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Content 7


The Doctor and the Pharmacist

Radio Show Articles:
January 26, 2013

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Mercury Treatment Activities Not Affecting Thimerosal-containing Vaccines
Blindness More Likely in Those Taking Aspirin Regularly
Heart Failure with Breast Cancer Chemotherapy: A Risk Worth Taking Seriously
Hydrogen Peroxide "Vaporizes" Some Hospital Room Contaminants
In Patients with Hyperlipidemia, Exercise and Statins Both Lengthen Life
Assisted Reproduction Treatment Increases Disease Activity in MS
Folic Acid Supplements Unlikely to Heighten Cancer Risks, Meta-Analysis Finds

Mercury Treatment Activities Not Affecting Thimerosal-containing Vaccines
A global treaty will soon be presented to countries for their ratification as part of a worldwide effort to control and reduce ways in which mercury is used, released, or emitted. Included in the treaty are items about certain mercury-added products (e.g., batteries, lamps, switches, skin-lightening cosmetics, pesticides, thermometers) that may not be manufactured, imported or exported any later than 2020. Also, mercury-added dental amalgams are also to be phased out.
Certain mercury-added products are to be exempted from the ban, including those used for military and civil protection, products with no mercury-free alternative, products used in religious or traditional practices, and vaccines containing thimerosal, an ethylmercury preservative.
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Blindness More Likely in Those Taking Aspirin Regularly
People taking aspirin regularly, such as those with heart problems, are more likely to develop a form of blindness. A JAMA Internal Medicine-published study of 2,389 people, showed aspirin takers had twice the risk of "wet" age-related macular degeneration. However, they said there was not yet enough evidence to change aspirin use.
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MM: This is an example of the cure being possible as deadly if not more so than the disease itself. I am not saying that breast cancer should not be treated but there are so many diagnoses of false positive that we need to keep this diagnosis in perspective and get a second opinion to confirm the best course of action to take.
J Am Coll Cardiol 2012 Dec 18; 60:2504
Heart Failure with Breast Cancer Chemotherapy: A Risk Worth Taking Seriously
Findings from a large database suggest that trastuzumab is associated with higher rates of HF or cardiomyopathy in clinical practice than it was in clinical trials.
The anthracyclines, often used in adjuvant chemotherapy for breast cancer, are known to cause potentially permanent left ventricular systolic dysfunction. Newer breast cancer therapies, including the monoclonal antibody trastuzumab, have also been implicated in incident cardiomyopathy. The clinical trials of trastuzumab that exposed this adverse effect were generally conducted in younger women and may substantially underestimate the risk in older women, who constitute a sizeable proportion of breast cancer patients receiving adjuvant chemotherapy.
Investigators used the Surveillance, Epidemiology, and End Results Medicare database to assemble a cohort of 45,537 women aged 67 to 94 (mean age, 76) with early-stage breast cancer and no recorded history of heart failure (HF). New-onset HF or cardiomyopathy was defined as a single inpatient claim or two outpatient claims more than 30 days apart after chemotherapy. Only about 2% of the cohort received trastuzumab, alone or with an anthracycline; an additional 12% received an anthracycline without trastuzumab. After multivariable adjustment, the 3-year incidence of HF or cardiomyopathy (per 100 patient-years) was 32.1 in the trastuzumab-only group, 41.9 in the trastuzumab–anthracycline group, and 20.2 in the anthracycline-only group, compared with 18.1 in patients receiving no adjuvant chemotherapy.
Comment: The number of trastuzumab recipients in this study was small, and the ascertainment of heart failure and cardiomyopathy events was relatively nonspecific, which probably inflated the risk estimate. Nonetheless, we should not entirely dismiss these results, which suggest a higher risk for adverse cardiac events than that established by clinical trials. Given the widespread use of cardiotoxic chemotherapeutic agents and early studies of risk-remediation strategies (JW Cardiol Jan 3 2007), it is high time for more-conclusive trials in representative populations to establish the best way to limit this important adverse effect.
Frederick A. Masoudi, MD, MSPH, FACC, FAHA Published in Journal Watch Cardiology January 16, 2013
Citation(s): Chen J et al. Incidence of heart failure or cardiomyopathy after adjuvant trastuzumab therapy for breast cancer. J Am Coll Cardiol 2012 Dec 18; 60:2504.
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MM: Superinfections in the hospital and in the community have become a massive clinical problem in recent years. Sometimes the simplest solutions are the best ones. Hydrogen peroxide rinses are generally considered safe for humans. Unfortunately these same solutions increase degradation and oxidation of metals and are therefore not used as frequently as might be appropriate. With the ever increasing presence of disposable items in the healthcare setting and plastic components and plastic coatings on metal components in the hospital and long term care settings this problem may be diminishing and could lead to more frequent use of hydrogen peroxide as a sanitizer in the healthcare setting. The major obstacle is likely to be budgeting but we need to assess whether the cost of treatment is less than or greater that the cost of prevention.
Clin Infect Dis 2013 Jan 1; 56:27
Hydrogen Peroxide "Vaporizes" Some Hospital Room Contaminants
enterococci acquisition and contamination at one major hospital.
Multidrug-resistant organisms (MDROs) can persist in hospital rooms and on medical equipment despite cleaning and disinfection — and may then be transmitted to patients. One proposal for limiting MDRO contamination is to use automated room-disinfection systems, such as hydrogen peroxide vapor or ultraviolet radiation, in addition to standard cleaning. A new study, conducted for 18 months in selected wards at Johns Hopkins Hospital, focused on cleaning with hydrogen peroxide vapor for 1.5 to 3 hours after routine postdischarge room cleaning. Wards cleaned in that manner were compared with those cleaned in the usual way. The hydrogen peroxide decontamination services were provided by a company that sells those services. One of the authors works for the company.
The risk for acquiring any MDRO was 64% lower among patients admitted to rooms that had been further cleaned with hydrogen peroxide vapor than among patients admitted to traditionally cleaned rooms. Most of that difference was attributable to an 80% lower rate of vancomycin-resistant enterococci (VRE) acquisition; differences for other MDROs were not significant. Environmental contamination by MDROs was also significantly lower in the peroxide-cleaned rooms than in the standard rooms. No health or safety problems were associated with the hydrogen peroxide vapor.
Comment: According to the authors, cleaning with hydrogen peroxide vapor had most of its effect on vancomycin-resistant enterococci because VRE was their facility's major MDRO. Even if the peroxide method can limit contamination by other MDROs, the extra time it requires may be an obstacle to its general implementation. Moreover, this study addressed only MDRO acquisition, not infection. Editorialists note that proving the effect of a particular cleaning technique on hospital infection rates is challenging. This will not be the last study of cleaning with hydrogen peroxide vapor.
Neil M. Ampel, MD Published in Journal Watch Infectious Diseases January 23, 2013
Citation(s): Passaretti CL et al. An evaluation of environmental decontamination with hydrogen peroxide vapor for reducing the risk of patient acquisition of multidrug-resistant organisms. Clin Infect Dis 2013 Jan 1; 56:27.
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MM: It's not enough to just take a pill. Study after study have indicated that lifestyle (inclusive of diet and exercise) has as much of an impact on health if not more than that of medication alone. As Hippocrates stated long ago, "...Make your food your medicine and your medicine your food..."
Lancet 2012 Nov 28;
In Patients with Hyperlipidemia, Exercise and Statins Both Lengthen Life
Moderate fitness or statin use led to about the same 10-year mortality.
Both taking statins and increasing physical activity lower mortality in patients at risk for cardiovascular disease, but few data exist on the comparative or synergistic effects of these interventions. Researchers followed more than 10,000 military veterans (97% men; 52% black) with dyslipidemia who received care through the U.S. Veterans Administration and underwent exercise tolerance tests between 1986 and 2011. Each patient was assigned to one of four fitness strata, based on peak exercise capacity at cohort entry (from ≤5.0 to >9.0 metabolic equivalents [MET]) and was classified as a statin user (for at least 3 months) or nonuser. Patients were followed prospectively for a median of 10 years.
After adjustment for potential confounders, statin use and better fitness were associated independently with lower mortality. Among nonusers, the most-fit patients had significantly lower mortality than the least-fit patients (adjusted hazard ratio, 0.37). Similarly, among statin users, the most-fit patients had significantly lower mortality than the least-fit patients (AHR, 0.32). Moderately fit nonusers (exercise tolerance, 5.1–7.0 MET) had mortality risk approximately equivalent to the least-fit statin users.
Comment: In this observational study, better fitness lowered mortality in hyperlipidemic patients, whether or not they were taking statins, and moderate fitness in nonusers lowered mortality as much as statin use. Physical activity is safe and effective, and an inexpensive alternative or adjunct to statin therapy. Why don't we advocate more strongly for it?
Bruce Soloway, MD Published in Journal Watch General Medicine January 15, 2013
Citation(s): Kokkinos PF et al. Interactive effects of fitness and statin treatment on mortality risk in veterans with dyslipidaemia: A cohort study. Lancet 2012 Nov 28; [e-pub ahead of print].
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MM: An interesting phenomena is that MS symptoms frequently go into remission during pregnancy when progesterone levels are elevated. We have seen this same clinical manifestation in several of our MS patients who are using bio-identical progesterone. Progesterone may truly be another tool in the treatment of MS.
Ann Neurol 2012 Nov; 72:682
Assisted Reproduction Treatment Increases Disease Activity in MS
Hormonal manipulation for infertility may enhance immune function and result in MS relapse.
Assisted reproduction treatment (ART) involving stimulation of ovulation is being used increasingly as a treatment for infertility. The effects on immune function in patients with multiple sclerosis (MS) have not been determined for gonadotropin-releasing hormone (GnRH), follicle-stimulating hormone (FSH), progesterone, and estradiol at the concentrations involved in ART. To study these effects, investigators prospectively recruited 16 patients with relapsing–remitting MS who had been trying to conceive naturally for at least 12 months. Disease-modifying therapy had been stopped for at least 15 months. ART included 26 treatments. If a given cycle did not result in a pregnancy, an additional ART cycle could be performed after 4 to 6 months.
No patient had relapses or activity on imaging within 9 months before ART. Within the 3-month risk period after ART, the annual exacerbation rate was 3.28 (rate ratio compared with unexposed periods, 6.93). Rate ratios were 8.70 for new T2 lesions and 8.82 for new gadolinium-enhancing lesions. ART was associated with a Th1 shift in lymphocytes, with increased interleukin (IL)-8, IL-12, interferon-{gamma}, transforming growth factor beta, vascular endothelial growth factor, and CXCL-12. Cells secreting anti–myelin oligodendrocyte glycoprotein immunoglobulin G were increased after ART. GnRH-induced CXCL-12 secretion increased mononuclear cell transmigration in ex vivo Boyden chambers, demonstrating enhanced chemoattractant effects associated with transmigration across the blood–brain barrier.
Comment: MS is more common in women of childbearing age. Sex hormones have been implicated in the disease initiation, and a relative remission is often seen during pregnancy. Sex hormones have pleomorphic effects on immunologic function. This study demonstrated that patients who were stable off disease-modifying therapies for 12 months while trying to conceive had a dramatic increase in disease activity associated with ART. The number of patients is small, but the finding is strengthened by immunologic assay findings demonstrating upregulation of both T- and B-cell function. For our patients choosing to undergo ART, they should be counseled on the potential increased risk for an MS relapse. For women whose MS has been active or aggressive, ART should be pursued cautiously.
— Robert T. Naismith, MD  Published in Journal Watch Neurology January 22, 2013
Citation(s): Correale J et al. Increase in multiple sclerosis activity after assisted reproduction technology. Ann Neurol 2012 Nov; 72:682.
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Folic Acid Supplements Unlikely to Heighten Cancer Risks, Meta-Analysis Finds
By Joe Elia
Despite concerns that folic acid could increase the risks for cancer, a Lancet meta-analysis finds little supporting evidence. Commentators say the question isn't resolved yet, however.
Researchers examined patient-level data from 13 randomized trials of folic acid supplementation including a total of 50,000 patients with treatment lasting, on average, 5 years. During the duration of treatment, they found no evidence of elevated risk for cancer overall, or for individual cancer types; nor did they find an effect trend with longer treatment duration. There was also no evidence of a decreased risk.
The typical supplementation doses (2.0 mg/day) were an order of magnitude higher than those typically delivered by national flour fortification programs (roughly 0.2 mg/day in the U.S.).
Commentators advise caution in interpreting the findings. They argue that folate's relationship with cancer is complex and that longer follow-up is needed.

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