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Content 7

 

The Doctor and the Pharmacist

Radio Show Articles:
December 3, 2016

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USPSTF Finalizes recommendations on Statin Use for Primary Prevention
Higher Vitamin D Level in Newborns associated with Reduced MS Risk Later
Low Vitamin D in Pregnancy and Increased MS Risk in Offspring:
   New Study Supports Potential Link
No Link Between Maternal Flu and Autism in Offspring
Prasterone Approved for Painful Intercourse due to Menopause
Meta-Analysis: Alpha Blockers Associated with Passage of Urethral Stones
VTE Risk Elevated in First Months of Testosterone Therapy
Swimming, Racquet Sports, and Aerobics Tied to Better Survival
Young Smokers Have Eight Times the MI Risk as Nonsmokers
Trump Picks Opponent of ACA to Lead Health and Human Services
Meta-Analysis Supports Lower Prediabetes Cutoff
New Visual Symptoms Common after LASIK
Pediatrics Group offers advice for Clinicians to help Children through Divorce
Palliative Care may lead to Improved Quality-of-Life, Symptom Burden
Thiazide Diuretic tied to lower Fracture Risk than other Antihypertensive Drugs
Physical Therapy for Ankle Sprains again called into Question

USPSTF Finalizes recommendations on Statin Use for Primary Prevention
By Amy Orciari Herman
The U.S. Preventive Services Task Force now recommends low- to moderate-dose statins for adults aged 40 to 75 without cardiovascular disease who have at least one CVD risk factor — dyslipidemia, diabetes, hypertension, or smoking — plus a 10-year CVD risk of 10% or greater. The grade B recommendation is published in JAMA.
In addition, the task force says providers should "selectively offer" statins to such adults whose 10-year CVD risk is 7.5% to 10% (grade C recommendation). To estimate a patient's 10-year risk, the group recommends using the American College of Cardiology/American Heart Association CVD risk calculator (see link below). However, because the calculator has been shown to overestimate risk, it should be considered "a starting point to discuss with patients their desire for lifelong statin therapy."
Lastly, the task force notes that the evidence is insufficient to weigh the benefits and harms of statin use in adults aged 76 and older (grade I recommendation).
Why We Chose This as Our Top Story:
Andre Sofair, MD, MPH: These broad recommendations will need to give clinicians a starting point to make patient-centered decisions in their practice. I would not look at these as one-size-fits-all recommendations.
William E. Chavey, MD, MS: Recommendations on statin use for primary prevention have been controversial. This report provides a refinement of current guidelines but still relies on overall risk rather than cholesterol level.
http://jamanetwork.com/journals/jama/fullarticle/2584058
http://jamanetwork.com/journals/jama/fullarticle/2584057
http://www.cvriskcalculator.com/
https://www.uspreventiveservicestaskforce.org/Page/Name/grade-definitions
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Higher Vitamin D Level in Newborns associated with Reduced MS Risk Later
By Robert T. Naismith, MD
Dr. Naismith is an associate editor with NEJM Journal Watch Neurology,from which this story was adapted. Full coverage is available to subscribers at the link below.
Higher serum vitamin D in the neonatal period is associated with reduced risk for multiple sclerosis years later, a Neurology study suggests.
The Danish Newborn Screening Biobank, which includes dried heel-prick blood samples from neonates, was linked to the Danish MS Registry so patients meeting MS criteria could be evaluated for newborn serum 25-hydroxyvitamin D levels compared with sex- and age-matched controls.
The analysis included some 520 newborns who developed MS over the next three decades and 970 controls. Mean neonatal vitamin D levels were significantly higher in controls than cases (35.9 vs. 33.0 nmol/L). The lowest vitamin D quintile conferred a 1.9-fold increased risk for MS compared with the highest quintile. Similarly, each 25-nmol/L increase in vitamin D conferred a 30% reduced risk for MS.
Comment: Although the evidence is not sufficient to recommend vitamin D to all mothers, it is reasonable to supplement 1000 to 2000 IU daily to high-risk mothers who have serum vitamin D levels <50 nmol/L (<20 ng/mL) and an immediate family member with MS.
http://www.neurology.org/content/early/2016/11/30/WNL.0000000000003454
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Low Vitamin D in Pregnancy and Increased MS Risk in Offspring: New Study Supports Potential Link
By Amy Orciari Herman, Edited by David G. Fairchild, MD, MPH, and Jaye Elizabeth Hefner, MD
Markedly deficient vitamin D levels during pregnancy are associated with increased risk for multiple sclerosis in one's offspring, suggests a case-control study in JAMA Neurology.
Using the Finnish Maternity Cohort, researchers identified nearly 200 young adults with confirmed MS and over 300 unaffected controls. Serum samples from participants' mothers, collected during pregnancy, were assessed for 25-hydroxyvitamin D (25[OH]D).
The average maternal 25(OH)D level was considered insufficient in both groups, and was somewhat lower among case mothers than controls (13.86 vs. 15.02 ng/mL). In multivariable-adjusted analyses of a subset of participants matched for region and date of birth, "clearly deficient" maternal 25(OH)D levels (<12.02 ng/mL) were associated with a near doubling of risk for MS in offspring, compared with higher levels.
An editorialist discusses potential mechanisms, including the possibility that vitamin D deficiency during myelinogenesis could lead to "weak myelin" that is particularly susceptible to the damage seen in MS.
Dr. Robert Naismith of NEJM Journal Watch Neurology notes: "While it is too early to recommend vitamin D during pregnancy for the prevention of MS, some groups are advocating for the more routine use of vitamin D within a pregnant population for a variety of potential health benefits.
http://jamanetwork.com/journals/jamaneurology/article-abstract/2499458
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No Link Between Maternal Flu and Autism in Offspring
By Kelly Young, Edited by David G. Fairchild, MD, MPH, and Jaye Elizabeth Hefner, MD
Influenza infection during pregnancy is not associated with increased risk for autism in the offspring, according to a study in JAMA Pediatrics.
Researchers examined maternal flu infection, vaccination during pregnancy, and autism diagnoses in nearly 200,000 children born between 2000 and 2010 in a California healthcare system. During a median follow-up of 8.3 years, 1.6% of the children were diagnosed with autism spectrum disorder.
After multivariable adjustment, there was no association between maternal influenza infection during any trimester and autism in the offspring. There was also no association between autism and receipt of the flu vaccine in the second or third trimester. An increased risk was observed with first-trimester vaccination (hazard ratio, 1.20), but this was no longer significant after further statistical adjustment.
The researchers emphasize that a change in vaccine policy is not warranted, but call for further studies on first-trimester vaccinations.
http://jamanetwork.com/journals/jamapediatrics/fullarticle/2587559
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Prasterone Approved for Painful Intercourse due to Menopause
By Kristin J. Kelley
The FDA has approved the first product that contains the hormone DHEA (dehydroepiandrosterone) as its active ingredient. Prasterone, a once-daily vaginal insert marketed as Intrarosa, is approved to treat dyspareunia brought on by menopause.
The approval was based on several studies: two 12-week placebo-controlled trials comprising 400 healthy postmenopausal women looked at the drug's efficacy, and five trials (four 12-week placebo-controlled and one year-long open-label) established prasterone's safety. Compared with placebo, the drug was associated with reduced pain during sexual intercourse. Common side effects included abnormal Pap smear results and vaginal discharge.
The FDA notes that DHEA is included in some dietary supplements, but the efficacy of these products has not been confirmed.
http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm529641.htm
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Meta-Analysis: Alpha Blockers Associated with Passage of Urethral Stones
By Kelly Young, Edited by André Sofair, MD, MPH, and William E. Chavey, MD, MS
Alpha blockers are associated with high rates of ureteral stone passage, a meta-analysis in The BMJ finds.
Researchers analyzed 55 trials involving nearly 600 patients with ureteral stones who were randomized to either alpha blockers (e.g., tamsulosin) or placebo/no treatment.
Patients taking alpha blockers were 49% more likely to pass their stones than control patients, with passage rates of 76% in the treatment group and 48% in the control group. The authors estimate that four people would need to be treated with alpha blockers for one patient to benefit. Only patients with larger stones (≥5 mm) appeared to benefit.
The authors conclude: "Given the low risk profile of these drugs and their wide therapeutic window, our findings suggest that clinicians who manage patients with ureteric colic should consider prescribing a course of an alpha blocker, unless it is medically contraindicated."
http://www.bmj.com/content/355/bmj.i6112
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VTE Risk Elevated in First Months of Testosterone Therapy
By Amy Orciari Herman, Edited by Susan Sadoughi, MD, and Richard Saitz, MD, MPH, FACP, FASAM
Among men using testosterone therapy, the risk for venous thromboembolism (VTE) peaks in the first 6 months of use and then declines thereafter, according to a case-control study in The BMJ.
Using records from 370 U.K. primary care practices, researchers identified over 19,000 men with VTE and 900,000 controls matched for age and VTE risk factors. Among the VTE cases, 0.36% occurred during current testosterone treatment, and 0.11% after recent treatment.
Current use of testosterone for less than 6 months was associated with a 63% increased risk for VTE relative to no use, accounting for an excess of 10 cases per 10,000 person-years. Longer-term treatment and recent treatment were not significantly associated with VTE.
The authors conclude: "These findings support the addition of the general warning for risk of venous thromboembolism with testosterone products required recently by the US Food and Drug Administration, although they highlight the fact that this increased risk is transient."
http://www.bmj.com/content/355/bmj.i5968
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Swimming, Racquet Sports, and Aerobics Tied to Better Survival
By Amy Orciari Herman, Edited by David G. Fairchild, MD, MPH, and Lorenzo Di Francesco, MD, FACP, FHM
Racquet sports, aerobics, and swimming may be your best bet for a long life, a British Journal of Sports Medicine study suggests.
Over 80,000 U.K adults completed surveys about their participation in various sports and were followed for roughly 9 years, during which 11% of participants died.
After multivariable adjustment, those who reported any participation in racquet sports in the 4 weeks before the survey had a 47% reduction in all-cause mortality, compared with those who reported no racquet sports. Similarly, swimming was associated with a 28% risk reduction, aerobics with a 27% reduction, and cycling with a 15% reduction. Soccer and running showed no association with mortality.
Racquet sports, swimming, and aerobics were also associated with reductions in cardiovascular mortality, while cycling, soccer, and running were not.
The authors note that relatively few runners and soccer players died during follow-up, which could have limited the study's ability to detect associations between these activities and mortality.
http://bjsm.bmj.com/content/early/2016/10/31/bjsports-2016-096822
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Young Smokers Have Eight Times the MI Risk as Nonsmokers
By Kelly Young, Edited by David G. Fairchild, MD, MPH, and Lorenzo Di Francesco, MD, FACP, FHM
Smokers under age 50 have eight times the risk for acute myocardial infarction as people that age who've never smoked or quit smoking, according to a Heart study.
Researchers examined the medical records of over 1700 people who'd experienced an ST-segment elevation myocardial infarction at a U.K. hospital and compared their smoking histories with those of local residents. Nearly half of STEMI patients said they were current smokers.
For all age groups, current smokers had 3.26 times the risk for acute STEMI as former and never smokers. Current smokers under age 50 had the highest risk (rate ratio, 8.47).
The authors conclude: "All current smokers must be encouraged into smoking cessation therapy to reduce their risk of acute STEMI, with a focus on the youngest smokers whose increased risk is often unrecognized."
http://heart.bmj.com/content/early/2016/10/31/heartjnl-2016-309595
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Trump Picks Opponent of ACA to Lead Health and Human Services
By Kelly Young, Edited by David G. Fairchild, MD, MPH, and Lorenzo Di Francesco, MD, FACP, FHM
President-elect Donald Trump has selected congressman Tom Price to be secretary of the U.S. Department of Health and Human Services, theNew York Times reports.
During his six terms as Republican congressman, Price has offered alternatives to the Affordable Care Act. An orthopedic surgeon, Price has objected to the ACA on the basis that it gets in the way of clinicians and patients making medical decisions. He has proposed legislation that would offer age-adjusted tax credits for purchasing health insurance. He has also backed bills that would bar Planned Parenthood from receiving federal funding.
Seema Verma, an expert on health policy, is Trump's pick to be administrator of the Centers for Medicare and Medicaid Services.
http://www.nytimes.com/2016/11/28/us/politics/tom-price-secretary-health-and-human-services.html?_r=0
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Meta-Analysis Supports Lower Prediabetes Cutoff
By Amy Orciari Herman, Edited by Susan Sadoughi, MD, and André Sofair, MD, MPH
Adults with fasting glucose concentrations as low as 100 mg/dL or hemoglobin A1c levels of 5.7% could face increased risk for cardiovascular events, a BMJ meta-analysis finds.
Researchers examined data on 1.6 million adults from 53 prospective cohort studies that measured blood glucose at baseline and reported on cardiovascular outcomes over a median 9.5 years' follow-up. Definitions for prediabetes included impaired fasting glucose according to World Health Organization criteria (110–124 mg/dL) or the American Diabetes Association's lower cutoffs (100–124 mg/dL), and elevated hemoglobin A1c according to U.K. criteria (6.0–6.4%) or lower ADA cutoffs (5.7–6.4%).
Compared with patients with normoglycemia, those with prediabetes — defined according to the various criteria — had significantly increased cardiovascular risks. In particular, patients with prediabetes defined by the ADA's lower fasting glucose cutoff had increased risks for overall cardiovascular events (relative risk, 1.13), coronary heart disease (RR, 1.10), stroke (RR, 1.06), and total mortality (RR, 1.13). The ADA's lower HbA1c cutoff also identified those at increased risk for cardiovascular events and heart disease, but not stroke or overall mortality.
http://www.bmj.com/content/355/bmj.i5953
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New Visual Symptoms Common after LASIK
By Amy Orciari Herman, Edited by Susan Sadoughi, MD, and André Sofair, MD, MPH
Patients undergoing LASIK (laser in situ keratomileusis) surgery often develop new visual symptoms afterward, according to a study in JAMA Ophthalmology.
Roughly 240 active-duty Navy personnel and 300 civilians who underwent LASIK for myopia, hyperopia, or astigmatism completed a self-administered, web-based symptom questionnaire before surgery and at several time points afterward.
Overall, visual symptoms improved after surgery. However, among participants with no visual symptoms before surgery, over 40% reported new symptoms 3 months afterward — most commonly, halo and starbursts. Such symptoms persisted in about a third of participants at 6 months. In addition, nearly 30% of participants reported new dry eye symptoms at 3 months.
Patients were more likely to report symptoms on the questionnaire than to their clinician.
The authors conclude: "Our findings support the need for adequate counseling about the possibility of developing new symptoms after LASIK surgery."
http://jamanetwork.com/journals/jamaophthalmology/article-abstract/2587831
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Pediatrics Group offers advice for Clinicians to help Children through Divorce
By Amy Orciari Herman, Edited by Susan Sadoughi, MD, and André Sofair, MD, MPH
A new clinical report from the American Academy of Pediatrics offers clinicians advice for helping children and families through parental separation and divorce. The group notes that over one million U.S. children experience the divorce or separation of their parents each year.
Published in Pediatrics, the guidance advises pediatric clinicians to do the following:

http://pediatrics.aappublications.org/content/138/6/e20163020
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Palliative Care may lead to Improved Quality-of-Life, Symptom Burden
By Amy Orciari Herman, Edited by Lorenzo Di Francesco, MD, FACP, FHM
Palliative care may confer improvements in quality-of-life and symptoms — but not survival — in patients with life-threatening illness, a JAMAmeta-analysis finds.
Researchers examined data from over 40 randomized trials examining the efficacy of palliative care in nearly 13,000 adults with cancer or heart failure. Roughly 2500 caregivers were also included. About a third of the trials were in ambulatory settings, with the remainder in hospitals or homes. Most of the trials used usual care as the control.
At 1 to 3 months' follow-up, palliative care was associated with significant improvements in patient quality-of-life and symptom burden. When analyses were limited to trials with low risk for bias, however, only the effect on quality-of-life remained significant. Palliative care showed no effect on survival.
The authors note: "High-quality palliative care studies with innovative and context-specific methods are needed that are responsive to the complexities of conducting research in seriously ill populations."
http://jamanetwork.com/journals/jama/article-abstract/2585979
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Thiazide Diuretic tied to Lower Fracture Risk than other
Antihypertensive Drugs

By Amy Orciari Herman, Edited by David G. Fairchild, MD, MPH, and Jaye Elizabeth Hefner, MD
The thiazide diuretic chlorthalidone might confer lower risk for pelvic and hip fractures than other antihypertensive drugs, according to a secondary analysis from the randomized ALLHAT trial published inJAMA Internal Medicine.
Researchers examined fracture outcomes in some 22,000 adults aged 55 and older who were assigned to receive chlorthalidone, the calcium-channel blocker amlodipine, or the ACE inhibitor lisinopril. At baseline, participants had moderate hypertension or were receiving antihypertensive medication and had one additional coronary risk factor.
During an average 5 years' treatment, 34 pelvic fractures and 307 hip fractures occurred. In adjusted analyses, fracture risk was significantly lower with chlorthalidone than with the other drugs (hazard ratio, 0.79). When chlorthalidone was compared with each drug separately, only the difference with lisinopril remained significant.
Commentators call the findings "good news," given that thiazides are a preferred drug class for first-line hypertension treatment.
http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2587085
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Physical Therapy for Ankle Sprains again called into Question
By Amy Orciari Herman, Edited by Susan Sadoughi, MD, and Richard Saitz, MD, MPH, FACP, FASAM
Physical therapy did not improve ankle function recovery in patients with simple sprains in a trial in The BMJ.
Some 500 patients aged 16 and older presenting to urgent care centers with simple ankle sprains were randomized to physical therapy plus usual care, or usual care alone. Physical therapy included up to eight clinic visits, plus home exercises. Usual care included an information sheet on sprain management at home (e.g., rest, ice, compression bandages).
The proportion of patients with an "excellent" recovery score on a self-assessment tool for ankle function did not differ significantly between the groups at 3 months (roughly 40%) or 6 months (60%).
The authors conclude that early supervised physical therapy doesn't result in "clinically important improvements" in recovery up to 6 months after ankle sprain. An editorialist, meanwhile, says it's "difficult ... to judge the clinical appropriateness" of the intervention, given the lack of details on the "magnitude, nature, intensity, and frequency" of the exercises.
http://www.bmj.com/content/355/bmj.i5650

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