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Content 7


The Doctor and the Pharmacist

Radio Show Articles:
December 20, 2014

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Prescribe Family Dinners for Cyberbullying
Explaining the Unexplained Growth in Autism Prevalence
Predicting Late Recurrence of Breast Cancer
High Adherence to Mediterranean Diet Linked to Marker of Healthy Aging
CDC Releases First Guidelines on Circumcision
Patterns of Parent-Infant Communication Differ by Gender
Maternal Overweight, Obesity Linked to Infant Mortality
Home-Based Intervention Improves Asthma Control in Adult Asthma Patients
Progesterone of No Clinical Benefit in Traumatic Brain Injury

MM: Parental and family connections are supportive. Having order and limits provide a sense of ease to most people. It only makes sense that re-instituting traditional family values and activities such as regular family dinners would decrease the need to dominate others and to bully them. Although our busy schedules make these activities challenging, we should try to implement as many of these activities as possible. I would add to this list, regular weekend family activities, game nights and other interactive events.All of these should help with self-confidence and provide tools for interacting on multiple levels.
JAMA Pediatr 2014 Nov; 168:1015
Prescribe Family Dinners for Cyberbullying
Among the nearly 20% of surveyed teens who experienced cyberbullying, family dinners were helpful in protecting them from its harmful effects.
Cyberbullying is known to adversely affect teen health. To assess its effects on mental health and substance use, researchers conducted a survey of Midwestern teens. The number and regularity of family dinners was used as a proxy for family interaction and support.
Results were as follows:

Comment: Cyberbullying is frequent and associated with numerous mental health and substance abuse problems in adolescents. The new finding from this study is the positive impact that family dinners (a surrogate for family communications) had on reducing the negative impact of cyberbullying. We should prescribe family dinners for many reasons.
Citation(s): Elgar FJ et al. Cyberbullying victimization and mental health in adolescents and the moderating role of family dinners. JAMA Pediatr 2014 Nov; 168:1015. (http://dx.doi.org/10.1001/jamapediatrics.2014.1223)

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MM: Autism growth has expanded beyond any reasonable growth rate. It's true that expanded qualifying criteria will increase the prevalence of a condition in the community but the prevalence of Autism has increased at all levels. I feel that we must examine non-traditional potential causes as well as those that we already recognize and re-assess the things that we simply assume are safe or damaging. We need to determine if we are on the correct path or one of those paths. This is true not just for ASD, but for other chronic and increasing diseases that are not adequately explained.
JAMA Pediatr 2014 Nov 3
Explaining the Unexplained Growth in Autism Prevalence
Autism prevalence is altered in part by changes in diagnostic criteria, inclusion of outpatients, and sex differences
Rates of autism spectrum disorder (ASD) have been increasing for reasons that are not fully understood. To examine this increase, investigators used data from the Danish Psychiatric Registry.
This registry is considered highly reliable because only child psychiatry specialists can diagnose ASD in Denmark. Also, the investigators were able to examine the effects of two changes in the registry: the change from the 8th edition to the 10th edition of the International Classification of Diseases in 1994 and the addition of outpatient diagnoses in 1995. Participants included birth cohorts between 1980 and 1991 (N=677,915); follow-up continued through December 2011 (3956 participants with ASD diagnoses).
To estimate prevalence changes, the researchers compared rates before and after the two changes to the registry and compared actual rates with those expected from prior trajectories. Overall, 60% of the increase in ASD rates was due to changes in diagnostic criteria or to the inclusion of outpatients, but in subanalyses, the effects due to changes in diagnostic schema were greater in boys.
Comment: These data solve part of the as-yet-unknown reasons for the increasing ASD rates. Still, 40% of rate increases remain unexplained, indicating the continued need for pregnant women to avoid environmental risk factors (e.g., pesticides, maternal smoking, phthalates). Milder male pathology may account for the increased prevalence, as suggested by the increase due to diagnostic schema occurring only in boys, along with the increases due to outpatient diagnoses. This concept is bolstered by the CDC's finding of higher prevalence in boys with milder severity (Natl Health Stat Report 2013 Mar 20; 65:1). Furthermore, in a genotyping study, risk polymorphisms differed between males with mild symptoms and higher IQs and girls or boys with lower IQs and greater severity (Nature 2014 Nov 13; 515:216).
Citation(s): Hansen SN et al. Explaining the increase in the prevalence of autism spectrum disorders: The proportion attributable to changes in reporting practices. JAMA Pediatr 2014 Nov 3; [e-pub ahead of print].
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MM: I like the idea of establishing better predictive models of Breast Cancer Recurrence as this allows us to limit treatments to those who are at greatest risk and not expose women to unnecessary treatments that are costly both economically on their Quality of Life (QOL). This approach should be expanded to other forms of cancer as well for both men and women.
J Clin Oncol 2014 Oct 20
Predicting Late Recurrence of Breast Cancer
Gene signatures with or without clinical data may help identify at-risk patients.
Late recurrence in breast cancer is more frequently a manifestation of endocrine–sensitive breast cancer compared with other breast cancers and may reflect tumor-cell dormancy. Equally important is the recent clinical finding that longer durations of endocrine therapy, particularly tamoxifen, may be appropriate for patients with hormone-sensitive, early-stage disease. All systemic therapy, including endocrine therapy, is associated with the potential for some adverse effects as well as a recognition that compliance declines with longer durations of therapy. Therefore, an ability to identify patients at risk for late recurrences would be valuable.
Now, investigators report on the use of the PAM50 risk of recurrence (ROR) score and the Clinical Treatment Score (CTS) to determine the risk for late distant disease recurrence among patients in the ABCSG8 trial (Ann Oncol 2014; 25:339) and the ATAC trial (J Clin Oncol 2013; 31:2783), both of which involved use of endocrine therapy for postmenopausal women with hormone-receptor–positive breast cancer. A total of 2137 women who did not have recurrence 5 years after diagnosis were included in the combined analyses. The ROR score was calculated using a 46-gene subset of the PAM50 genes plus tumor size. Risk stratification was based on the predicted distant recurrence risk at 10 years: (ROR score 0–26 = low-risk [<10%], ROR score 26–68 = intermediate risk [10%–20%], and ROR score >68 = high risk [>20%]).The CTS was developed using information on nodal status, tumor size, grade, age, and treatment.
The CTS was the strongest prognostic factor 5 years after diagnosis. The ROR score was significantly prognostic by itself in years 5 to 10. In HER2-negative, node-negative patients, more prognostic information for late distant recurrence was identified using the ROR score than the CTS.
Comment: Gene signatures with or without clinical data may help identify patients at risk for late recurrences, and by extension those with estrogen-receptor–positive breast cancer who are most likely to benefit from extended endocrine therapy. Prospective data will be required to validate the utility of these assays.
Citation(s): Sestak I et al. Prediction of late distant recurrence after 5 years of endocrine treatment: A combined analysis of patients from the Austrian Breast and Colorectal Cancer Study Group 8 and Arimidex, tamoxifen alone or in combination randomized trials using the PAM50 risk of recurrence score. J Clin Oncol 2014 Oct 20; [e-pub ahead of print].
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MM: More conscientious living and eating should lead to a longer and better life and improved Quality of Life. This is a pretty simple premise but many of us are so addicted to certain aspects of our lifestyles that it is difficult, in fact almost impossible to modify them. The fear of death that is far away is simply not enough to make most people alter their lifestyles. A nearer, more imminent result is a much better incentive. This is one of the reasons that the HCG weight loss and metabolic syndrome protocol seems to be so effective. Patients see an immediate change in their weight, their appearance and many times, their need for medication for other conditions such as arthritis, hypertension and diabetes. This combination of short and long term benefits is likely the best way to establish overall lifestyle modification.
High Adherence to Mediterranean Diet Linked to Marker of Healthy Aging
By Larry Husten, Edited by David G. Fairchild, MD, MPH, and Lorenzo Di Francesco, MD, FACP, FHM
Women who closely follow a Mediterranean diet have longer telomeres, a key measure of healthy aging, a BMJ study finds.
The study included some 4700 Nurses' Health Study participants who completed food-frequency questionnaires and who also had their telomere length measured. Women who adhered closely to a Mediterranean diet (emphasizing vegetables, fruits, nuts, whole grains, legumes, fish, and monounsaturated fats, plus moderate alcohol intake) had longer telomeres after adjustment for characteristics likely to influence telomere length, including age, body mass index, smoking history, and exercise.
The authors calculated that the difference in telomere length among women who were more adherent to the Mediterranean diet could translate into an average gain of about 4.5 years of life, roughly comparable to the difference between nonsmokers and smokers or being highly active and less active. "Our results," they conclude, "further support the benefits of adherence to the Mediterranean diet for promoting health and longevity."
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MM: I'm not a big fan of adult circumcision but its lifelong benefits are difficult to deny for a male infant.
CDC Releases First Guidelines on Circumcision
By Kelly Young, Edited by David G. Fairchild, MD, MPH, and Lorenzo Di Francesco, MD, FACP, FHM
Uncircumcised adolescent and adult males who have sex with women should be counseled about circumcision following an assessment of their HIV risk, according to new circumcision guidelines from the CDC.
These males should be told of the potential benefits and harms: Adult male circumcision has been shown to reduce the risk for HIV infection acquired through heterosexual sex by 50% to 60%, based on data from sub-Saharan Africa. In addition, the risk for genital herpes and some strains of human papillomavirus are reduced by roughly 30%. Rates of adverse events (e.g., pain, bleeding) range from 2% to 4%.
The CDC notes that no definitive data exist on whether circumcision reduces the risk for HIV and other sexually transmitted infections for men who only have sex with men.
Circumcision is not explicitly recommended for newborns. Parents should be told of the potential benefits and risks: Circumcised infants are less likely to experience urinary tract infections, a relatively uncommon event. In childhood, balanitis and balanoposthitis are less common in circumcised boys. Complication rates are roughly 0.5% in infants and increase as the child gets older


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MM: It certainly makes sense that the greater the exposure to and repetition of a particular stimulus is likely to make the greatest impact on a young mind and I have no doubt that women provide the majority of child care in most societies but as a father I have seen my children and granddaughter respond immediately and joyfully as soon as they hear their father's voice. I think the most important part of this article is the recommendation to, "narrate your life" to your child irrespective of whether you are a man or a woman.
Pediatrics 2014 Dec 1; 134:e1603
Patterns of Parent-Infant Communication Differ by Gender
Mothers initiated communication more frequently and elicited more responses from infants compared with fathers.
Vocal communication between infants and parents is the foundation for developing language skills, which begins shortly after birth. New digital technology was used to define patterns of reciprocal vocalizations between mothers and fathers and their infants during their first year of life.
In a prospective cohort study, researchers assessed language output of 33 late-preterm and term infants and their parents. Sixteen-hour communication sessions were recorded during the birth hospitalization, in the home at 44 weeks' postmenstrual age (PMA), and at infant age 7 months using a digital language environment analysis instrument worn by the infant in a custom-made vest. Each session was analyzed for adult word count, infant vocalization count, and conversational exchanges.
Infants were exposed to significantly more female adult speech from birth to age 7 months. Mothers responded more frequently to their infant's vocalizations compared with fathers, and infants preferentially responded to female adult speech from birth to 7 months. Mothers preferentially responded to girls versus boys at birth and 44 weeks' PMA. A nonsignificant trend was observed for fathers to respond preferentially to boys at 44 weeks' PMA and 7 months.
Comment: Mothers provided the majority of language input and responded quicker to infants' vocal cues compared with fathers. Infants had preferential vocal responses to their mothers, and parents seemed to respond to infants preferentially based on gender. The study was limited by the small sample size, and most participating families were white, highly educated, and urban residents. The pattern of parent-infant communication requires further study in other settings. Nonetheless, these findings are similar to those of previous studies and remind us to inform mothers and fathers about the capacity of infants to listen to and respond to speech at an early age. Years ago, a wise parent taught me to encourage parents of young infants to “narrate your life.”
Citation(s): Johnson K et al. Gender differences in adult-infant communication in the first months of life. Pediatrics 2014 Dec 1; 134:e1603.

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MM: I'm pretty sure that we'vc all heard that a pregnant woman should be able to eat whatever she wants because she is "eating for two", but, this is just not the case today. When a society has starvation and nourishment deprivation, then this adage may be viable but today we have an over-abundance of calorie laden products that are readily available. In fact, pregnant women need to pay greater attention to their food intake and focus on healthier choices; especially whole foods that are as free from chemicals and additives as possible.
Maternal Overweight, Obesity Linked to Infant Mortality
By Amy Orciari Herman, Edited by David G. Fairchild, MD, MPH, and Lorenzo Di Francesco, MD, FACP, FHM
Infant mortality rates appear higher among women who are overweight or obese in early pregnancy, a BMJ study finds.
Using a Swedish birth registry, researchers studied associations between maternal weight in early pregnancy and neonatal outcomes among nearly 1.6 million live singleton births from 1992 to 2010. Overall, rates of infant mortality (within the first year of life) rose with increasing maternal BMI, ranging from 2.4 per 1000 births among normal-weight women to 5.8 per 1000 among those with BMIs of 40 or greater. The association between high BMI and infant mortality was observed mainly among term infants (e.g., death from birth asphyxia), although an excess of preterm deliveries among overweight and obese women also contributed to the association.
An editorialist writes: "Midwives and doctors who are involved in antenatal care should counsel women about the risks associated with overweight and obesity, and help them set targets for gestational weight gain informed by pre-pregnancy body mass index."
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JAMA Intern Med 2014 Nov 24;
Home-Based Intervention Improves Asthma Control in Adult Asthma Patients
Quality of life also was better, compared with usual care.
Patients in lower socioeconomic groups are affected disproportionately by asthma, and many adult patients do not know how to self-manage their disease. Researchers in Seattle randomized 366 lower-income adults with uncontrolled asthma to home-based asthma management or usual asthma care. The home-based program included five in-home visits during 7 months from trained community health workers who provided asthma education (e.g., asthma action plans, spacers, inhalers, allergen avoidance measures) and social services support.
During the 12-month study, participants in the home-based group (compared with the usual-care group) averaged 2 more symptom-free days during each 2-week period (number needed to treat [NNT] to gain 2 symptom-free days per 2 weeks, 7); the intervention group also scored significantly higher on a quality-of-life measure. In both groups, patients averaged 1.4 fewer urgent care visits during the study than during the previous year; the difference between groups was not significant.
Comment: With every outpatient visit for asthma, I give patients asthma action plans and instruct them on inhaler use and trigger avoidance. Still, many patients don't use their controller medications regularly or correctly and can't verbalize their management plans. Rather than stepping up to increasingly expensive asthma medications, home- and school-based interventions might be better and less expensive ways to improve asthma control. As the authors point out, the per-patient cost of the home-based intervention was US$1300 — less than the cost of a 1-year supply of a typical inhaled steroid.
Citation(s): Krieger J et al. Community health worker home visits for adults with uncontrolled asthma: The HomeBASE Trial randomized clinical trial. JAMA Intern Med 2014 Nov 24; [e-pub ahead of print].
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MM: I remember in the 1990's hearing Dr. John Lee present data that women who were injured in automobile accidents and sustained brain or spinal cord injuries, statistically fared better if these injuries occurred in the latter portion of their menstrual cycle. The better outcomes corresponded with higher systemic levels of progesterone. The fact that progesterone was higher at the time of injury seemed to support the theory of a better functional outcome. Unfortunately, it appears that in order to have improved results, the levels must be higher to start with and not after a traumatic injury or event. Although this information doesn't support post injury supplementation, it certainly doesn't preclude the benefits of general supplementation.
Progesterone of No Clinical Benefit in Traumatic Brain Injury
By Amy Orciari Herman, Edited by Susan Sadoughi, MD, and Richard Saitz, MD, MPH, FACP, FASAM
Progesterone does not improve functional outcomes in patients with traumatic brain injury (TBI), according to two phase 3 studies in the New England Journal of Medicine. The finding contrasts with earlier animal studies and phase 2 trials among adult patients, which had suggested some benefit.
In one study, nearly 1200 patients aged 16 to 70 with severe TBI were randomized to receive intravenous progesterone or placebo, beginning within 8 hours after injury and continuing for 120 hours. In the second study, some 880 adults with severe, moderate-to-severe, or moderate TBI were similarly randomized, with treatment starting by hour 4 and continuing for 96 hours.
The primary endpoint — favorable functional outcome at 6 months on Glasgow scales — did not differ significantly between progesterone and placebo recipients in either trial. Secondary outcomes, including mortality, also did not differ.
Asked to comment, Richard Zane of NEJM Journal Watch Emergency Medicine said: "As logical or intuitive as it may seem, it appears that progesterone does not improve outcomes in TBI and should not be used in acute care. More to come, I am sure."

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