family Physician. Apr 2009; 79(7): 583-587. • Schneider C, Segre T. Green Tea: Potential Health Benefits. American Family Physician. Apr 2009; 79(7): 591-594.