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Content 7


The Doctor and the Pharmacist

Radio Show Articles:
February 28, 2015

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Study Highlights Risks with NSAID Use After Myocardial Infarction
Clostridium difficile Infection in the U.S.
A Healthful Diet Is Associated with Lower Risk for COPD
ADHD Linked to Higher Risk for Premature and Accidental Death
Do Energy Drinks Contribute to Hyperactivity and Inattention?
Early Peanut Introduction Reduces Risk for Peanut Allergy
Do Light Runners Come Out Ahead? Hold That Thought

MM: It's fine to tell people that a product that they use for pain is dangerous or even life threatening but if you fail to give them a viable alternative, then you are merely setting them up to fail. A wonderful alternative for chronic or acute pain is our ALL FLEX PRO. ALL FLEX PRO is a combination of herbs and minerals that reduce pain & inflammation and do not increase the risk for bleeding the way that NSAIDs do. Simply take 2 capsules 2-3 times daily and in many cases pain is greatly reduced. The advantages are that this product has few chances for drug interactions, few, if any, adverse reactions of its own and in a word, WORKS! ALL FLEX PRO comes with a MONEY BACK GUARANTEE. If it fails to provide pain relief, then we will refund the purchase price of this nutritional product.
Study Highlights Risks with NSAID Use After Myocardial Infarction
By Larry Husten, Edited by David G. Fairchild, MD, MPH, and Lorenzo Di Francesco, MD, FACP, FHM
A JAMA study raises specific concerns about the safety of nonsteroidal anti-inflammatory drugs among people who've had a recent myocardial infarction.
Using data from national registries, Danish researchers studied over 60,000 people with a first MI, one third of whom received a prescription for an NSAID following discharge. Overall, NSAID users had double the rate of bleeding events as nonusers. In particular, people taking standard dual antiplatelet therapy with aspirin and clopidogrel had 3.3 bleeding events per 100 person-years; the addition of an NSAID increased this risk to 7.6 events per 100 person-years. Increased bleeding risks were found even when NSAIDs were used for 3 days or fewer.
In addition, the rate of cardiovascular events was increased by the addition of an NSAID to other drugs.
The authors note that NSAID use in people with established heart disease remains common, despite guidelines discouraging this practice.
Editorialists conclude that for now, "practitioners would do well to advise patients with cardiovascular disease against all NSAID use (except low-dose aspirin), especially patients with a recent acute coronary syndrome."
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MM: This study emphasizes the importance of establishing a healthy gut and the microorganisms that share it with us. CDI causes discomfort and possible death as a result of dehydration secondary to diarrhea. This condition is known as dysbiosis. By providing a healthier gut, a person is less likely to experience this aggressive dysbiotic condition. Regular, daily use of bacterial probiotics and the occasional use of a more aggressive non-bacterial probiotic such as Saccharomyces Boulardii, when taking antibiotics or subsequent to an intestinal dysbiosis can certainly be life altering and possibly life saving. This is a simple approach and a simple, inexpensive answer. The answer is NOT stronger antibiotics. It is more prudent use of what we have and working with natural products that assist and augment our systems, not overwhelm them.
N Engl J Med 2015 Feb 26; 372:825
Clostridium difficile Infection in the U.S.
Survey data suggest that the burden of CDI may be higher than previously projected.
Clostridium difficile infection (CDI) is a costly disease with frequent recurrences and increased mortality in some patient groups. To enhance our understanding of the epidemiology of CDI in the U.S., the CDC conducted active surveillance at 10 representative sites (total population, ~11.2 million) in 2011.
The investigators identified all positive C. difficile toxin or molecular assay results at 88 inpatient and 33 outpatient laboratories serving surveillance-area residents. They also gathered information on the patients' demographic characteristics and healthcare exposures and the locations of specimen collection. Using data from these sites, they built models to project the national burden of CDI.
Nationwide, an estimated 453,000 (95% confidence interval, 397,100–508,500) cases occurred in 2011, with 83,000 of the episodes representing first recurrences; an estimated 29,300 patients died. Incidence was higher in women than in men (incidence rate ratio, 1.26; 95% CI, 1.25–1.27), in whites than in nonwhites (IRR, 1.72; 95% CI, 1.56–2.00), and in individuals aged ≥65 years than in those aged <65 (IRR, 8.65; 95% CI, 8.16–9.31). An estimated 159,700 cases were community associated and 293,300 were healthcare associated, with 107,600 of them hospital acquired. The NAP1 strain was identified more often in healthcare-associated cases than in community-associated ones (30.7% vs. 18.8%; P<0.001).
Comment: Novel approaches are needed now to reduce the burden of CDI. This potentially recurrent infection deserves all the attention it has received, particularly when one considers the morbidity and mortality involved. With almost half a million cases in one year in this country, increased clinical and bench research activities are certainly warranted.
Citation(s): Lessa FC et al. Burden of Clostridium difficile infection in the United States. N Engl J Med 2015 Feb 26; 372:825.
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MM: I find the proposition interesting and intriguing that the lungs may be super-sensitive to oxidants and anti-oxidants. We normally think of the lungs as our initial filters and although they do not readily regenerate, they are considered pretty resilient to environmental insults. This premise of the lungs being susceptible to internal pressures and possibly responsive to those same pressures opens a tremendous number of possibilities.
BMJ 2015 Feb 3; 350:h286
A Healthful Diet Is Associated with Lower Risk for COPD
Even among smokers, those with the healthiest eating patterns were less likely to develop chronic obstructive pulmonary disease.
Smoking is the main cause of chronic obstructive pulmonary disease (COPD), but as many as one third of COPD patients have never smoked. Might other modifiable behaviors, such as diet, affect risk for COPD? To explore this issue, researchers examined the association between diet quality and risk for COPD in >120,000 health professionals (73,000 women and 47,000 men) who completed food frequency questionnaires between 1984 and 2000. Participants' diets were scored using the Alternate Healthy Eating Index 2010 (AHEI-2010): The healthier the diet (i.e., the higher the intakes of whole grains, polyunsaturated fats, nuts, and long-chain ω-3 fats and the lower the intakes of red or processed meats, refined grains, and sugar-sweetened drinks), the higher the score.
During the study, 723 women and 167 men received diagnoses of COPD. Incidence of newly diagnosed COPD was associated inversely with AHEI-2010 score. Adjusted for multiple variables, including smoking, risk for developing COPD was one third lower among participants in the highest quintile versus the lowest quintile of AHEI-2010 scores (hazard ratio, 0.7). Results were similar in subanalyses of ex-smokers (HR, 0.5) and current smokers (HR, 0.7).
Comment: In this study, a healthful diet was associated with lower risk for COPD. These results are consistent with those of previous studies in which diets rich in antioxidants were associated with better lung function and lower COPD-related mortality. Although this association between diet and lung function isn't necessarily intuitive, it is biologically plausible. The authors note that the lungs exist in a high-oxygen environment and might be exquisitely susceptible to dietary exposures, both toxic and protective.
Citation(s): Varraso R et al. Alternate Healthy Eating Index 2010 and risk of chronic obstructive pulmonary disease among US women and men: Prospective study. BMJ 2015 Feb 3; 350:h286.

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MM: We don't normally think of ADHD as a deadly condition. It sort of makes sense that if a person is bored with their environment they may be more likely to get distracted or perform more interesting, more potentially hazardous tasks and that could lead to a more dangerous overall environment. That being said, do the answers to the "dangers" of ADHD lie in drug therapies? Or are there other alternatives that may enhance a person's perception and attention? I believe that some of these answers lie, at least in part, by stabilizing the brain through stabilizing the gut, reducing systemic inflammation, limiting processed sugars and grains and improving the overall internal environment of the individual. This may be achieved, in part, by maintaining a healthy gut. Probiotics and Digestive Enzymes serve to stabilize the GI environment and reduce inflammation. Couple this with Omega-3 fatty acids high in DHA, a good Vitamin D3 supplement that enhances telomere maintenance and you have a starting point towards possibly moderating ADHD.
ADHD Linked to Higher Risk for Premature and Accidental Death
By Jenni Whalen, Edited by Susan Sadoughi, MD, and Richard Saitz, MD, MPH, FACP, FASAM
Individuals with attention-deficit/hyperactivity disorder (ADHD) are at increased risk for premature death, according to a Lancet study.
Researchers used Danish national registries to follow nearly 2 million people, including 32,000 with ADHD, from their first birthday to 2013 (maximum: 32 years). During follow up, roughly 100 people with ADHD died prematurely. Those with ADHD had more than double the risk for premature death, most commonly from unnatural and accidental causes, compared with those without ADHD (all-cause mortality rate: 5.85 vs. 2.21 per 10,000 person-years). Women with ADHD, individuals diagnosed with ADHD in adulthood, and patients with comorbidities were at highest risk.
A Lancet commentator writes, "For too long, the validity of ADHD as a medical disorder has been challenged... For clinicians, early identification and treatment should become the rule rather than the exception."
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Acad Pediatr 2015 Feb 8
Do Energy Drinks Contribute to Hyperactivity and Inattention?
Consumption of energy drinks was independently associated with risk for these behaviors among middle school students.
The consumption of sweetened beverages, including energy drinks (e.g., Monster, Red Bull, 5-Hour Energy) has increased among adolescents. Preliminary studies suggest an association between consumption of sweetened beverages and hyperactivity/inattention.
In a community-based study at 12 urban middle schools, students completed an online health behavior survey in 2011. Answers to a standardized behavioral questionnaire were used to determine risk for hyperactivity/inattention. The study sample included 1649 students (average age, 12.4 years), of whom 47% were Hispanic, 38% were black, and 15% were white, and most were in low-income families.
Students in the normal range for hyperactivity/inattention behaviors consumed significantly fewer sweetened beverages per day (2.17 vs. 2.72) and were significantly less likely to consume energy drinks (13% vs. 21%) than those at-risk for these behaviors. The odds of being at risk for hyperactivity/inattention increased by 14% for each additional sweetened beverage consumed, after adjustment for age, race/ethnicity, sex, school lunch eligibility, family structure (two parents or other), and consumption of all sugary foods. Consumption of energy drinks was associated with 66% greater risk for hyperactivity/inattention.
Comment: The finding of an association between increased consumption of sweetened beverages and hyperactivity/inattention raises questions about the mechanism for this effect. Are these behaviors a result of caffeine in energy drinks (80–120 mg per 12-oz. can) added to the sugar load from traditional drinks? The results should be interpreted with caution as the study relied on self-reported behavior, but it seems reasonable to ask children about their consumption of energy drinks. I suspect there is significant variability in individual behavioral response to high-sugar and caffeine drinks
Citation(s): Schwartz DL et al. Energy drinks and youth self-reported hyperactivity/inattention symptoms. Acad Pediatr 2015 Feb 8; [e-pub].
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MM: Severe peanut allergy seems not to be as dangerous to the very young as it is to children who are older and to adults with these allergies. These conditions tend to be much more dangerous as we get older until they become potentially lethal when we reach adulthood. Early exposure to potential allergens in our environment such as dog dander, eggs, dairy and other potential allergens seems, in many cases to reduce the lifelong sensitivity of these items. Early presentation of probiotics to a child's system appears to also demonstrate some of these immunological stabilizing effects. Early presentation may truly be the embodiment of "an ounce of prevention is worth a pound of cure."
N Engl J Med 2015 Feb 23
Early Peanut Introduction Reduces Risk for Peanut Allergy
Peanut consumption from infancy through age 5 decreased development of peanut allergy in high-risk infants
During the past 10 years, the prevalence of childhood peanut allergy in Western countries has doubled to rates of 1.4% to 3%. In 2000, the American Academy of Pediatrics recommended that children at high risk for the allergy should avoid peanut consumption until age 3. In 2008, these recommendations were withdrawn due to lack of evidence.
To determine which of these strategies is more effective for preventing peanut allergy in high-risk infants, investigators in the U.K. conducted a single-center, randomized, controlled, open-label study involving 640 infants (age range, 4–11 months) with severe atopic dermatitis or egg allergy. The participants were randomized to peanut consumption (2 grams of peanut protein 3 times per week) or peanut avoidance until age 5. They were also stratified into two cohorts: those with negative skin-prick results and those with wheal size 1 mm to 4 mm. Infants with skin-prick wheals >4 mm and those who reacted to an oral peanut challenge were excluded. At age 5, all children underwent another peanut challenge.
Among children with a negative skin-prick test at baseline, the prevalence of peanut allergy was significantly lower in the peanut-consumption group than the peanut-avoidance group (1.9% vs. 13.7%). Likewise, among patients with initial positive skin-prick tests but no reaction on challenge, prevalence was also significantly lower in the intervention group (10.6% vs. 35.3%).
Comment: Early peanut ingestion provided a remarkable 86% risk reduction for peanut allergy in unsensitized children and a 70% reduction in sensitized children. Although we don't know if this extrapolates to other foods, we should no longer recommend avoidance of allergenic foods in infants. An accompanying editorial recommends skin-prick testing of all high-risk infants, and in those with negative skin tests or challenges, regular consumption of peanuts until age 5. This may be logistically difficult, but the benefits could be tremendous in light of the surging prevalence of peanut allergy.
Citation(s): Du Toit G et al. Randomized trial of peanut consumption in infants at risk for peanut allergy. N Engl J Med 2015 Feb 23; [e-pub]. (http://dx.doi.org/10.1056/NEJMoa1414850) Gruchalla RS and Sampson HA.Preventing peanut allergy through early consumption — ready for prime time? N Engl J Med 2015 Feb 23; [e-pub].
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MM: One of the best personal anecdotes that I get from this study is that I don't have to feel guilty if I only get out one day a week during the very busy times or simply the times of year when the weather discourages any exercise at all. Seriously though, the human body is designed to be in motion, not to be a couch potato and that is what this study demonstrates. Movement and light exercise improves cardiac health, arthritis, depression and a host of other ailments. The bottom line is that we must get up and move around to live and enjoy our lives to our fullest potential.
J Am Coll Cardiol 2015 Feb 10; 65:411
Do Light Runners Come Out Ahead? Hold That Thought
In a trial widely reported to show the benefit of low-level jogging over high-intensity jogging, the data don't match the perception.
Exercise has been convincingly associated with longevity and health. However, what level of exercise conveys the maximal benefit is not yet clear, and some experts postulate that there is an extreme level of intensity that may actually harm.
As part of the Copenhagen City Heart Study, 1098 joggers and 3950 nonjoggers were followed prospectively over a 12-year period. The researchers categorized jogging intensity as light (1 to 2.4 hours/week), moderate (2.5 to 4 hours/week), or strenuous (>4 hours/week). Compared with nonjoggers, joggers were younger and generally healthier (lower blood pressure and body-mass index and lower prevalence of smoking and diabetes). There were 28 deaths among joggers and 128 among nonjoggers.
Not surprisingly, jogging was associated with a lower mortality than no jogging. With adjustment for age, sex, smoking, alcohol intake, education, and diabetes, light-intensity joggers had a significantly lower mortality (hazard ratio, 0.29; 95% confidence interval, 0.11–0.80) compared with nonjoggers. Mortality with moderate jogging (HR, 0.65; 95% CI, 0.20–2.07) and with strenuous jogging (HR, 0.60; CI, 0.08–4.36) was not significantly different compared with mortality with no jogging; however, these findings were based on only 115 moderate and 47 strenuous joggers compared with 282 sedentary nonjoggers.
Comment: As in many other studies, even low-level exercise was associated with reduced mortality in this analysis. However, I do not believe that this study proves that more-strenuous activity is associated with a worse outcome, because the number of individuals performing strenuous activity was in actuality quite small. An editorial also points out the limitations of this study.
Citation(s): Schnohr P et al. Dose of jogging and long-term mortality: The Copenhagen City Heart Study. J Am Coll Cardiol 2015 Feb 10; 65:411.

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