• Guidelines Issued on Managing Pediatric Obesity
• Consumption of Soda and Other Sugar-Sweetened Drinks Still High
• Fish Oil Supplementation in Pregnancy Tied to Reduced Asthma Risk in Offspring
• New FDA, EPA Fish Consumption Guidance for Pregnant Women and Young Kids
• Red Meat Consumption Linked to Diverticulitis Risk in Men
• Vitamin D Supplementation Lacking in Breast-Fed Infants
• FDA: Topical Chemo Drug Lethal to Pets
• E-Cigarettes Tied to Markers of Higher Cardiovascular Risk
• "Weekend Warriors" See Survival Benefits
• Physical Activity Tied to Less Depression in Young Children
• New Immigration Policies Creating Anxiety in Medical Education & Care
• 1 in 3 Adults Diagnosed with Asthma Might Not Have It
• Lung Cancer Screening in Real World Has High False-Positive Rate
• Treatment of Subclinical Hypothyroidism in Pregnancy Carries Benefits and Risks
• Data from Home Sleep Testing Could Be as Good as Sleep Lab Testing for OSA
• Multiparametric MRI Might Help Men Avoid Unnecessary Prostate Biopsies
• Overdiagnosis of Noninvasive Tumors Followed Organized Breast Cancer Screening
• Could Acupucture Help Colicky Infants?
Guidelines Issued on Managing Pediatric Obesity
By Amy Orciari Herman, Edited by Susan Sadoughi, MD, and Richard Saitz, MD, MPH, FACP, DFASAM
The Endocrine Society has updated its guidelines on evaluating, treating, and preventing obesity in childhood.
Among the recommendations, published in the Journal of Clinical Endocrinology & Metabolism:
- Children or adolescents with a BMI at or above the 85th percentile should be assessed for metabolic syndrome, diabetes, and other related conditions.
- Evaluation of pediatric obesity should not include fasting insulin measurement, as "it has no diagnostic value."
- Obese youth should undergo laboratory evaluations for obesity-related endocrine disorders only if their stature or growth rate is below the expected for age and pubertal stage.
- Children with extreme obesity (e.g., BMI ≥120% of the 95th percentile) before their fifth birthday should be tested for genetic obesity syndromes, such as Prader-Willi syndrome.
As in the prior guidelines, the group emphasizes family-centered lifestyle modification for both preventing and treating obesity.
https://academic.oup.com/jcem/article-lookup/doi/10.1210/jc.2016-2573
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Consumption of Soda and Other Sugar-Sweetened Drinks Still High
By Kelly Young, Edited by Susan Sadoughi, MD, and André Sofair, MD, MPH
Two thirds of U.S. children and half of adults still drink at least one soda or other sugar-sweetened beverage every day, according to CDC data.
Using 2011–2014 data from the National Health and Nutrition Examination Survey (NHANES), researchers calculated that 63% of children aged 2 to 19 consume one or more sugar-sweetened beverage on any given day. About 10% of youth consumed three or more sugary drinks a day.
Sugar sweetened beverages accounted for an average of 7% of children's daily caloric intake.
For adults aged 20 and up, 49% drank at least one sugar-sweetened beverage a day.
For all ages, consumption was higher among males than females. Adolescents and young adults consumed the most. Consumption was lowest among non-Hispanic Asians.
https://www.cdc.gov/nchs/products/databriefs/db271.htm
https://www.cdc.gov/nchs/products/databriefs/db270.htm
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Fish Oil Supplementation in Pregnancy Tied to Reduced Asthma Risk in Offspring
By Amy Orciari Herman
Maternal use of omega-3 fatty acid supplements during pregnancy could lower the risk for asthma in offspring, a New England Journal of Medicine study finds.
Some 700 women between 22 and 26 weeks' gestation were randomized to receive daily supplements containing 2.4 g of fish oil or olive oil (placebo) until 1 week after delivery. The fish oil capsule contained the omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA).
The primary outcome — diagnosis of persistent wheeze or asthma when offspring were aged 3 to 5 years — occurred significantly less often in the fish oil versus olive oil group (17% vs. 24%). Among women with the lowest blood levels of EPA and DHA at randomization, fish oil cut the risk for the primary outcome in half.
An editorialist calls the findings "highly promising" but urges caution, noting that it's "imperative to ensure that [the high omega-3 dose used] had no adverse effects on behavior, cognition, or other long-term outcomes."
http://www.nejm.org/doi/full/10.1056/NEJMoa1503734?query=
pfwRS&jwd=000101421649&jspc=
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New FDA, EPA Fish Consumption Guidance for Pregnant Women and
Young Kids
By Kelly Young
The FDA and Environmental Protection Agency have broken down which fish are safest to eat — based on mercury levels — for young children and women of childbearing age, particularly those who are breast-feeding or pregnant.
Consistent with other dietary guidelines, the agencies recommend that women of childbearing age eat two to three servings of fish lower in mercury every week. Children should eat one to two servings weekly. For adults, a serving is 4 ounces of uncooked fish; for children aged 4–7 years, it's 2 ounces.
Adults should eat two to three servings weekly of "best choice" fish (e.g., canned light tuna, cod, crab, haddock, lobster, shrimp, salmon, tilapia) or one serving weekly of "good choice" fish (e.g., yellowfin and albacore tuna, grouper, halibut, mahi mahi). The "best choice" category includes 90% of the fish eaten in the U.S., according to the FDA.
"Fish to avoid" because of their high mercury content include king mackerel, marlin, orange roughy, shark, swordfish, Gulf of Mexico tilefish, and bigeye tuna.
The chart linked below categorizes 62 types of fish based on their average mercury levels.
http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm537362.htm
http://www.fda.gov/Food/FoodborneIllnessContaminants/Metals/ucm393070.htm
http://www.jwatch.org/fw108929/2014/06/11/fda-and-epa-pregnant-and-breast-feeding-women-should-eat?query=pfwRS&jwd=000101421649&jspc=
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Red Meat Consumption Linked to Diverticulitis Risk in Men
By Amy Orciari Herman, Edited by David G. Fairchild, MD, MPH, and Jaye Elizabeth Hefner, MD
High intake of red meat is associated with increased risk for diverticulitis in men, according to a study in Gut.
Some 46,000 male health professionals without diverticular disease at baseline completed food-frequency questionnaires every 4 years from 1986 through 2012. During that time, roughly 760 cases of diverticulitis occurred.
Compared with men in the lowest quintile of red meat intake (1.2 servings/wk), those in the highest quintile (13.5/wk) had nearly a 60% increased risk for diverticulitis. In particular, risk increased 18% with each daily serving of red meat. Unprocessed red meat accounted for most of the association.
Replacing one serving of red meat per day with fish or poultry was associated with a 20% lower risk for diverticulitis.
The authors note that "chronic low-grade systemic inflammation may be an essential step" underlying the association between red meat consumption and diverticulitis.
http://gut.bmj.com/content/early/2017/01/03/gutjnl-2016-313082
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Vitamin D Supplementation Lacking in Breast-Fed Infants
By Kelly Young, Edited by David G. Fairchild, MD, MPH, and Jaye Elizabeth Hefner, MD
Roughly half of infants are not receiving vitamin D supplementation as recommended by the American Academy of Pediatrics, according to a study in Annals of Family Medicine.
Researchers surveyed 180 mothers who at least partially breast-fed their infants (aged 6 weeks to 5 months). Roughly 55% said they had given their infants vitamin D supplements in the past week, and only 42% overall administered the recommended 400 IU. Most mothers (88%) said that they preferred supplementing themselves rather than their infants.
The authors conclude: "Promotion of breastfeeding as a complete nutritional source could be facilitated by providing adequate maternal vitamin D supplementation to breastfeeding mothers. Maternal choice of mode of supplementation may help ensure adequate vitamin D status for infants."
http://www.annfammed.org/content/15/1/68
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FDA: Topical Chemo Drug Lethal to Pets
By Amy Orciari Herman, Edited by André Sofair, MD, MPH, and William E. Chavey, MD, MS
Fluorouracil cream (USP 5%), used to treat actinic keratoses and basal cell carcinoma, can be deadly when accidentally ingested by pets, the FDA warned.
Five dogs have reportedly died after ingesting the cream. While the agency has not received reports of cat illness or death, it notes: "If an owner applies fluorouracil cream to an afflicted area and touches their cat, the cat may accidentally ingest the medication when grooming itself and suffer adverse events."
When prescribing fluorouracil cream, clinicians should advise patients to take steps to avoid pet exposure, including safe medication storage and prompt cleaning or disposal of applicators. Providers may also advise patients to cover any skin areas that have been treated.
http://www.fda.gov/animalveterinary/newsevents/cvmupdates/ucm537434.htm
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E-Cigarettes Tied to Markers of Higher Cardiovascular Risk
By Kelly Young, Edited by Susan Sadoughi, MD, and Richard Saitz, MD, MPH, FACP, DFASAM
E-cigarette use is associated with higher cardiac sympathetic tone and increased oxidative stress, both indicative of elevated cardiovascular risk, suggests a small study in JAMA Cardiology.
Sixteen young, otherwise healthy e-cigarette users were compared with 18 people who didn't use e-cigarettes. Participants underwent electrocardiograms and had blood samples drawn.
The high-frequency component of heart rate variability was lower among e-cigarette users, compared with non-users, suggesting reduced vagal tone. E-cigarette users also saw increases in the low-frequency component and the low-frequency-to-high-frequency ratio, suggesting sympathetic predominance. One measure of oxidative stress — low-density lipoprotein oxidizability — was higher in the e-cigarette group.
An editorialist writes that the findings "demonstrate that the use of e-cigarettes is not without consequence and might impose cardiovascular harm.... Nevertheless, changes in [heart rate variability] and low-density lipoprotein oxidizability are indirect indices of cardiovascular injury, and it remains unclear to what extent these changes represent an increase in CVD risk."
http://jamanetwork.com/journals/jamacardiology/article-abstract/2600166
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"Weekend Warriors" See Survival Benefits
By Amy Orciari Herman, Edited by David G. Fairchild, MD, MPH, and Jaye Elizabeth Hefner, MD
Exercising just a couple of times a week could help lower your mortality risk, finds an observational study in JAMA Internal Medicine.
Researchers examined data on nearly 64,000 U.K. adults aged 40 and older who reported on their activity level several times from 1994 through 2008. Activity levels were defined as follows:
- Inactive: no moderate-to-vigorous activity
- Insufficiently active: <150 minutes/week of moderate-intensity activity and <75 min/wk of vigorous-intensity activity
- "Weekend warrior": ≥150 min/wk of moderate-intensity or ≥75 min/wk of vigorous-intensity activity from 1–2 sessions
- Regularly active: ≥150 min/wk of moderate-intensity or ≥75 min/wk of vigorous-intensity activity from 3 or more sessions
During some 9 years' follow-up, 8800 participants died, including 2800 from cardiovascular disease (CVD) and 2500 from cancer. Compared with inactive adults, insufficiently active adults and weekend warriors had significant risk reductions in all-cause mortality (about 30%) and CVD mortality (about 40%); regularly active adults had slightly greater risk reductions. Reductions in cancer mortality ranged from 14% for insufficiently active adults to 21% for regularly active adults.
http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2596007
http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2596003
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Physical Activity Tied to Less Depression in Young Children
By Amy Orciari Herman, Edited by Susan Sadoughi, MD, and André Sofair, MD, MPH
Moderate-to-vigorous physical activity is associated with fewer depression symptoms even in elementary-school-aged children, according to an observational study in Pediatrics.
Some 800 children in Norway were assessed for depression and level of physical activity (using waist accelerometers) at ages 6, 8, and 10 years. The prevalence of major depression was under 0.5% at all three ages.
In adjusted analyses, higher levels of moderate-to-vigorous physical activity at ages 6 and 8 were associated with fewer depression symptoms 2 years later. Each hour of activity per day conferred roughly 0.2 fewer depression symptoms. Sedentary behavior, however, was not associated with major depression.
The authors write, "Although the effects of [physical activity] were small, they are similar to those obtained by psychosocial intervention programs in children and adolescents." They conclude, "Increasing [physical activity] in children at the population level may prevent depression, at least at subclinical levels."
http://pediatrics.aappublications.org/content/139/2/e20161711
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New Immigration Policies Creating Anxiety in Medical Education & Care
By Joe Elia, Edited by Susan Sadoughi, MD, and Richard Saitz, MD, MPH, FACP, DFASAM
The Trump administration's actions on immigration have prompted warnings that the policies may result in physician shortages in underserved areas and confusion in graduate medical education. Two essays and a letter to the editor detail the problems in the New England Journal of Medicine.
One perspective says that since the president signed the January 27 order limiting immigration, "there has been pandemonium among residents, fellows, and [graduate medical education] offices throughout the country."
Another concludes: "Immigration policy that blocks ... our trainees and faculty from safely traveling to other countries is a step backward, one that will harm our patients, colleagues and America's position as a world leader in health care and innovation."
And finally, a letter from two international medical graduates relates the concern of a patient who asked: "Will you be able to stay in the United States for a few more months? I don't want to change my physician during the last few months of my life." The writers note that almost a quarter of physicians working in the U.S. are international graduates
http://www.nejm.org/doi/full/10.1056/NEJMp1701251?query=
pfw&jwd=000101421649&jspc=
http://www.nejm.org/doi/full/10.1056/NEJMp1701339?query=
pfw&jwd=000101421649&jspc=
https://www.whitehouse.gov/the-press-office/2017/01/27/
executive-order-protecting-nation-foreign-terrorist-entry-united-states
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1 in 3 Adults Diagnosed with Asthma Might Not Have It
By Amy Orciari Herman
Asthma was ruled out in a third of adults who were re-evaluated several years after first being diagnosed with the condition. The findings appear in JAMA.
Over 600 randomly selected adults who'd received a physician diagnosis of asthma within the previous 5 years completed symptom questionnaires and underwent spirometry (patients on long-term oral steroids or unable to tolerate spirometry were excluded). If asthma wasn't confirmed during spirometry, patients underwent serial bronchial challenge tests. If appropriate, patients were gradually tapered off all asthma medications over 6 weeks.
Roughly 200 patients were determined not to have current asthma. These patients were less likely to have received diagnostic testing for airflow limitation at their initial diagnosis, compared to those with confirmed asthma.
Editorialists see two clinical takeaways: "First, patients who have been diagnosed with adult-onset asthma may not continue to have asthma or to require asthma treatment indefinitely. Second, physiological testing, such as spirometry before and after bronchodilator administration, is an essential component of the diagnosis of asthma to avoid unnecessary treatment or an incorrect diagnosis."
http://jamanetwork.com/journals/jama/article-abstract/2598265
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Lung Cancer Screening in Real World Has High False-Positive Rate
By Kelly Young, Edited by David G. Fairchild, MD, MPH, and Jaye Elizabeth Hefner, MD
A pair of studies in JAMA Internal Medicine illustrate the difficulties of implementing lung cancer screening.
In the first, eight Veterans Health Administration medical centers identified and screened patients using low-dose computed tomography (LDCT). Over 2100 patients who were eligible for screening based on smoking history and other factors completed LDCT. Overall, 60% had nodules, but just 1.5% had lung cancer diagnosed within 330 days. The researchers calculate a false-positive rate of 97.5%.
Editorialists calculate that "for every 1000 people screened, 10 will be diagnosed with early-stage lung cancer (potentially curable), and 5 with advanced-stage lung cancer (incurable); 20 will undergo unnecessary invasive procedures (bronchoscopy and thoracotomy) directly related to the screening; and 550 will experience unnecessary alarm and repeated CT scanning (with its associated irradiation)."
In a second study, researchers compared data from the 2010 and 2015 National Health Interview Survey. The proportion of respondents who said they'd undergone lung screening with LDCT increased from 2010 to 2015 (1.3% vs. 2.1%). Use of CT scans even increased among never smokers and low-risk smokers — patients who aren't eligible for screening. The authors say this "raises concerns about overuse."
http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2599437
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Treatment of Subclinical Hypothyroidism in Pregnancy Carries Benefits
and Risks
By Amy Orciari Herman
Treatment of subclinical hypothyroidism during pregnancy is associated with reduced risk for pregnancy loss — but increased risk for other adverse pregnancy outcomes — according to a retrospective study in The BMJ.
Using a large medical claims database, researchers studied roughly 5400 U.S. women with subclinical hypothyroidism during pregnancy (thyroid-stimulating hormone [TSH] level, 2.5–10.0 mIU/L). Of these, 16% received thyroid hormone therapy, most often levothyroxine.
Pregnancy loss (miscarriage or stillbirth) was less common in treated than untreated women (11% vs. 14%) — a difference that was significant after adjustment for prior pregnancy loss and other confounders. In a subanalysis, treatment was associated with reduced risk for pregnancy loss among women with pretreatment TSH levels of 4.1–10.0 mIU/L, but not among those with lower levels.
Of note, treated women were significantly more likely than untreated women to experience preterm delivery (7.1% vs. 5.2%), preeclampsia (5.5% vs. 3.9%), and gestational diabetes (12.0% vs. 8.8%).
http://www.bmj.com/content/356/bmj.i6865
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Data from Home Sleep Testing could be as Good as Sleep Lab Testing for OSA
By Kelly Young, Edited by David G. Fairchild, MD, MPH, and Jaye Elizabeth Hefner, MD
Limited-channel sleep studies, which can be conducted at home, may be noninferior to full polysomnography for patients with suspected obstructive sleep apnea, suggests an Annals of Internal Medicine study.
Roughly 400 adults with suspected OSA underwent full polysomnography in a sleep lab. Patient data were then randomized to one of three levels to be given to physicians, who then diagnosed and treated patients accordingly:
- Full polysomnography (level 1 data): electroencephalography, electrooculography, chin and leg electromyography, airflow, thoracoabdominal bands, snoring sensor, body position, electrocardiography (ECG), oxygen saturation
- Level 3 data: airflow, thoracoabdominal bands, body position, ECG, oxygen saturation
- Level 4 data: oxygen saturation, heart rate
Moderate-to-severe OSA diagnoses did not differ across the groups. Level 3 data were deemed noninferior to full data based on patient-reported functional outcomes at 4 months. However, treatment based on level 4 data was linked to worse symptoms, possibly because of lower physician confidence in the diagnosis, the authors write.
Editorialists conclude that "it is reasonable" to use home sleep testing "in a broad range of patients being evaluated for OSA."
http://annals.org/aim/article/2599136/physician-decision-making-clinical-outcomes-laboratory-polysomnography-limited-channel-sleep
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Multiparametric MRI Might Help Men Avoid Unnecessary Prostate Biopsies
By Kelly Young
Multiparametric magnetic resonance imaging (MP-MRI) may help clinicians identify roughly a quarter of men who could avoid unnecessary prostate biopsies, according to an industry-supported study in the Lancet.
Nearly 600 men with suspected prostate cancer who were biopsy-naive underwent three tests: MP-MRI, transrectal ultrasound-guided biopsy (TRUS-biopsy), and transperineal template prostate mapping biopsy (TPM-biopsy). Using TPM-biopsy as the reference standard, 40% of men were diagnosed with clinically significant prostate cancer. MP-MRI had greater sensitivity than TRUS-biopsy for detecting clinically significant cancers (93% vs. 48%) but lower specificity (41% vs. 96%). If follow-up biopsy were performed only in men with suspicious MP-MRI scores, then 27% would potentially avoid primary biopsy.
The authors conclude: "The primary outcome data provide a strong argument for recommending MP-MRI to all men with an elevated serum PSA before biopsy. Using MP-MRI as a triage test would reduce the problem of unnecessary biopsies ... reduce the diagnosis of clinically insignificant disease and improve the detection of clinically significant cancers."
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)32401-1/fulltext
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Overdiagnosis of Noninvasive Tumors Followed Organized Breast Cancer Screening
By Kelly Young, Edited by David G. Fairchild, MD, MPH, and Jaye Elizabeth Hefner, MD
Seventeen years of organized breast cancer screening in Denmark has not reduced the incidence of advanced cancers — but has led to increased detection of noninvasive tumors and ductal carcinoma in situ (DCIS) — according to a study in the Annals of Internal Medicine.
Using cancer registries, researchers identified roughly 200,000 women aged 35 to 85 diagnosed with breast cancer from 1980 to 2010. Cancer detection rates were compared in screening and nonscreening areas. (Screening was introduced into different regions of the country at different times.)
Screening was not associated with a decrease in advanced tumors. The authors estimate that one out of every three invasive tumors and DCIS cases diagnosed after screening were overdiagnoses.
An editorialist writes, "We must carefully examine screening, realize its limitations, maximize its effectiveness, and try to improve it. In addition, we must examine all elements of breast cancer control (to include prevention) and evaluate how they are best used."
http://annals.org/aim/article/2596394/breast-cancer-screening-denmark-cohort-study-tumor-size-overdiagnosis
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Could Acupucture Help Colicky Infants?
By Kelly Young, Edited by David G. Fairchild, MD, MPH, and Jaye Elizabeth Hefner, MD
Acupuncture might help infants with colic recover faster than usual care, suggests a small study in Acupuncture in Medicine.
Swedish researchers enrolled 150 colicky infants aged 2–8 weeks who had not responded to a diet free of cow's milk. All attended a study clinic twice a week for 2 weeks and were randomized to the following arms:
- Standardized minimal acupuncture: One needle was inserted at an acupuncture point.
- Semi-standardized individualized acupuncture: Needles were inserted at acupuncture points a maximum of five times per visit, depending on symptoms.
- Control: Infants spent 5 minutes alone with acupuncturist, but no needles were inserted.
When both acupuncture groups were combined, the primary outcome — parent-report total time crying by the second intervention week — was significantly lower with acupuncture than control (115 vs. 86 minutes/day reductions). But when acupuncture groups were considered separately, the results were not statistically significant.
Researchers contend that this difference is still "clinically relevant for parents."
http://aim.bmj.com/content/early/2017/01/03/acupmed-2016-011208
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