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Content 7


The Doctor and the Pharmacist

Radio Show Articles:
October 4, 2014

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Ebola Update: Contacts of Texas Patient So far Test Negative, Children Possible Exposed
First Ebola Case Diagnosed in U.S. - Man Traveled from Liberia to Texas
Child Dies from Enterovirus D68 Complications: Neurologic Symptoms Increasingly Reported
One Consultant's Regimen for Refractory Clostridium difficile Infection
Surgical Ligation, Laser Ablation, or Foam Sclerotherapy for Varicose Veins?
Possible Breakthrough in Treating Patients with Alopecia Areata
7-Fiber Supplementation for Irritable Bowel Syndrome: A Meta-Analysis

MM: Government officials are reassuring us that the US health system is advanced and will protect us. To me these are somewhat empty promises. Ebola manifests as flu-like symptoms and typically takes about a week to manifest itself following exposure but may take as little at 3 days and as long as 21 days to show up. The good news is that it is not supposed to be transmissible until symptoms appear. The bad news is that it seems to have a mortality rate of about 50%. The virus is transmitted via bodily fluids but appears to not be transmitted by coughing or sneezing. The bottom line is that we have to be personally vigilant and must watch for signs or symptoms that seem like flu but tend to linger or get worse. Hopefully our worries are unfounded but this is likely an instance where the ounce of prevention is worth much more than the pound of cure.
Ebola Update: Contacts of Texas Patient So far Test Negative, Children Possible Exposed
By Kelly Young, Edited by Susan Sadoughi, MD, and Richard Saitz, MD, MPH, FACP, FASAM
Several children have been asked to stay home after being exposed to a man who tested positive for Ebola in Texas, health officials said in a news conference on Wednesday. The patient is currently in serious but stable condition.
Five school-aged children may have had contact with the patient in the home over the weekend and then went to school earlier this week. They are currently asymptomatic and are being monitored at home. The four schools will remain open, but will have additional healthcare staff available.
The patient was initially seen in the hospital on Friday with a fever and abdominal pain but was sent home with a suspected viral infection. At the time, he was not vomiting and did not have diarrhea. He returned to the facility on Sunday and was admitted. A hospital official told reporters that a nurse asked about the patient's travel history at the initial visit, but that information was not communicated to the whole care team.
Paramedics who transported the patient have tested negative but will be monitored during the 21-day incubation period. The man was vomiting on the way to the hospital.
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MM: At this point we are probably learning more about Ebola than any of us would have imagined. The story of how it made its way to Texas has been on almost every news outlet that we tend to come across. The biggest take home from all this information is "awareness" of what it is, how it is transmitted, how it may be recognized and what to do if it is suspected that a person is infected. These bits of knowledge along with what we hope is an outstanding supportive portion of the U.S healthcare system are what should keep this potential threat in its place and away from most Americans.
First Ebola Case Diagnosed in U.S. - Man Traveled from Liberia to Texas
By Joe Elia, Edited by Susan Sadoughi, MD
A man exposed to Ebola while traveling in Africa has been hospitalized in a Dallas hospital, critically ill with confirmed Ebola Zaire, CDC officials confirmed at a press conference on Tuesday.
Symptoms developed 4 days after his flight here from Liberia. The CDC said the man was not feverish when he boarded the plane, thus presenting "zero risk of transmission on the flight." The disease is spread by direct contact — not by air — only while patients are sick and not beforehand while carrying the virus.
The case is the first ever diagnosed in the U.S., and CDC director Tom Frieden urged clinicians to take a travel history of patients presenting with fever. Travel to West Africa within the preceding 21 days should raise a red flag.
Officials said the man was visiting family members when he became infected, and that there were only a "handful" of potential exposures here — all of whom are being traced. He is under intensive care at Texas Health Presbyterian Hospital, a tertiary care facility.
In a statement, the CDC noted that in the past decade, the U.S. has had five imported cases of viral hemorrhagic fever illnesses similar to Ebola, and none resulted in local transmission.
Frieden offered reassurance at the press conference: "We're stopping this in its tracks."
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MM: Infections of any kind have the potential to be life threatening. A significant mitigating factor regarding whether this potential is realized is the starting point of a person's health. If the immune system is compromised. If their health status is already weakened, then the person appears to be at greater risk. This is not surprising. Those who are weak or frail are typically at increased risk compared to the general population. Strategies that strengthen the body and the immune system work hand in hand to prevent disease and improve likely outcomes if infection occurs. These may include exercise, Vitamin D3, Vitamin C, Probiotics and Digestive Enzymes that assist in the breakdown of our food and the extraction of the beneficial components of that food.
Child Dies from Enterovirus D68 Complications: Neurologic Symptoms Increasingly Reported
By Amy Orciari Herman, Edited by Susan Sadoughi, MD, and Richard Saitz, MD, MPH, FACP, FASAM
A 10-year-old Rhode Island child died last week from Staphylococcus aureus sepsis associated with enterovirus-D68 infection, the state's department of health confirmed on Wednesday. It's the first reported death associated with EV-D68 since the outbreak began in August.
The state department of health notes that the combination of enterovirus 68 and S. aureus is dangerous but rare. "Many of us will have EV-D68," said the department's director. "Most of us will have very mild symptoms and all but very few will recover quickly and completely."
Separately, the New York Times reported that cases of limb weakness or paralysis potentially associated with EV-D68 are increasing, with the most recent reports in Michigan, Missouri, and Massachusetts.
As of September 30, EV-D68 infection had been confirmed in 472 people across 41 states and Washington, D.C., the CDC reports.
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MM: My, how the world has changed in only 10 years! I recall when I invited Dr. Kelly Karpa to speak about probiotics at our Roselle location in 2010 and virtually no one had even heard the term except for a small portion of the alternative medicine community. She brought up the notion of complete fecal transplantation and people cringed. Now this study states that when fecal transplantation is not available then one can consider antibiotics and kefir (probiotics). Isn't it amazing how our attitudes are capable of changing when we discover something in nature that actually works better than what our industrial products can do?
Clin Infect Dis 2014 Sep 15; 59:858
One Consultant's Regimen for Refractory Clostridium difficile Infection
Good success is reported from a long antibiotic taper in conjunction with the fermented dairy drink kefir.
Stool transplantation, when available, has become the treatment of choice for patients with recalcitrant Clostridium difficile infection (CDI). However, when stool transplantation is not available, clinicians are left on their own, with no single best option among a variety of drugs administered singly or in combination with various tapering or intermittent dosing regimens. One Minnesota clinician now reports his experience treating patients with refractory CDIs by using an 8-week single-antibiotic taper, administered in combination with the fermented dairy drink kefir (a yogurt-like product available in supermarkets).
Twenty-five patients (mean age, 68) in whom two to seven courses of conventional CDI treatment had failed were treated; all had CDIs related to previous antibiotic use, and four were receiving immunosuppressants. Patients took metronidazole (4 patients) or vancomycin (21 patients) every 6 hours for 2 weeks, then every 3 days in a tapering-dose schedule for 6 weeks; they also drank 5 oz of kefir with every meal (i.e., at least thrice daily) for the duration of the antibiotic taper and for 7 weeks afterwards. During 9 months after completion of the taper, 21 patients remained symptom-free; 4 patients relapsed, were retreated with a 2-week course of vancomycin followed by a 2-week course of rifaximin, and were symptom-free 1 year later.
Comment: This anecdotal report might provide some guidance for physicians for whom the logistics of stool transplantation are insurmountable. The success rate is pretty good, and the idea of using a probiotic to repopulate the gut both during and after pulsed antibiotics makes sense.
Citation(s): Bakken JS.Staggered and tapered antibiotic withdrawal with administration of kefir for recurrent Clostridium difficile infection. Clin Infect Dis 2014 Sep 15; 59:858. (http://dx.doi.org/10.1093/cid/ciu429)

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MM: Being in the Durable Medical Equipment and Compression Hosiery business means that people ask us all the time about different approaches to resolving varicose and spider veins. Most of our patients seen to prefer laser treatments over other approaches both preceded and followed by the wearing of graduated compression hosiery. This seems to speed the healing process and also makes the legs much less tired for those who must spend a lot of time on their feet.
N Engl J Med 2014 Sep 25; 371:1218
Surgical Ligation, Laser Ablation, or Foam Sclerotherapy for Varicose Veins?
In a randomized trial, the balance of benefits and complications tended to favor laser.
Several options are available for treating patients with varicose veins. In this trial, researchers in the U.K. randomized 798 patients with primary symptomatic varicose veins to laser ablation, foam sclerotherapy, or surgical ligation and stripping. (In foam sclerotherapy, a foam sclerosing agent is injected under ultrasound guidance; in laser ablation, the vein is cannulated with a laser-tipped catheter). The great saphenous vein was involved in most cases.
At 6 months, disease-specific quality-of-life scores (according to questionnaire-based assessment of pain, swelling, skin changes, cosmetic concerns, and interference with activity) improved slightly more with surgery and laser than with foam, but only the surgery-versus-foam comparison reached statistical significance. General quality-of-life scores improved to a similar extent in all three groups. Completely successful ablation of the great saphenous vein occurred more often in those treated with laser (82%) and surgery (78%) than in those treated with foam (43%). Rates of procedural complications and of “any complication at 6 weeks” were lower in the laser group than in the other groups. Comment In this study, most differences in outcomes were not dramatic, but the balance of benefits and complications tended to favor laser ablation. Although the study has limitations (e.g., blinding was not possible, and 31% of laser patients had foam procedures for residual varicosities during follow-up), these results should help guide treatment decisions.
Citation(s): Brittenden J et al. A randomized trial comparing treatments for varicose veins. N Engl J Med 2014 Sep 25; 371:1218.

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MM: Alopecia Areata is a rare auto-immune disorder, where a patient’s immune system misidentifies his or her own hair follicles and attacks them causing the hair to fall out. It has nothing in common with genetic hair loss, although it is possible to suffer from both conditions at the same time. Alopecia Areata is a complicated condition. It is often first seen in children that can occur or even reoccur throughout one’s life. This aggressive treatment may be an answer to some and if it is effective for genetic hair loss in men or women the economic potential of this product is beyond belief, but realize that it promises to be a very expensive treatment if it reaches the point that it is readily available to the American or international public.
Nat Med 2014 Sep; 20:1043
Possible Breakthrough in Treating Patients with Alopecia Areata
An inhibitor of Janus kinases facilitated hair regrowth.
Alopecia areata is an autoimmune disease that is mediated by a particular subset of cytotoxic T cells that attack hair follicles. The most well-established treatment, intralesional steroids, is not consistently effective.
A team from Columbia University studied mice that spontaneously develop alopecia areata, with histopathology nearly identical to that of alopecia areata in humans. The team found that T cells attack hair follicles using interferon-γ (IFN-γ) pathways, which, in turn, act through Janus kinases (JAK). This biochemistry matters: Two FDA-approved small-molecule inhibitors of JAK exist, because JAK are central to the pathology of myeloproliferative diseases. In these mice, systemic administration of JAK inhibitors prevented development of alopecia areata. Topical administration of JAK inhibitors to diseased skin caused hair regrowth and reversed established disease.
The team administered one of the available JAK inhibitors — ruxolitinib (Jakafi; FDA-approved for myelofibrosis) — orally to five human patients with alopecia areata and achieved nearly complete regrowth of hair within 5 months.
Comment: The ability of FDA-approved, available JAK inhibitors to prevent and reverse alopecia areata in a mouse model and in humans is encouraging. Obviously, larger, controlled human studies will be necessary. But this report offers hope for people with alopecia areata who have not responded to conventional therapy.
Citation(s): Xing L et al. Alopecia areata is driven by cytotoxic T lymphocytes and is reversed by JAK inhibition. Nat Med 2014 Sep; 20:1043.

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MM: It seems that most patients are recommended to use a fiber supplement if they have IBS. Unfortunately the success rate is only about 14% so that means that 86% of those who hope for beneficial results from fiber fail to obtain it.None the less, this is an inexpensive and safe option so it should be considered as a first line therapy even though it has such a low success rate.
Am J Gastroenterol 2014 Sep; 109:1367
7-Fiber Supplementation for Irritable Bowel Syndrome: A Meta-Analysis
Soluble fiber improves symptoms in only a small proportion of patients, but it might be worth a try.
Consensus on whether fiber supplementation improves symptoms of irritable bowel syndrome (IBS) has wavered over the years. This new meta-analysis, which includes 14 randomized trials and 906 patients, addresses the question once again. In half the studies, patients used bran and, in the other half, they used psyllium (soluble fiber).
The primary outcome was global assessment of IBS symptoms. Psyllium was associated with statistically significant improvement in symptoms (and no evident harms), but seven patients had to be treated to benefit one patient. For bran, a modest benefit did not reach statistical significance. The most recent large trial (BMJ 2009; 339:b3154) — a 275-patient, 12-week comparison between bran, psyllium, and placebo — was considered to be the least biased study and yielded results similar to those of the meta-analysis overall.
Comment: Although the authors of this analysis conclude that “soluble fiber is effective in treating IBS,” the number needed to treat of 7 suggests that only a minority of patients will benefit substantially. Nevertheless, fiber supplementation is relatively inexpensive and safe, and thus is worth a try in most cases.
Citation(s): Moayyedi P et al. The effect of fiber supplementation on irritable bowel syndrome: A systematic review and meta-analysis. Am J Gastroenterol 2014 Sep; 109:1367. (http://dx.doi.org/10.1038/ajg.2014.195)

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