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Content 7


The Doctor and the Pharmacist

Radio Show Articles:
January 11, 2014

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Sock It to Me
Compression Stockings, Rather than Bandages, for Venous Leg Ulcers
Weight Concerns and Disordered Eating Common in 13-Year-Olds
Dietary supplements Blamed for Sharp Rise in Drug-Related Liver Injuries
More on Proton-Pump Inhibitors and Clostridium difficile Infection
Infant Feeding and Maternal Mortality
Earlier Age of Menarche Is Not Associated with Earlier Age at First Sexual Intercourse
Pregnant and Still Smoking After All These Years?
2000 Steps a Day May Keep the Doctor Away
Dietary Fiber is still Good For You
Hip Replacements Commonly performed in the U.K. Without Clinical Efficacy Studies

MM: What a great idea! It certainly makes sense that re-infection from resistant organisms retained in clothing would be a large contributor to propagating toenail fungus. Most consumers don't realize how resilient fungal organisms are. If your washer doesn't reach temperatures high enough to kill these organisms then another option might be boiling the socks for 10-20 minutes after taking them out of the washer. Additionally, we have demonstrated great success with the treatment of a number of fungal infections by incorporating the drug Ibuprofen into the anti-fungal cream or ointment. This tends to potentiate the effect of the anti-fungal locally and we see much faster and more complete resolution of the fungus than when using the cream in its original state.
Int J Dermatol 2013 Nov; 52:1392
Sock It to Me
Laundering at high temperatures will help to prevent recurrences of onychomycosis.
Recurrences of toenail onychomycosis are common. From where do the new infecting fungi come? Some people believe dormant spores in stockings or shoes may contain fungal organisms ready to re-infect their wearer.
To see if laundering of socks killed fungi, an Israeli group collected socks from 81 subjects with onychomycosis and tinea pedis. Samples of fabric from the toe and heel areas were washed with domestic detergent and water at either 40ºC or 60ºC in a domestic washing machine. Each laundered sample and each unlaundered control sample were dried and cultured on Sabouraud's dextrose agar without antibiotics. Cultures from 40 of 81 unwashed sock toe samples isolated Trichophyton species, with or without other organisms, as did 36 of 81 samples from the heel. Washing at 40ºC greatly reduced the probability of isolating fungi; Trichophyton species were found in two specimens from the toe area and two from the heel area. Trichophyton spp. were not isolated from any samples washed at 60ºC, although Aspergillus spp. occasionally survived in these samples.
Comment: Other similar studies have found similar results. A temperature of 40ºC does not differ much from body temperature, so the markedly reduced incidence of positive cultures in fabric washed at this temperature suggests fungi may sometimes simply wash out or be killed by detergent. Washing with detergent at 60ºC may eliminate all fungi. Aspergillus spp. molds seem able to survive this temperature. Perhaps it is prudent to recommend laundering all socks (previously washed and unwashed) at 60ºC after treatment of onychomycosis. Fungi are hardy creatures, and socks previously washed at ecologically trendy low temperatures may retain fungal spores waiting to sprout and infect a moist foot or nail.
Citation(s): Amichai B et al. The effect of domestic laundry processes on fungal contamination of socks. Int J Dermatol 2013 Nov; 52:1392.

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MM: Graduated Compression Hosiery is a product line that we have provided for patients at Mark Drugs for more than 20 years. The compression is greatest at the foot and ankle and gradually decreases as it approaches the torso. This encourages blood enter the extremity with fresh oxygen and nutrients and to return venous blood to the heart, decreasing swelling and edema while ridding the local tissue of metabolic breakdown products. The overall process seems to speed the healing process and as this article indicates, reduces the likeliness of an ulcerous return to the area. Many insurance plans will pay for these hosiery and they are available in comfortable and attractive styles and a variety of colors, strengths and textures. They are relatively easy to put on and care for and greatly reduce the cost of ulcer care when compared to other alternatives.
Lancet 2013 Dec 6
Compression Stockings, Rather than Bandages, for Venous Leg Ulcers
Healing times were similar, but hosiery wearers experienced fewer ulcer recurrences.
Four-layer compression bandages have long been standard care for venous leg ulcers, but they are bulky and require frequent professional attention. Newly developed two-layer compression hosiery delivers equivalent compression, is thinner, and can be self-applied by many patients. In the first direct comparison of these two compression systems, researchers in the U.K. randomized about 450 adults, each with at least one venous leg ulcer, to treatment with bandages or hosiery until patients were unable to continue their assigned treatments or until index ulcers healed. Patients were followed for as long as 1 year after randomization.
Median time to ulcer healing was 99 days for hosiery and 98 days for bandages; about 70% of index ulcers healed in each group. More patients in the hosiery group than in the bandage group changed to nontrial treatments (38% vs. 28%), suggesting that the hosiery system might not be suitable for all patients. Ulcers recurred in 14% of hosiery patients and in 23% of bandage patients. Patients in the hosiery group reported slightly better quality of life than those in the bandage group. Per-patient annual costs were about US$500 lower for hosiery users, mostly because nursing interventions were required less frequently.
Comment: Given the lower rate of ulcer recurrence, improved quality of life, and lower costs, two-layer compression hosiery probably is a cost-effective alternative to traditional compression bandages for some patients. Two-layer systems can be purchased in kits consisting of an understocking and an overstocking that together apply 40 mm of compression.
Citation(s): Ashby RL et al. Clinical and cost-effectiveness of compression hosiery versus compression bandages in treatment of venous leg ulcers (Venous leg Ulcer Study IV, VenUS IV): A randomised controlled trial. Lancet 2013 Dec 6; [e-pub ahead of print].
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J Adolesc Health 2013 Dec 17
Weight Concerns and Disordered Eating Common in 13-Year-Olds
…and are associated with both short- and long-term negative outcomes.
Peak onset of eating disorders is between ages 15 and 19 years, but younger teens also display eating disorder symptoms. Investigators in England examined eating disorder symptoms during early adolescence in 7082 adolescents (50% girls; 96% white) enrolled in the Avon Longitudinal Study of Parents and Children. Height and weight were measured at ages 13 and 15 years. Parents completed a semi-structured interview designed to identify psychiatric disorders, including eating disorder behaviors and cognitions, and their effect on family and adolescent functioning.
By parental report, 12% of girls and 5% of boys at age 13 years were “terrified” about gaining weight or getting fat, and 5% of girls and 2% of boys were “upset or distressed a lot” about their weight or shape. Three patterns of weight concerns/eating behaviors emerged: bingeing/overeating, weight/shape concerns with weight control behaviors, and food restriction. Binging/overeating was associated with social impairment and family burden and emotional and behavioral disorders in both sexes. Weight concerns were associated with social impairment in both sexes and with family burden in girls. Food restriction was associated with all four negative outcomes in boys and with family burden and behavioral disorders in girls. Bingeing/overeating and weight concerns at age 13 were associated with higher body-mass index (BMI) z-scores at age 15 in both sexes, while food restriction predicted lower BMI-z scores.
Comment: Disordered eating and concerns about weight and shape are common among 13-year-old teens and associated with both short- and long-term negative outcomes. How best to minimize the emergence of these behaviors and cognitions and prevent progression to full-blown eating disorders is unclear, but some research suggests strategies that include focusing on healthy eating rather than dieting and avoidance of weight-based teasing or parental discussions of their own dieting behaviors (NEJM JW Pediatr Adolesc Med Feb 1 2012 and NEJM JW Pediatr Adolesc Med Jul 23 2008).
Citation(s): Micali N et al. Frequency and patterns of eating disorder symptoms in early adolescence. J Adolesc Health 2013 Dec 17; [e-pub ahead of print].
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MM: This is an example of "a few bad apples". Muscle building and weight loss supplements tend to be the rabble rousers in the natural product and supplement arena. There has been a long history of hidden prescription components in this group and unfortunately this class of items taints the reputation of many otherwise safe products.
Dietary supplements Blamed for Sharp Rise in Drug-Related Liver Injuries
By Amy Orciari Herman
Dietary supplements, including many marketed for muscle-building and weight loss, account for a spike in drug-related liver injuries over the past decade, according to a front-page story in Sunday's New York Times. Many patients ultimately recover, but some end up requiring transplants or dying from liver failure.
Supplements accounted for nearly 20 percent of drug-related liver injuries that led to hospitalization in 2010-2012, the Times reports, up from 7 percent in 2004. The data, from the NIH's National Liver Network, showed that many of the products were bodybuilding supplements that contained steroids not listed on the label. Use of green tea extract was also frequently reported. The extract contains catechins, which are said to increase metabolism; in high doses, they can cause liver toxicity.
Of over 50,000 supplements sold in the U.S., less than 1% have been examined well enough to determine their adverse effect profile, one expert told the Times.
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MM: The proponents of PPI's seem to be constantly seeking ways to justify the continued long term use of this class of dangerous drug. When used for the correct purpose and for the proper duration, PPI's can be quite useful and effective (6-12 week treatment of gastric or duodenal ulcer). Unfortunately, there is so much money and profit to be made by promoting the inappropriate use of this class of drugs that the consumer and the medical community in bombarded with information to make it seem alright. Bottom line: It's NOT ALRIGHT!
Am J Gastroenterol 2013 Nov; 108:1794
More on Proton-Pump Inhibitors and Clostridium difficile Infection
In the latest study of this possible association, U.S. inpatients treated with PPIs were not at increased risk for recurrent C. difficile infection.
In the past, gastric acid was not believed to be important in protecting against Clostridium difficile infection (CDI) because acid-resistant spores were presumed to be the principal vector of transmission. However, that belief was challenged by findings from observational studies showing an increased risk for CDI with use of proton-pump inhibitors (PPIs). Most recently, findings of observational studies on the association between PPI use and CDI have been conflicting.
To investigate this issue further, researchers in the U.S. assessed whether in-hospital PPI use was associated with increased risk for recurrent CDI. Electronic medical records of 894 patients hospitalized with incident CDI were retrospectively reviewed. Twenty-three percent of patients had CDI recurrence within 15 to 90 days after the initial positive test. Clinical factors assessed as covariates included comorbidities, patient demographics, and use of acid suppressants or non-CDI antibiotics.Receipt of PPIs was not associated with cumulative CDI recurrence (adjusted hazard ratio, 0.82; 95% confidence interval, 0.58–1.16). Neither duration of PPI use nor dose was associated with CDI recurrence.
Comment: To date, evidence is insufficient to conclude that proton-pump inhibitor use is definitively linked with Clostridium difficile infection. The most recent guideline on detection, prevention, and treatment of CDI does not include restriction or avoidance of PPIs (Am J Gastroenterol 2013; 108:478). Clinicians should be aware of this potential relationship yet understand that confounding factors may play a significant role in the reported association. Appropriate usage of PPIs should continue unless evidence of potential harm becomes conclusive.
Citation(s): Freedberg DE et al. Proton pump inhibitors and risk for recurrent Clostridium difficile infection among inpatients. Am J Gastroenterol 2013 Nov; 108:1794.
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MM: Apparently breast feeding is not good only for a baby's growth, psychological health, immune function and for maternal-child bonding but for maternal CV health as well. Does this mean that cardiologists will now be teaming up with nurse midwives?I would hope so. The numbers are pretty impressive.
BMC Public Health 2013 Nov 13; 13:1070
Infant Feeding and Maternal Mortality
Cardiovascular mortality was doubled in mothers who never breast-fed compared with those who did.
Recent findings suggest that curtailed lactation can raise maternal risk for high blood pressure, diabetes, visceral adiposity, hyperlipidemia, and cardiovascular disease (CVD). To assess whether lifetime duration of breast-feeding predicts maternal cardiovascular mortality, investigators analyzed data from a Norwegian population-based prospective cohort study including 21,889 women (age range, 30–85). Linkage to the national Cause of Death Registry indicated that, after median follow-up of 14.5 years, 1246 women died from CVD.
Among parous women younger than 65 at study entry, those who never breast-fed had more than twice the risk for dying from CVD as those who ever breast-fed. Among parous women aged 45 to 64 at enrollment, those who never nursed were 3 times as likely to die from CVD compared with ever-nursing mothers. Adjusting for age, parity, education, marital status, and traditional risk factors for CVD (e.g., smoking, obesity, diabetes) did little to attenuate this excess mortality among nonbreast-feeding mothers.
Comment: As cardiovascular disease is the most common cause of death among women in developed nations, identifying potentially modifiable risk factors is important. These findings suggest that mothers who have never breast-fed may require special attention to CVD risk reduction. The study also highlights the importance of initiatives such as “Baby Friendly” hospitals, which can significantly increase breast-feeding rates.
Citation(s): Natland Fagerhaug T et al. A prospective population-based cohort study of lactation and cardiovascular disease mortality: The HUNT study. BMC Public Health 2013 Nov 13; 13:1070.
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MM: In my opinion, family involvement and local social morés have a greater impact on how early a girl will start having sexual intercourse rather than her body's physiological potential. If a girl is socially and sexually mature, then she may decide to engage in sexual behavior. It then becomes more dependent on family and social institutional support coupled with local social pressure than mere physiological readiness.
Pediatrics 2013 Dec; 132:1028
Earlier Age of Menarche Is Not Associated with Earlier Age at First Sexual Intercourse
 In a prospective study, girls with menarche before age 12 years were not more likely to initiate sex by age 16 years.
Previous cross-sectional and retrospective studies suggest early menarche is associated with earlier age of first sexual intercourse (FSI). These investigators used data from the Western Australia Pregnancy Cohort Study to prospectively examine this association. Extensive information was collected at ages 1, 2, 3, 5, 8, 10, 14, 17, and 20 years for 2868 live-born children (1405 girls).
A total of 554 girls provided 17-year follow-up information and valid sexual activity data. By age 17 years, 50% had initiated sexual activity. Median age of FSI for the entire cohort was 16 years. FSI by age 16 years was reported by 56% of girls with early menarche (age <12 years), 50% with average menarche (ages 12-13 years), and 41% with later menarche (age ≥14 years). Adjusted relative risks of FSI by age 15 or 16 years were similar for girls with early versus average age at menarche. The mean interval between age at menarche and FSI was 5.0 years for girls with early menarche, 3.7 years for girls with average menarche, and 2.5 years for girls with later menarche.
Comment: This prospective study used sophisticated statistical methods that maximized use of longitudinal data. The results are reassuring and challenge previous assumptions. Nonetheless, early maturing girls may be at risk for other adverse psychosocial outcomes, especially if their peer groups consists of older friends or, because of advanced physical development, they are treated as being more cognitively mature than they are.
Citation(s): Marino JL et al. Age at menarche and age at first sexual intercourse: A prospective cohort study. Pediatrics 2013 Dec; 132:1028.

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MMWR Surveill Summ 2013 Nov 8; 62:1
Pregnant and Still Smoking After All These Years?
Nationally, rates of smoking during pregnancy barely changed between 2000 and 2010.
Women who smoke during pregnancy incur excess risk for preterm delivery and infant death. According to Pregnancy Risk Assessment Monitoring System data from 40 U.S. states, self-reported prevalence of smoking before pregnancy did not change significantly from 2000 to 2010. In 2010, 23% of U.S. mothers in 27 states reported smoking during the 3 months before pregnancy, and 11% said they smoked during pregnancy. However, these rates varied markedly by region: although >30% of mothers in West Virginia reported smoking during pregnancy, <5% of mothers in Utah (and, interestingly, New York City) did so.
Comment: Because smoking increases women's risk for cardiovascular disease and cancer and is associated with pregnancy-related complications such as fetal brain anomalies (NEJM JW Psychiatry Nov 4 2013), smoking cessation counseling is necessary to both well-woman and preconception care. Nevertheless, to truly bring down rates of smoking, we must advocate effectively for comprehensive tobacco-control measures, including smoke-free workplaces and tobacco excise taxes. Insurance coverage of nicotine-replacement therapy (which is safe during pregnancy, although varenicline and bupropion have yet to be studied in this setting; Prim Health Care Res Dev 2013; 14:327) also should be supported.
Citation(s): Tong VT et al. Trends in smoking before, during, and after pregnancy — Pregnancy Risk Assessment Monitoring System, United States, 40 sites, 2000–2010. MMWR Surveill Summ 2013 Nov 8; 62:1.
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MM: It doesn't take a lot of work but this data demonstrates that as little as 2000 steps or about 1 mile will improve CV health. A little can truly go a long way.
2000 Steps a Day May Keep the Doctor Away
By Amy Orciari Herman
Walking 2000 steps a day — about 20 minutes of moderate-intensity walking — can lower the odds of cardiovascular events among high-risk adults, according to an analysis from the NAVIGATOR trial published in the Lancet.
Researchers studied some 9300 adults aged 50 and older with existing cardiovascular disease or impaired glucose tolerance and at least one additional cardiovascular risk factor. Ambulatory activity was measured with a pedometer for 7 days at baseline and 1 year.
During roughly 6 years' follow-up, 531 cardiovascular events occurred. Each 2000-step/day increment in ambulatory activity at baseline was associated with a roughly 10% lower risk for cardiovascular events. Similarly, each 2000-step increase in activity from baseline to 1 year was associated with an 8% lower risk, while each 2000-step decrease conferred an 8% higher risk.
Commentators say the trial "adds compelling and reassuring evidence for the benefits of physical activity on cardiovascular health."
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MM: This speaks to the question of whether psyllium or other fibers are potentiqally beneficial for conbatting CV disease and apparently the answer is NO.
Dietary Fiber is still Good For You
By Joe Elia
Dietary fiber's salutary effects on health — specifically in preventing cardiovascular disease — are reaffirmed in a BMJ meta-analysis.
Researchers examined 22 cohort studies in predominantly Westernized countries that looked at the relation between fiber intake and cardiovascular risk. Most data were from food-frequency questionnaires. The analysis presents risks based on dose-response curves rather than simple "high" or "low" intakes.
Overall, total fiber intake was inversely associated with cardiovascular risk. Specifically, each 7 grams a day of fiber intake was associated with a risk ratio of 0.9 for both coronary heart disease and cardiovascular disease. Only insoluble fiber (wheat bran, brown rice, and other whole grains) had a significant lowering of risk.
Both the researchers and an editorialist acknowledge the limitations of dietary-recall studies. The editorialist writes that despite this, "clinicians should enthusiastically and skillfully recommend" more fiber in their patients' diets.
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MM: In the U.S. there are no requirements to establish clinical efficacy of a new product. This allows "me too" products to enter the market place that may be the same or even potentially inferior to products already on the market. Consumers have the right to know and so clinicians that a product is superior if it will be used. That way both the consumer, the clinician and the ultimate payer may decide which product is best in each case.
Hip Replacements Commonly performed in the U.K. Without Clinical Efficacy Studies
By Kelly Young
Many hip prostheses available to orthopedic surgeons do not have published evidence to support their use, according to a BMJ study.
Using the National Joint Registry of England and Wales, researchers found that a quarter of all brands available to surgeons in 2011 had no published studies on their clinical effectiveness. Roughly 8% of all total hip arthroplasties performed used prostheses with no evidence of effectiveness.
Editorialists point out that in the U.S., formal efficacy trials are not required for moderate-risk devices such as hip prostheses if the manufacturer can demonstrate "substantial equivalence" to a product already on the market. They write: "Physicians who adopt new technologies that have little or no evidence of superiority over existing products need to be educated about the implications of their choices. They should also ensure that their patients know about the benefits and risks of the new — but often unproved — medical devices that they are receiving."

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