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Content 7


The Doctor and the Pharmacist

Radio Show Articles:
January 28, 2012

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Foods Fried in Olive, Sunflower, or Other Vegetable Oils Not Linked to Heart Risk
When Should Bone-Density Tests Be Repeated?
Chronic Fatigue Syndrome/Myalgic Encephalomyelitis Can Cause Frequent School Absence
Overall Prevalence of Childhood Obesity Is Stable
Lifestyle Intervention Can Be Effective in Obese Adolescents with Polycystic
  Ovarian Syndrome
Leave My Appendix, Please
Is HIV Becoming More Virulent?
Millions of Dollars in New Drug Fees to Go to the FDA
FDA Fines the American Red Cross $9.6 Million
Oral HPV Infection Found in 7% of Americans
No Decline in Pulmonary Function with Marijuana Use
Gout and Diuretics in Hypertensive Patients
Can Exercise Prevent Gestational Diabetes?
Influenza in Neurologically Compromised Patients
Erectile Dysfunction Appears to Be More Prevalent in Psoriatic Patients

MM: Wow! Talk about effects of the Mediterranean Diet! Fried foods are comfort foods and certainly delicious. Heart disease is also a great concern of our aging population. Unfortunately frying foods also tends to lead to increased weight gain and enhanced Metabolic Syndrome. Another potential problem is heat level. Frying foods at very high heat will have a deleterious effect on the structure of the oil and will initiate free radicals that tend to have a deleterious effect on the heart and other organs. It is my opinion that the use of this “non-negative” effect of frying foods be viewed with caution.
Foods Fried in Olive, Sunflower, or Other Vegetable Oils Not Linked to Heart Risk
Foods fried in olive, sunflower, or other vegetable oils were not associated with increased cardiac risk in a BMJ study.
Some 41,000 adults in Spain completed a food frequency questionnaire, which included questions about their consumption of fried food and the kind of oil used to prepare it. Nearly two thirds of participants reported using olive oil for frying, while the rest used sunflower or other vegetable oils. After a median follow-up of 11 years, fried food consumption was not associated with MI, angina requiring revascularization, or all-cause mortality.
The authors caution that they could not separate the effect of the oil from the type of food being fried. Editorialists conclude: "Advice should focus on achieving an appropriate balance of fried foods — such as fish, meat, and potatoes — because these contain considerable amounts of nutrients that affect the risk of coronary heart disease."
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MM: This is a question that is frequently asked. We are concerned with the future and with tests that show ongoing changes. A problem is that few people understand what these tests actually mean long term. This data helps to establish guidance and is long overdue.
N Engl J Med 2012 Jan 19; 366:225
When Should Bone-Density Tests Be Repeated?
A 15-year interval is reasonable in older women if baseline BMD is normal or only mildly osteopenic.
For many conditions, screening is conducted at arbitrary intervals — and bone-mineral density (BMD) testing is no exception. In a prospective study, researchers sought to determine reasonable intervals for BMD screening. They identified 5000 women (age, ≥67) without osteoporosis at baseline BMD testing and followed them for up to 15 years. Baseline BMD levels were classified as normal (femoral neck or total-hip T scores, –1.00 or higher) or as indicative of mild osteopenia (T-score range, –1.01 to –1.49), moderate osteopenia (range, –1.50 to –1.99), or advanced osteopenia (range, –2.00 to –2.49).
The interval during which at least 10% of women developed osteoporosis (T score –2.5 or lower) was longer than 15 years for those whose baseline BMDs were normal or only mildly osteopenic and was 5 years for those with baseline moderate osteopenia and 1 year for those with baseline advanced osteopenia. These estimates changed very little after adjustment for age, body-mass index, and several other relevant variables. The estimated time for 2% of women to experience hip or vertebral fractures was at least 15 years for those with normal BMD or mild osteopenia and 5 years for those with moderate-to-advanced osteopenia.
Comment: This analysis challenges the practice of repeating bone-mineral density tests routinely every few years. Very few older women with normal BMD developed osteoporosis within 15 years after a normal test result. For women whose baseline BMDs fell within the lower portion of the osteopenic range, screening intervals required to avoid missing the development of osteoporosis were progressively shorter. Future updates of screening guidelines should incorporate these findings. However, keep in mind that factors other than BMD affect fracture risk, and that this study did not address who might benefit from treatment.
— Allan S. Brett, MD Published in Journal Watch General Medicine January 24, 2012
Citation(s): Gourlay ML et al. Bone-density testing interval and transition to osteoporosis in older women. N Engl J Med 2012 Jan 19; 366:225.
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MM: The time of year is not discussed here but it is entirely possible that since this study was done in the UK there could be a seasonal effect going on. Serotonin and vitamin D levels may have a significant effect on both physical and mental health. Full spectrum light bulbs and oral vitamin D3 supplementation could have a profound beneficial effect on these young people as well as people of all ages. Considering the relatively low success rate of conventional treatments in this study I think that looking at an integrative approach may be a good idea.
BMJ Open 2011 Dec 12; 1:e000252
Chronic Fatigue Syndrome/Myalgic Encephalomyelitis Can Cause Frequent School Absence
Nearly 1% of students at three U.K. schools missed ≥20% of school and were diagnosed with CFS/ME.
According to the U.K. National Institute for Health and Clinical Excellence (NICE) guidelines, chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) in children can be characterized by disabling fatigue lasting 3 months or longer with one additional symptom, where no other cause for fatigue can be established. To examine whether school-based clinics can help identify students with CFS/ME, researchers reviewed attendance records of 2855 students aged 11 to 16 years at three secondary public schools in the U.K.
Five percent (146 students) had missed at least 20% of school during a 6-week term without an identifiable reason (illness, vacation, or truancy); 112 students were evaluated at the school clinic for potential medical causes for the absence, including CFS/ME. Nearly half (48) of these children described significant fatigue, and 2 were discovered to have a previous diagnosis of CFS/ME. Of the 42 children who were evaluated further by a CFS/ME specialist, 23 fulfilled NICE criteria for CFS/ME. The remainder had fatigue secondary to mood disorders or other medical problems leading to chronic fatigue. Symptoms of CFS/ME in the 23 students were milder than symptoms in a comparison group referred to the CFS/ME clinic. Nineteen students attended follow-up appointments for advice about sleep and activity management; some received cognitive-behavioral therapy or graded exercise therapy. After 6 months, 12 of the 19 children were able to attend school full-time, 1 child had somewhat improved attendance, and 6 continued to have school absences.
Comment: In this study, nearly 1% of students missed at least 20% of school because of CFS/ME. CFS/ME is challenging to diagnose and appears to be largely unrecognized. The good news is that many students in this study seemed to respond to treatment. This diagnosis should be considered along with other chronic medical conditions and mood disorders in teenagers with frequent school absence. As with other diagnostic challenges, a thorough review of organ systems, psychosocial assessment, physical examination, and judicious lab testing are critical first steps.
F. Bruder Stapleton, MD Published in Journal Watch Pediatrics and Adolescent Medicine January 25, 2012
Citation(s):Crawley EM et al. Unidentified chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) is a major cause of school absence: Surveillance outcomes from school-based clinics. BMJ Open 2011 Dec 12; 1:e000252.
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MM: All I can think of is “baby steps”. 32% of our children being overweight or obese is simply too high! This bodes poorly for our future. It is readily accepted that as we age it becomes more, not less difficult to maintain a bountiful activity level , weight and health maintenance. Those reported in this study, and our entire population, must take a pro-active stance to increasing physical activity, instructing better food choices and eliminating products that are detrimental from our cabinets. I’m not proposing a “big brother” legal approach but I am saying that education and emphasis are paramount if we are to survive as a culture and this has to start at home.
JAMA 2012 Jan 17
Overall Prevalence of Childhood Obesity Is Stable
But prevalence might be increasing in boys.
Researchers analyzed National Health and Nutrition Examination Survey data from 1999 to 2010 to identify trends in childhood obesity.
Among infants and toddlers, prevalence of obesity (weight-for-length ≥95th percentile on the CDC's 2000 growth charts) was 9.7% in 2009 to 2010 and had not increased significantly since 1999. The highest prevalence was among Mexican American infants and toddlers (15.7%).
Among children aged 2 to 19 years, 17% were obese (body-mass index [BMI] ≥95th percentile for age and sex) in 2009 to 2010, and 32% were obese or overweight (BMI ≥85% for age and sex). Although prevalence of obesity in children increased from 1999 to 2007, prevalence has not changed significantly since 2007. However, boys had a significantly higher prevalence of obesity than girls, but the difference remained significant only among non-Hispanic white boys compared with non-Hispanic white girls. In 2009 to 2010, obesity was most common in non-Hispanic black children (24.3%) and Hispanic children (21.2%).
During the 12-year period, odds for being obese were significantly higher for non-Hispanic black boys and girls (odds ratios, 1.27 and 1.99) and Mexican American boys and girls (ORs, 1.81 and 1.47) than for non-Hispanic white children. Trend analysis of obesity prevalence since 1999 showed significant increases among boys aged 2 to 19 years (but not girls); analysis by race showed a significant increasing trend only in non-Hispanic black boys. Mean BMI increased significantly in boys aged 12 to 19 years.
Comment: Childhood obesity continues to be a major problem, but at least the overall prevalence did not increase in 2010. Efforts to promote healthy diets and physical activity must continue as we learn more about interventions that might reduce obesity rates.
— F. Bruder Stapleton, MD Published in Journal Watch Pediatrics and Adolescent Medicine January 25, 2012
Citation(s): Ogden CL et al. Prevalence of obesity and trends in body mass index among US children and adolescents, 1999–2010. JAMA 2012 Jan 17; [e-pub ahead of print]. (http://dx.doi.org/10.1001/jama.2012.40)
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MM: Once again we see that lifestyle change, which is the most difficult of approaches because it involves longitudinal commitment and definitive action and participation by the patient is a most cost effectiveand clinically approach to health improvement.
J Clin Endocrinol Metab 2011 Nov; 96:3533
Lifestyle Intervention Can Be Effective in Obese Adolescents with Polycystic Ovarian Syndrome
Obese girls with PCOS who lost weight also reduced cardiovascular risk.
Weight loss in adult women with polycystic ovarian syndrome (PCOS) is associated with normalization of menstrual function and decreases in androgen levels. PCOS typically presents in adolescence, but little is known about the effect of interventions in adolescent girls with PCOS. German investigators evaluated the effects of a 1-year lifestyle intervention (physical activity, nutrition education, and individual and group behavior therapy for girls and their families) on a range of physiologic abnormalities associated with PCOS.
Of 127 obese girls who presented with PCOS, 59 (mean age, 15 years; mean body-mass index [BMI], 33.2 kg/m2) completed the 1-year intervention; 26 girls had successful weight loss (BMI standard deviation reduction >0.2), and 33 girls had increases in BMI or reductions ≤0.2. The weight-loss group had significant reductions from baseline in mean waist circumference; 2-hour glucose values during oral glucose tolerance tests; systolic and diastolic blood pressures; carotid intima–media thickness; and levels of triglycerides, insulin, luteinizing hormone, and testosterone (total and free). Mean high-density lipoprotein cholesterol and sex hormone–binding globulin levels also significantly increased. Low-density lipoprotein cholesterol and fasting glucose levels did not change. At 1 year, 61% of girls in the weight-loss group had normal menstrual function.
Comment: This study demonstrates that adolescent girls with PCOS who were able to successfully complete a year-long intervention and lose weight experienced significant improvements in menstrual function, hormonal parameters, and cardiovascular risk profiles. However, questions remain about how to provide access to and payment for such programs and how to identify adolescents who are most likely to successfully complete the intervention.
Alain Joffe, MD, MPH, FAAP Published in Journal Watch Pediatrics and Adolescent Medicine January 25, 2012
Citation(s): Lass N et al. Effect of lifestyle intervention on features of polycystic ovarian syndrome, metabolic syndrome, and intima-media thickness in obese adolescent girls. J Clin Endocrinol Metab 2011 Nov; 96:3533.
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MM: We have noted many times that treatment and potential reversal of GI problems must be preceeded by re-introduction of probiotics and other “friendly” micro-organisms. The opinion that the appendix is nothing more than a vestigial organ has passed its time. This is a storage house for friendly bacteria that helps to modulate inflammation, the immune system and countless other functions. As more study is performed it will undoubtedly show that this apparently “inactive” organ performs a variety of complementary and necessary tasks.
Clin Gastroenterol Hepatol 2011 Dec; 9:1072.
Leave My Appendix, Please
Appendectomy might be a risk factor for recurrence of Clostridium difficile infection.
Incidental appendectomies are often performed during abdominal and gynecologic surgeries, with about 1000 of these procedures needed to prevent 13 cases of appendicitis. Appendectomy might reduce the risk for ulcerative colitis (UC) and, in patients who develop UC, result in a more benign clinical course of disease. However, a new study suggests that it might be a risk factor for recurrence of Clostridium difficile infection.
Researchers identified 396 patients with C. difficile infection, of whom 244 had undergone abdominal computed tomography (CT) scans, allowing both historical and radiologic determination of appendectomy. An additional 10 patients without CT had two separate histories, enabling confident determination of prior appendectomy. Of these 254 patients with known appendix status, 194 had a first episode of C. difficile infection, and 60 had recurrent infection.
Numerous potential risk factors for C. difficile recurrence were examined, including age, sex, history of diabetes, history of bowel cancer, history of bowel surgery, appendectomy, ongoing antibiotic use during or after treatment of C. difficile infection, recent proton-pump inhibitor use, recent steroid use, recent chemotherapy, and the Charlson index score of comorbidities. In multivariate analysis, appendectomy was independently associated with an increased risk for recurrent C. difficile infection (P<0.001), as was age >60 (P=0.03). The recurrence rate was 18% in patients with an appendix versus 45% in those without.
Comment: These data represent a small victory for the appendix, which is sorely needed. If this effect is verified in prospective studies, particularly given the increasing incidence of C. difficile infection, the risk/benefit equation for incidental appendectomy might need to be recalculated, and prior appendectomy could become a recognized risk factor for recurrence of C. difficile infection.
Douglas K. Rex, MD Published in Journal Watch Gastroenterology January 27, 2012
Citation(s): Im GY et al. The appendix may protect against Clostridium difficile recurrence. Clin Gastroenterol Hepatol 2011 Dec; 9:1072.
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MM: Not too long ago it was reported that there was a possible “cure” for HIV. Now we see the other perspective, that HIV virulence is becoming greater. I think that we must learn from the past and realize that micro-organisms are extremely adaptive and that it only takes a small number of virulent organisms to overwhelm an environment when other, weaker organisms have been eradicated thereby eliminating “competive inhibition”. This story is not over by any means.
AIDS 2012 Jan 14; 26:193
Is HIV Becoming More Virulent?
A meta-analysis suggests that over the course of the epidemic, the mean virologic set point of HIV-infected patients has been increasing and the mean baseline CD4-cell count has been decreasing.
Any change in HIV virulence over time could have important implications for transmissibility, disease progression, and timing of treatment initiation. However, studies attempting to assess changes in virulence have yielded discrepant results. To address this issue, investigators conducted a meta-analysis, looking at trends in baseline CD4-cell count and virologic set point over time. Twelve studies, spanning 1984 to 2010 and involving more than 20,000 individuals, were included in the analysis.
Baseline CD4-cell counts appeared to decrease over time (by roughly 5 cells/mm3/year), whereas virologic set points appeared to increase (by 0.013 log copies/mL/year). When the investigators limited their analysis to the nine studies in which all patients had known dates of seroconversion, both trends were statistically significant.
Comment: Although these results are not definitive, they are compatible with increasing HIV virulence over time. If such an increase is indeed occurring, it could result in higher transmission rates, faster disease progression, and a greater urgency for early antiretroviral therapy (ART). Notably, studies of HIV virulence are becoming increasingly difficult to conduct, as the natural course of infection is progressively affected by earlier treatment initiation, resulting in fewer patients reaching clinical endpoints. The use of baseline CD4-cell counts and virologic set points as surrogate markers therefore seems reasonable, although the definitions for these variables (in particular, the timing of measurement) varied across the studies in a way that could have affected the results. Furthermore, although these variables were chosen to minimize the effects of treatment, ART clearly influences not only individual outcomes but also transmissibility, which may have an effect on study outcomes independent of changes in virulence. Last but not least, the 12 studies included in the meta-analysis were only a selected subset of the 32 studies identified, making it difficult to generalize the results.
Helmut Albrecht, MD Published in Journal Watch HIV/AIDS Clinical Care January 13, 2012
Citation(s): Herbeck JT et al. Is the virulence of HIV changing? A meta-analysis of trends in prognostic markers of HIV disease progression and transmission. AIDS 2012 Jan 14; 26:193.
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MM: I agree that users of a “service” should pay that that use but with so much money going to the FDA by those who are supposed to be watched I get a bit nervous. Who will be watching the watchdogs?
Millions of Dollars in New Drug Fees to Go to the FDA
Under an agreement between the FDA and industry, the FDA would collect hundreds of millions of dollars in new fees from pharmaceutical companies to help speed up the review of generic drugs.
The user-fee proposal is being submitted to Congress for approval by lawmakers. The agreements would each charge drug manufacturers application fees for traditional drugs, generic drugs, and generic biotech drugs. The FDA plans on collecting $299 million in fees annually to hire additional generic drug reviewers starting in fiscal year 2013.
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FDA Fines the American Red Cross $9.6 Million
The American Red Cross, the biggest U.S. supplier of donated blood, was fined $9.59 million by the FDA after they found that 16 of its facilities failed to comply with blood-safety rules. The FDA inspectors found "significant violations" from April 2010 to October 2010, including inadequate "managerial control," record-keeping, and quality assurance.
The FDA found no evidence that the lapses led to serious health consequences for blood recipients. The fines result from an inspection conducted 15 months ago at the organization's Donor & Client Support Center in Philadelphia. Red Cross officials state that "We are disappointed that the FDA believed it necessary to issue a fine for an inspection conducted so long ago, and it is important to know we have already taken corrective steps to address those matters and that improvements in operations have been made."
[Editor's note: This appears to mean that the FDA is now supported by our (1) taxes, (2) by user fees from the pharmaceutical industry, and (3) by our donations to charities.]
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Oral HPV Infection Found in 7% of Americans
The prevalence of oral human papillomavirus infection was 7% in the U.S. in 2009–2010, according to an analysis of NHANES data published in JAMA.
The analysis included more than 5500 individuals, aged 14 to 69, who underwent in-home interviews and provided oral rinse samples for HPV testing. Among the other findings:

The authors say their findings "provide evidence that oral HPV infection is predominantly sexually transmitted," and an editorialist advises physicians to "encourage their patients who engage in oral sex to use barrier protection."
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JAMA 2012 Jan 11; 307:173 2011 Aug 8/22; 171:1363
No Decline in Pulmonary Function with Marijuana Use
But the effects of heavy use still are unclear.
The known associations between tobacco use and respiratory symptoms, chronic obstructive pulmonary disease, and lung cancer have been assumed to apply to smoking marijuana as well, but prior studies have shown only mucosal damage with no effect on actual pulmonary function. This secondary analysis of a multisite, prospective cohort study of coronary artery disease risk factors provided multiple assessments of tobacco and marijuana smoking and pulmonary function during 20 years in >5000 adults.
In adjusted analyses, there was a clear decrement in forced vital capacity (FVC) and forced expiratory volume at 1 second (FEV1) with current and lifetime exposure to tobacco smoking, but no such decrement with exposure to marijuana smoking. In fact, significant increases were noted in FVC and FEV1 with lifetime use of marijuana at low levels (10–20 joint-years, meaning 1 joint daily for 10–20 years). A nonsignificant decline in FEV1 occurred at high exposures (>40 joint-years), whereas FVC remained elevated at high exposures.
Comment: Occasional marijuana use appears not to be associated with impaired pulmonary function. The trend toward an association between decreased function and heavier use might have been significant with a larger number of heavy users. The finding that low-level use appears to be safe is not necessarily surprising, because marijuana use is measured in joints per day and cigarette smoking in packs per day.
Thomas L. Schwenk, MD Published in Journal Watch General Medicine January 26, 2012
Citation(s): Pletcher MJ et al. Association between marijuana exposure and pulmonary function over 20 years. JAMA 2012 Jan 11; 307:173.
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MM: Anyone who has ever had a gout attack will tell you that it is a miserable experience. Unfortunately the conventional treatments for this acute condition are expensive and cause a tremendous amiount of GI upset. As more of our population is diagnosed with hypertension and other metabolic syndrome issues, there will undoubtedly be more prescribing of diuretics and more incidence of gout.
At Mark Drugs we have found All Flex ProTM to be extremely effective for the acute treatment of a gout attack. Two capsules every hour till the attack subsides seems to work. We have experienced no GI upset or other clinical side effects with this approach. Please call us or go to our website, www.MarkDrugs.com for more information.

Arthritis Rheum 2012 Jan; 64:121
Gout and Diuretics in Hypertensive Patients
Diuretic use raised risk for gout by several percentage points.
Observational data have suggested that gout is associated independently with both hypertension and diuretic use. In a prospective study, researchers determined incidence of diuretic-associated gout in nearly 6000 hypertensive patients with no histories of gout at baseline.
During 9 years of follow-up, 37% of patients received diuretics. Incidence of gout was 5.5% among diuretic users (5.0% among thiazide users and 7.0% among loop-diuretic users) and 2.9% among patients who did not use diuretics. After adjustment for potentially confounding variables (except serum uric acid), use of thiazides and loop diuretics were both significantly associated with incident gout (hazard ratios, 1.4 and 2.3, respectively). Compared with serum uric acid levels in nonusers of diuretics, levels rose by a mean of 0.65 mg/dL among those who began taking thiazides and 0.96 mg/dL among those who began taking loop diuretics. The association between diuretics and gout was no longer significant after additional adjustment for serum uric acid; this finding is consistent with the assumption that diuretic-induced increases in serum uric acid mediate the association between diuretic use and gout.
Comment: According to these results, diuretic use raises risk for gout by several percentage points in hypertensive patients. Increased risk for gout is among the potential adverse effects of thiazides that clinicians should consider when choosing first-line antihypertensive drugs.
— Allan S. Brett, MD Published in Journal Watch General Medicine January 26, 2012
Citation(s): McAdams DeMarco MA et al. Diuretic use, increased serum urate levels, and risk of incident gout in a population-based study of adults with hypertension: The Atherosclerosis Risk in Communities cohort study. Arthritis Rheum 2012 Jan; 64:121.
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MM: Exercise during pregnancy may not prevent GD but moderate exercise should be recommended for a variety of reasons including general muscle tone and potentially decreased lower back pain during pregnancy. This does not mean go out and run 5 miles a day or become a gym rat but a regular lifelong program of movement should be encouraged. Many people benefit by making exercise into a social experience. This may prove additionally beneficial for “mental health” as well as physically. I enjoy a good run and workout but I love walking with my wife and daughters even more. Both activities provide benefits. Seek out that which you find the most enjoyable and your compliance should improve.
Obstet Gynecol 2012 Jan; 119:29
Can Exercise Prevent Gestational Diabetes?
Trial results do not provide a clear answer.
Regular exercise helps prevent type 2 diabetes, but whether similar benefits apply to physical activity and gestational diabetes (GD) is not definitively known. To assess whether exercise during pregnancy can lower risk for insulin resistance and GD, Norwegian investigators randomized 855 pregnant women to a 12-week structured exercise program (weekly supervised sessions with encouragement to follow a home exercise program twice weekly) or to standard prenatal care. Women in the control group were not discouraged from exercising independently. Adherence was defined as exercising at least 3 days per week at moderate to high intensity. All participants underwent oral glucose tolerance testing at study entry (18–22 weeks' gestation) and completion (32–36 weeks' gestation).
Incidence of GD was similar in the exercise and control groups (7% and 6%, respectively). Levels of insulin resistance also showed no difference between groups, regardless of adjustment for factors such as baseline fasting insulin levels. Of note, only 55% of women in the exercise group met the definition of adherence; 10% of women in the control group exercised at least 3 days per week. An exploratory analysis in which adherent women in the exercise group were compared with women in the control group showed no difference in incidence of GD (7% and 6%), but fasting insulin was lower in the adherent women.
Comment: These results might not be generally applicable given that 100% of the study participants were white and only 10% had body mass indexes above 27. Also, the apparent lack of benefit from exercise is questionable, given that almost half of the women in the exercise group did not adhere to the protocol (whereas 10% of the control group exercised regularly). Given that the trial was not powered to compare adherent and nonadherent women, results of the exploratory analysis should be interpreted with caution. The authors point out the need for research on exercise in pregnant women with risk factors for gestational diabetes (e.g., obesity); however, a pressing priority is effective promotion of physical activity in such women.
Diane J. Angelini, EdD, CNM, FACNM, FAAN, NEA-BC Published in Journal Watch Women's Health January 26, 2012
Citation(s):Stafne SN et al. Regular exercise during pregnancy to prevent gestational diabetes: A randomized controlled trial. Obstet Gynecol 2012 Jan; 119:29.
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MMWR Morb Mortal Wkly Rep 2012 Jan 6; 60:1729
Influenza in Neurologically Compromised Patients
An outbreak of influenza in patients with incapacitating neurological conditions caused severe infection, despite immunization.
Children with neurological and neurodevelopmental conditions are known to be at increased risk for severe — sometimes lethal — influenza virus infection. In February 2011, an influenza outbreak occurred in an Ohio residential facility that houses such patients. Among 130 residents, 76 developed acute respiratory signs and symptoms; 13 (all of whom had been immunized several months earlier) developed severe influenza-related illness.
Of the 13 severely ill residents, 10 required hospitalization, and 7 died. Median age was 22 (range, 14–33), similar to that of the other facility residents. Samples from nine of these individuals were tested; six samples were positive for influenza A virus by rapid influenza diagnostic test, and one was positive for 2009 influenza A (H1N1) virus by reverse-transcriptase polymerase chain reaction. Eight of the severely ill residents received oseltamivir, but only four of them did so ≤48 hours after illness onset.
Comment: Diagnosis in these patients was difficult and, in some cases, delayed, resulting in suboptimal timing of antiviral therapy with a neuraminidase inhibitor. In addition, vaccine protection was less than expected, perhaps because of an unacceptably low temperature in the storage refrigerator. (The optimal storage temperature is 35° to 46°F.) Vaccination of severely neurocompromised patients should be accompanied by vaccination of healthcare workers and any other individuals who might transmit influenza in the environment. During an outbreak, the index of suspicion should be high, and antiviral therapy should be started early to minimize morbidity and mortality.
Stephen G. Baum, MD
Published in Journal Watch Infectious Diseases January 25, 2012
Citation(s):Centers for Disease Control and Prevention (CDC). Severe influenza among children and young adults with neurologic and neurodevelopmental conditions — Ohio, 2011. MMWR Morb Mortal Wkly Rep 2012 Jan 6; 60:1729.
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J Sex Med 2011 Oct 24
Erectile Dysfunction Appears to Be More Prevalent in Psoriatic Patients
Dermatologists should ask male patients with psoriasis about ED and make appropriate referrals.
Erectile dysfunction (ED) became easier to discuss with the development of sildenafil and an accompanying marketing campaign that included then-Senator Bob Dole. Now, most internists discuss ED with their male patients. In a relatively small study published last year, questionnaires completed by patients with psoriasis suggested that the disease was not an independent risk factor for ED. The authors noted that increasing age and hypertension were risk factors for ED and concluded that dermatologists should screen for ED (Br J Dermatol 2011; 164:103) in these patients.
Now, using a population-based dataset, researchers from Taiwan analyzed more than 4000 patients with ED and compared them 1:3 with non-ED controls. Of the 18,424 participants, 77 (1.7%) of the ED patients and 59 (0.4%) of the controls had an antecedent diagnosis of psoriasis. The risk for having a prior psoriasis diagnosis in patients with ED (odds ratio, 3.85) remained after adjusting for monthly income, geographic location, hypertension, diabetes, hyperlipidemia, coronary heart disease, obesity, and alcohol abuse/alcohol dependence syndrome status.
Comment: I have not asked patients with psoriasis about erectile dysfunction, and I doubt that many other dermatologists have done so. However, ED has negative effects on quality of life, and asking questions and referring patients for care of ED is easy. Therefore, I will likely begin to include inquiries about this problem in the patient history, with appropriate referrals for further evaluation and care.
Jeffrey P. Callen, MD Published in Journal Watch Dermatology January 27, 2012
Citation(s): Chung S-D et al. Psoriasis and the risk of erectile dysfunction: A population-based case-control study. J Sex Med 2011 Oct 24. [e-pub ahead of print]
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