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Content 7


The Doctor and the Pharmacist

Radio Show Articles:
February 6, 2016

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Risks for Second Basal Cell Carcinomas
Evidence against "Fat but Fit"
Relation between Central Obesity and Cardiovascular Mortality in
   People of Normal Weight
Bariatric Surgery Is associated with Postoperative Improvements
   in Depression
Zika Virus spreads quickly in parts of the Americas
Zika News: Sexual Transmission and Blood Donation delays
Another win for Kangaroo Care
A Novel Therapy Is superior to Antibiotics for treating
   Staphylococcus aureus Infections in mice
Surgical vs. Nonoperative management for Pediatric Appendicitis
New Asthma and Diabetes drugs are too expensive, independent group says
FDA proposes ban on use of Tanning Beds by those under 18
CDC: Opioid overdose deaths hit all-time high in 2014
FDA lifts 30-year ban on Blood Donation from men who have sex with men
Frozen Feces are effective for recurrent C. Difficile Infection
A Low-Fiber diet might not be good for Crohn Disease
Sports Participation in Athletes with Heart Disease: Updated Scientific Statement

J Invest Dermatol 2015 Nov; 135:2649
Risks for Second Basal Cell Carcinomas
Many people with a BCC will develop another. What is the magnitude of risk, and what factors increase that risk?
Investigators performed prospective, population-based cohort studies of recruited participants in separate cohorts in the Netherlands: 7983 participants older than 55 recruited from 1989 to 1993; 3011 added from 2000 to 2001; and 3932 subjects added from 2006 to 2008, for a total of 14,926. Subject data were analyzed against a nationwide data base.
Of 1077 participants who developed a first basal cell carcinoma (BCC) during the study period, 293 developed a second a median of 3 years later. The strongest predictor of developing a subsequent BCC was having more than one BCC at initial diagnosis (hazard ratio, 2.6; 95% confidence interval, 2.0–3.4; P<0.001). Other strong predictors were lower age at first BCC (HR, 1.6; CI, 1.3–2.0; P<0.001) and superficial first BCC (HR, 1.5; CI, 1.1–2.0; P<0.01). Non-significant associations included sex, body-mass index, pigment status, outdoor work, sunburn propensity, smoking, alcohol consumption, and anatomic location of first BCC, although most of these showed a slight-to-moderate trend for increased risk. Coffee consumption was associated with deceased risk for subsequent BCC (HR, 0.7; CI, 0.6–0.9; P< 0.05).
COMMENT: Participants with more than one BCC at initial visit were 2.5 times more likely to develop a new BCC than patients with only one, supporting the concept of field cancerization. Coffee consumption decreased risk. Caffeine can inhibit UVB-induced cancers in animals and induces apoptosis in UV-damaged human keratinocytes. The helpful effect of coffee may just be due to lifestyle differences among study participants. It would be nice to know about more risk factors so we could adjust follow-up screening visit intervals to better reflect probabilities of detecting new cancers.
CITATION(S):Verkouteren JAC et al. Predicting risk of a second basal cell carcinoma. J Invest Dermatol 2015 Nov; 135:2649.
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MM: Apparently it is not sufficient to simply work out and keep your heart pumping. We must also be aware of the body surrounding that heart and need to focus on not having too much of that body. Weight control and management is one of the most difficult personal chores of many individuals in western civilization. Our abundance of readily available high fat and high carbohydrate laden foods make the choices delicious but contribute to the problem of obesity. There are many options that people may choose for weight loss but not all of them work for everyone. Many people benefit greatly from group support such as Jenny Craig or Weight Watchers but there are many who respond to a regimented weight loss program such as the HCG Metabolic Syndrome and Weight Loss Program. For those who want something in between, take a look at the new Revive IV and Oxygen Lounge to see what options they offer for weight management. Go to www.ReviveIVo2.com for pricing and more information.
Evidence against "Fat but Fit"
By Amy Orciari Herman, Edited by André Sofair, MD, MPH
Aerobic fitness in adolescent males is associated with reduced risk for early death — but only up to a certain body-mass index — suggests a study in the International Journal of Epidemiology.
Researchers followed 1.3 million Swedish men from the time of mandatory military conscription (at age 18) in 1969–1996 through 2012. Aerobic fitness at the time of conscription was assessed with a cycle test.
During roughly 29 years' follow-up, over 44,000 men died. In adjusted analyses, men in the highest fifth of aerobic fitness at baseline had a 41% lower risk for all-cause mortality than those in the lowest fifth. However, the benefits of fitness decreased with increasing baseline BMI, with no protective effect seen at BMIs of 35 or greater. In addition, mortality risk was 30% lower among unfit normal-weight men than fit obese men.
The authors write, "These results counter the notion that the 'fat but fit' condition does not increase mortality risk."
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Ann Intern Med 2015 Nov 10
Relation between Central Obesity and Cardiovascular Mortality in
people of Normal Weight

Waist-to-hip ratio might be more accurate than body-mass index for determining CV risk.
Are risks for cardiovascular-related and total mortality higher among people who have normal body-mass indexes (BMIs) but central obesity? Using data from the National Health and Nutrition Examination Survey (NHANES), researchers evaluated this association in >15,000 adults (age range, 18–90). Participants were categorized as normal weight (BMI, 18.5–27.4 kg/m2), overweight (BMI, 27.5–32.9 kg/m2), or obese (BMI, ≥33 kg/m2). Men with waist-to-hip ratio (WHR) ≥0.90 and women with WHR ≥0.85 were considered to be centrally obese.
Multivariate analyses demonstrated that normal-weight men and women with central obesity were more likely to die during a mean follow-up of 14 years than were other participants. For example, a man with a normal BMI and central obesity had a higher mortality risk than did an overweight or obese man with normal WHR (hazard ratios, 2.2 and 2.4, respectively). Similar patterns were seen in women.
COMMENT: These researchers found that central obesity is a risk factor for mortality even among individuals with normal BMIs. The results also suggest that WHR might be a better marker than BMI for mortality risk. As noted by the authors, BMI is a measure of both lean and fat mass, whereas WHR is associated with visceral fat accumulation, which has a stronger association with adverse metabolic profile than does BMI alone.
CITATION(S): Sahakyan KR et al. Normal-weight central obesity: Implications for total and cardiovascular mortality. Ann Intern Med 2015 Nov 10; [e-pub]. (http://dx.doi.org/10.7326/M14-2525)
Poirier P.The many paradoxes of our modern world: Is there really an obesity paradox or is it only a matter of adiposity assessment? Ann Intern Med 2015 Nov 10; [e-pub]. (http://dx.doi.org/10.7326/M15-2435)
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MM: I would not necessarily attribute a reversal of depression to this particular surgery but I do believe that if a person feels trapped in their body and is unhappy about that body, then, if they take a demonstrative action to change that condition, they will feel better about and happier with themselves. The fact that this study started with a prevalence of mood disorders only somewhat higher than the normal population lends one to believe that what may have been measured was a group of subjects in a "depressed state" of "mood" in addition to clinically depressed patients and not only clinical depression.
JAMA 2016 Jan 12; 315:150
Bariatric Surgery Is associated with Postoperative Improvements in Depression
Prevalence of depression declined by as much as 74% after surgery.
Many researchers have examined mental health outcomes associated with bariatric surgery. In this meta-analysis, researchers assessed the prevalence of preoperative and postoperative mental illness and its relation to weight-loss outcomes. In 59 studies (>65,000 patients), researchers reported mental illness prevalence, and in 27 studies (>50,000 patients), investigators assessed associations between preoperative mental illness and postoperative outcomes in bariatric surgery patients. Mean age range of participants was 40 to 50; mean body-mass index range was 45 kg/m2 to 50 kg/m2.
Before surgery, prevalence of any mood disorder was 23%. The most common mood disorders were depression and binge eating disorder, with prevalences (19% and 17%, respectively) substantially higher than those in the general population. Estimated prevalence of depression declined postoperatively by 8% to 74%, and depression severity declined by 40% to 70%. Binge eating disorder was assessed in two studies; this disorder declined postoperatively but returned to baseline in one study. No consistent association was found between presence or absence of preoperative mental illness and postoperative weight loss.
COMMENT: This meta-analysis suggests that weight loss after bariatric surgery is similar among patients with or without preoperative depression and that bariatric surgery alleviates depression in many patients.
CITATION(S):Dawes AJ et al. Mental health conditions among patients seeking and undergoing bariatric surgery: A meta-analysis. JAMA 2016 Jan 12; 315:150.

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MMWR Morb Mortal Wkly Rep 2016 Jan 29; 65:55
Zika Virus Spreads Quickly in Parts of the Americas
This mosquito-borne virus is challenging public health and affecting travel in Central and South America.
Zika virus, recognized in 1947 as a member of the RNA flavivirus genus, is transmitted to humans by infected Aedes mosquitoes. Zika outbreaks occurred in Micronesia in 2007 and French Polynesia in 2013; concerns have intensified since Zika infection emerged in Brazil in 2015, coupled with epidemiologically linked neurologic and fetal developmental abnormalities, including microcephaly. Two articles discuss clinically pertinent information about Zika illness.
Like dengue and chikungunya, which have recently spread through Central America and the Caribbean, Zika's most common manifestations — maculopapular rash, arthralgias, conjunctivitis, myalgias, headache, vertigo, and vomiting — start 2 to 7 days after an infected mosquito's bite. However, chikungunya- and dengue-related arthralgias may recur and last for months, whereas Zika illness is usually mild and self-limited and lasts about a week.
The greatest concern in Brazil is Zika's apparent link, without firm proof of causality, to more than 4000 cases of microcephaly in children born to infected mothers. The infection also appears to increase the risk for Guillain-Barré syndrome.
Zika virus infection, diagnosed using reverse-transcriptase polymerase-chain-reaction testing of blood, has also been detected in other body fluids including semen, suggesting possible sexual transmission (supported by one case report). No specific therapy exists. Given that dengue and chikungunya may coexist with Zika infection, nonsteroidal anti-inflammatory drugs should be avoided until and unless dengue is excluded, to prevent exacerbation of thrombocytopenia and hemorrhage.
COMMENT: The extent, spread, and clinical spectrum of Zika infection must still be determined. Pregnant women should avoid exposure. Absent a vaccine or therapy, mosquito control is paramount in containing this epidemic. The culprit mosquitoes (A. aegypti and albopictus) exist in the southern United States. Therefore, patients who import the disease to the U.S. should be protected from mosquito exposure through use of screens, air conditioning, and repellent until they are noninfectious. Infections should be reported to the Centers for Disease Control and Prevention.
CITATION(S):Hennessey M et al. Zika virus spreads to new areas — Region of the Americas, May 2015–January 2016. MMWR Morb Mortal Wkly Rep 2016 Jan 29; 65:55.
Chen LH and Hamer DH.Zika virus: Rapid spread in the Western Hemisphere. Ann Intern Med 2016 Feb 2; [e-pub].

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Zika News: Sexual Transmission and Blood Donation Delays
By Amy Orciari Herman, Edited by Susan Sadoughi, MD, and Richard Saitz, MD, MPH, FACP, FASAM
The Zika virus continues to hold the spotlight. Here's the latest:
A case of sexually transmitted Zika infection was reported in Dallas on Tuesday. The patient acquired the virus after having sexual contact with a person with Zika symptoms who had traveled to Venezuela, an area with active Zika transmission. In response, the CDC is advising men who've traveled to areas with circulating Zika to "consider wearing condoms," the New York Times reports. In addition, pregnant women should "avoid contact with semen from men recently exposed to the virus."
Elsewhere, the American Red Cross is asking potential blood donors to defer giving blood for 28 days after visiting areas with Zika transmission. Additionally, people who develop Zika symptoms within 14 days of donating blood should contact the Red Cross so their donation can be quarantined. The maximal length of Zika viremia is thought to be less than 28 days, according to the AABB (formerly, the American Association of Blood Banks).
On Wednesday, January 27, 2016, the CDC added Jamaica and Tonga to the list of areas with active Zika transmission. Women who are pregnant should consider delaying travel areas with active Zika outbreaks.
In Brazil, the number of Zika-linked cases of microcephaly has passed 4000, Reuters reports, and an Associated Press story explains why higher temperatures translate to greater spread of the virus.
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MM: I have always considered "touch" to be an outstanding therapeutic tool. Whether it is the embrace of a loved one or simply the hand holding of someone in need, simple human touch has historically demonstrated infinite possibilities for expressing love, concern or simple compassion for one in need. In today's social and professional environment, we have been made aware of the need for respect of personal space and, in general, this is a good thing. However, let us not forget the potential benefit of human contact. There are times when a patient is in physical or emotional pain and an appropriate hand taken in those of a compassionate caregiver or a hand to a forearm or shoulder may be as effective as a handful of anti-anxiety or pain pills.
Pediatrics 2015 Dec 22
Another win for Kangaroo Care
In a meta-analysis, kangaroo care was associated with a significant decrease in infant mortality and neonatal sepsis.
Kangaroo care — early and continuous maternal skin-to-skin contact — in preterm infants has a sustained beneficial effect on cognition, sleep, executive function, and maternal anxiety (NEJM JW Pediatr Adolesc Med Feb 2014)  and Biol Psychiatry 2013 Oct 3; [e-pub]). In addition, it has been shown to improve breast-feeding, cardiorespiratory stability, and responses to procedural pain.
Researchers conducted a systematic review of randomized controlled trials and observational studies of neonatal outcomes in newborns who received kangaroo care. Of 124 studies included in the analysis, 44% were randomized controlled trials and 68% examined preterm infants. The duration of kangaroo care was <2 hours per day in 48% of studies.
Pooled analyses showed that compared to conventional care, kangaroo care was associated with a significant 36% decrease in mortality among low-birth-weight newborns. Kangaroo care was also associated with significant decreases in neonatal sepsis (47% lower), hypothermia, hypoglycemia, and hospital readmission. Other benefits were increased exclusive breast-feeding, lower mean respiratory rate, lower pain measures, and higher oxygen saturation, temperature, and head circumference growth.
COMMENT: The most dramatic findings of this study were the effect of kangaroo care on infant mortality and neonatal sepsis. Although most of the benefits were seen in preterm infants, they were also found to a smaller degree in full-term newborns. This review provides strong support for kangaroo care as a standard of care, especially for premature infants.
CITATION(S): Boundy EO et al. Kangaroo mother care and neonatal outcomes: A meta-analysis. Pediatrics 2015 Dec 22; [e-pub].
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Nature 2015 Nov 19; 527:323
A Novel Therapy is superior to Antibiotics for treating Staphylococcus aureus Infections in Mice
An antibody–antibiotic combination molecule effectively kills intracellular S. aureus.
Staphylococcus aureus has developed resistance to many antibiotics. Moreover, sometimes S. aureus infections respond poorly even when the bacteria are sensitive to the antibiotics used. A team of industry-backed investigators speculated that this latter problem was caused by bacterial invasion of cells, which allowed the bacteria to evade circulating antibiotics.
The researchers created a rifampicin-derived antibiotic attached to an antibody that binds to the surface sugars of S. aureus. When bacteria that are coated with this novel molecule are ingested by cells, intracellular chemicals activate the antibiotic and kill the intracellular bacteria. In mice, a single injection of this novel molecule was dramatically more successful than treatment with vancomycin, daptomycin, or linezolid in reducing bacterial burden following experimental S. aureus infection.
COMMENT: This study strongly supports the hypothesis that S. aureus has an intracellular phase that protects it from antibiotics and allows it to persist. The study also provides persuasive evidence that a novel antibody–antibiotic molecule can eradicate the bacteria in their intracellular harbor, at least in mice. Whether this approach will work in humans, and whether it would also work for other bacterial pathogens with an intracellular life — for example, Mycobacterium tuberculosis — remains to be seen. This clever idea could go nowhere — or it could be a landmark in the fight against several major bacterial pathogens.
CITATION(S):Lehar SM et al. Novel antibody–antibiotic conjugate eliminates intracellular S. aureus. Nature 2015 Nov 19; 527:323.

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JAMA Surg 2015 Dec 16
Surgical vs. Nonoperative Management for Pediatric Appendicitis
At 1 year, the rate of perforated appendicitis was similar between groups, while total disability days and healthcare costs were lower in the nonoperative group.
Is nonoperative management of uncomplicated appendicitis in children safe? To find out, researchers at a pediatric emergency department prospectively studied children aged 7 to 17 years who presented with nonperforated acute appendicitis and ≤48 hours of abdominal pain and who underwent either laparoscopic appendectomy or nonoperative medical management based on patient and family choice. Patients in the surgery group received intravenous antibiotics and underwent appendectomy within 12 hours. Those undergoing nonoperative management received IV antibiotics for at least 24 hours followed by a 10-day course of oral antibiotics. Patients with worsening or nonchanging symptoms after 24 hours underwent appendectomy.
Of 102 children enrolled, 37 chose nonoperative management and 65 chose surgery. Nonoperative patients were less likely to have been transferred and less likely to speak primarily English. The success rate of nonoperative management (i.e., no appendectomy) at 1 year (the primary outcome) was 76%. In the surgery group, the negative appendectomy rate was 6% and the 1-year postoperative complication rate was 8%. At 1 year, the rate of perforated appendicitis was similar between the nonoperative and surgery groups (3% and 12%), and the nonoperative group had fewer median disability days (8 vs. 21) and lower appendicitis-related healthcare costs ($4219 vs. $5029). The two groups had similar quality of life scores.
COMMENT: Nonoperative medical management is an option for older children with acute appendicitis and no radiologic or clinical evidence of perforation and should be offered as an alternative to surgery. Shared decision making is family-friendly and patient-centric, and acknowledges the patient's right to weigh in on decisions that directly affect him or her.
CITATION(S): Minneci PC et al. Effectiveness of patient choice in nonoperative vs surgical management of pediatric uncomplicated acute appendicitis. JAMA Surg 2015 Dec 16; [e-pub].
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New Asthma and Diabetes Drugs Are Too Expensive, Independent Group Says
By Kelly Young, Edited by David G. Fairchild, MD, MPH, and Lorenzo Di Francesco, MD, FACP, FHM
The Institute for Clinical and Economic Review says that the price of the new asthma drug mepolizumab (Nucala) needs to be lowered by at least two thirds to be cost-effective for patients. Mepolizumab is a humanized monoclonal antibody to interleukin-5 approved for those aged 12 and older with severe eosinophilic asthma.
In its review, the group writes that the drug should cost between $7787 and $12,116 annually to reach the cost-effectiveness range of $100,000 to $150,000 per quality-adjusted life year gained. Its current list price is $32,500 per year.
In a separate review, the group says that the price of the new diabetes medication insulin degludec (Tresiba) would need to be discounted by 8%–10% — to $7006–$7154 annually — to be cost-effective.
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FDA Proposes Ban on Use of Tanning Beds by Those Under 18
By Amy Orciari Herman, Edited by André Sofair, MD, MPH
The FDA on Friday, December 18, 2015, proposed that use of sunlamp products, including tanning beds and booths, be prohibited among those under age 18. In addition, the agency recommended that adults 18 and older be required to sign a risk-acknowledgment form before using sunlamp products for the first time and every 6 months thereafter.
In 2014, the FDA imposed black-box warnings on sunlamps to note that they should not be used by minors given the associated increased risk for melanoma. In addition, the agency reports in its latest news release that sunlamp products account for over 3000 emergency department visits each year in the U.S.
Also on Friday, the FDA proposed a rule that would require sunlamp makers and tanning facilities to take steps to improve the devices' safety. Among the proposed regulations: sunlamps should have emergency shut-off buttons and more-prominent warnings.
The proposed rules are open for public comment for 90 days at the link below.
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CDC: Opioid Overdose Deaths Hit All-Time High in 2014
By Amy Orciari Herman, Edited by André Sofair, MD, MPH
Opioid overdose deaths in the U.S. hit a record high in 2014 — reaching 9.0 per 100,000 people — according to a CDC analysis of national mortality data. This represents a 14% increase from 2013.
Among the other findings, published in MMWR:

CDC Director Tom Frieden said: "The opioid epidemic is devastating American families and communities. To curb these trends and save lives, we must help prevent addiction and provide support and treatment to those who suffer from opioid use disorders. This report also shows how important it is that law enforcement intensify efforts to reduce the availability of heroin, illegal fentanyl, and other illegal opioids."
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FDA Lifts 30-Year Ban on Blood Donation from Men who have Sex with Men
By Kelly Young, Edited by David G. Fairchild, MD, MPH, and Jaye Elizabeth Hefner, MD
The FDA is ending its blood donation ban for men who have sex with men, putting it in line with policies in the United Kingdom and Australia.
Previously, men who have sex with men were prevented from ever donating blood in the U.S. Now, the agency is changing the policy to a 12-month deferment since last sexual contact with another man. Other groups with elevated HIV risk (for example, those with recent blood transfusion) must also wait 12 months before donating blood. Published studies, the FDA notes, show no change in risk to the blood supply in countries that have enacted 12-month deferral policies.
In addition, the FDA changed the rationale for recommending against blood donations from patients with hemophilia or other clotting disorders. The agency no longer considers clotting factor concentrates an HIV risk factor because of better safety measures used in their production. However, indefinite deferral is recommended because the large needles used in blood donation could harm hemophilia patients. The FDA is no longer recommending donation deferral for people who've had sex with a person using clotting factor concentrates
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JAMA 2016 Jan 12; 315:142
Frozen Feces Are Effective for Recurrent C. Difficile Infection
Frozen FMT was non-inferior to fresh FMT in resolving diarrhea at 13 weeks post-transplantation.
Fecal microbiota transplantation (FMT) is an effective treatment for recurrent Clostridium difficile infection. Obtaining fresh stool from volunteer donors is expensive and inconvenient because it requires screening donors for a number of infections.
In the current randomized, controlled non-inferiority trial, investigators assessed clinical resolution in 219 patients with recurrent or refractory C. difficile infection who were administered either frozen or fresh (within 24 hours of being passed) feces by rectal enema. Donors received recommended health screening.
Clinical resolution (resolution of diarrhea at 13 weeks after undergoing 1–2 FMTs) was 83.5% with frozen and 85.1% with fresh feces in the per-protocol analysis and 75.0% with frozen and 70.3% with fresh in the intention-to-treat analysis.
COMMENT: These results could increase the availability of donor feces for FMT by establishing the efficacy and safety of frozen feces.
CITATION(S): Lee CH et al. Frozen vs fresh fecal microbiota transplantation and clinical resolution of diarrhea in patients with recurrent Clostridium difficile infection: A randomized clinical trial. JAMA 2016 Jan 12; 315:142.

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Clin Gastroenterol Hepatol 2015 Dec 31
A Low-Fiber Diet Might Not Be Good for Crohn Disease
Patients with highest fiber intake had lower risk for disease flare than those with lowest intake.
Patients with Crohn disease (CD), particularly if they have obstruction, are commonly instructed to follow a low-fiber or low-residue diet. To examine the effect of fiber in CD, investigators evaluated 1619 patients with inflammatory bowel disease (1130 had CD and 489 had ulcerative/indeterminate colitis) participating in an Internet cohort study and in remission at baseline, based on disease activity index. Patients completed a 26-item dietary survey and were followed up 6 months later.
Patients with ulcerative colitis (UC) ingested more fiber than CD patients, but no association was found between fiber intake and risk for disease flare in UC patients. However, CD patients with the highest quartile of fiber intake had a 43% lower risk for flare than patients with the lowest fiber intake. CD patients with the middle quartiles of fiber intake had intermediate risk for flares.
COMMENT: It is possible that patients with more-severe CD, or with more frequent flares or history of obstruction with flares, self-selected for a low-fiber diet to avoid symptoms. However, this study suggests that fiber should be encouraged in patients with CD in remission, and the observation warrants additional controlled study.
Note to readers: At the time NEJM JW reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.
CITATION(S):Brotherton CS et al. Avoidance of fiber is associated with greater risk of Crohn's disease flare in a 6-month period. Clin Gastroenterol Hepatol 2015 Dec 31; [e-pub]. (http://dx.doi.org/10.1016/j.cgh.2015.12.029)
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J Am Coll Cardiol 2015 Dec 1; 66:2343
Sports Participation in Athletes with Heart Disease: Updated Scientific Statement
Competitive sports risk may be less than previously thought with long QT syndrome and implantable cardioverter-defibrillators and greater with arrhythmogenic right ventricular cardiomyopathy.
Competitive sports participation in individuals with heart disease is controversial. In most published series, athletes who experienced sudden cardiac death typically had had underlying heart disease. This fact has driven calls for screening athletes with electrocardiography (ECG) and for restricting individuals with underlying heart disease from playing competitive sports.
Recently, the American College of Cardiology and American Heart Association updated their Scientific Statement regarding competitive sports participation for athletes with heart disease. This comprehensive document included 15 sections on multiple topics. Although the recommendations changed little from those in the 36th Bethesda Conference document published in 2005, there were some important divergences:

The 15 Task Force reports are available free online at: 
An Author's Perspective:
This updated scientific statement contains some key changes from previous documents. However, the science on whether competitive sport worsens the phenotype or triggers arrhythmias is still quite limited. Much of the statement relies on consensus opinion, and we all await more data in this field.
Dr. Link, Deputy Editor of NEJM Journal Watch Cardiology, led 2 of the 15 Task Forces and was a member of 3 others.
CITATION(S):Maron BJ et al. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Preamble, principles, and general considerations. J Am Coll Cardiol 2015 Dec 1; 66:2343.

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