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Content 7


The Doctor and the Pharmacist

Radio Show Articles:
March 29, 2014

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Some OTC Cold Medicines Expose Patients to Potentially Dangerous Phenylephrine Levels
Most Flu is Asymptomatic
Delaying Antibiotics Doesn't Worsen Respiratory Infection Symptoms
Do Bleach Baths Prevent Recurrent Staph Infections?
More Common Tests and Treatments That Pediatricians Should Question
Studies Provide Little Support for Guidelines on Dietary Fats and Supplements
Women in their 60's are More Likely to Face Alzheimer's Than Breast Cancer
Blood test Shows Early Promise in Identifying People at Risk for Alzheimer Disease
Loss of Protective Protein Linked to Alzheimer's
How Heavy Marijuana Use May Hurt the Developing Brain: An Animal Study

MM: Cold and flu medications are some of the most used and most under-estimated products on the OTC market. They contain a variety of components that most people can't read the names of and typically don't care because they are so miserable from their cold symptoms. They want something that is fast and effective. Unfortunately many of these typical components carry with them potential danger associated with liver and kidney toxicity and elevated blood pressure. Mark Drugs carries 2 NATURAL products that do not share these potential problems. Nature Hist CT and our Allergy Relief Products. nature Hist-CT is a chewable tablet that starts working in just minutes and Allergy Relief is an oral capsule that lasts for several hours. Neither product causes drowsiness or increases blood pressure. Additionally, they may be used concurrently if necessary to provide both rapid and longer duration relief.
Some OTC Cold Medicines Expose Patients to Potentially Dangerous Phenylephrine Levels
By Amy Orciari Herman
Plasma concentrations of phenylephrine spike to potentially risky levels when the drug is used in combination with acetaminophen, according to a letter in the New England Journal of Medicine. Drugs that combine phenylephrine and acetaminophen include over-the-counter cold medicines such as DayQuil and Tylenol Cold and Flu.
The letter's authors, including drug company employees, report findings from three crossover trials: when healthy volunteers took phenylephrine (10 mg) in combination with acetaminophen (1000 mg), the maximal plasma concentration of phenylephrine was four times higher than when they took phenylephrine alone.
Combining the drugs increased phenylephrine exposure "beyond levels that were previously deemed to be safe and effective," the authors write, thereby "increasing the potential risk of adverse events." Among those potential events are "higher blood pressure, elevated heart rate and nervousness," the New York Times reports.
The FDA "said it was aware of the finding but suggested it was not a safety concern," according to the Times.
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MM: There is a lot of hype about the flu and the flu vaccine but up to 75% of people who actually have the infection are asymptomatic. That means no significant symptoms! This is the same whether a person is vaccinated or not. Therefore, the question must be asked whether there is truly any benefit to this particular vaccine. Pregnant women are strongly encouraged to receive the flu vaccine due to the distinct danger of flu to the fetus during pregnancy but the question still remains as to how much real protection is afforded from the flu vaccine.
Most Flu is Asymptomatic
By Joe Elia
Influenza, whether of the seasonal or pandemic variety, is asymptomatic in most people with serologically confirmed infection, according to a study in the Lancet Respiratory Medicine.
Researchers studied five successive cohorts of people in England during the 2006-2011 flu seasons. The cohorts ranged in size from 600 to 3500, and all members provided blood samples before and after each flu season. Their households were contacted weekly to identify flu-like illness and symptoms.
On average, roughly 20% of the unvaccinated had serologic evidence of influenza infection, but up to three quarters of the infected were asymptomatic. The proportions did not vary significantly between seasonal and pandemic influenzas. The pandemic H1N1 strain was associated with less severe symptoms than the seasonal H3N2 strain.
A commentator says an important unanswered question is how much the asymptomatic cases contribute to flu transmission
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MM: Again we see that antibiotics should not only be reserved for the most severe and dangerous infections but also offer no significant benefit over doing nothing in mild infectious cases. This supports the premise that many times what appears to be a bacterial infection may be viral or that the body is capable of combating mild infections in most cases without outside antibiotic support.
Delaying Antibiotics Doesn't Worsen Respiratory Infection Symptoms
By Kelly Young
Delayed antibiotic prescription is not associated with increased symptom severity in patients with respiratory tract infections, according to a BMJ study.
Clinicians in the U.K. assessed nearly 900 patients aged 3 years and older presenting with respiratory tract infections. A third were deemed to require immediate antibiotics. The remainder were randomized to one of five strategies: They were asked to re-contact the clinic for an antibiotic prescription if needed; received a post-dated prescription; were instructed to wait but allowed to collect the prescription from the front desk; received a prescription but were asked to wait to use it; or did not receive a prescription.
The primary outcome — patient-reported symptom severity on days 2 to 4 — did not differ significantly among the groups, including the group prescribed antibiotics immediately. Antibiotic use was also not significantly different across the randomized groups (26%-39%).
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MM: Sometimes the easiest and lowest tech solutions are the best. Although this mild bleach solution appears to have a beneficial result in the early testing, we must realize that microorganisms can develop a resistance to bleach, and other bactericidal products. So, although this appears to be a valid alternative approach, it may be only a temporary fix.
Clin Infect Dis 2014 Mar 1; 58:679
Do Bleach Baths Prevent Recurrent Staph Infections?
A large study says “maybe.”
One of the big frustrations of managing community-acquired methicillin-resistant Staphylococcus aureus (MRSA) infections is the recurrence rate, which studies put at about 50%. To interrupt the cycle, clinicians have tried a variety of preventive measures, usually some combination of antiseptics (e.g., chlorhexidine, dilute bleach) and topical antibiotics (e.g., mupirocin).
In a randomized, single-blind trial, Houston researchers evaluated the preventive efficacy of bleach baths alone in 987 healthy immunocompetent children (age range, 3 months–18 years) who had sustained one to three skin or soft tissue infections ascribed to S. aureus. The 3-month recurrence rate was 21% in children who were treated only with “standard hygienic measures” (i.e., frequent soap-and-water handwashing, nail grooming, and daily bathing), and 17% in children who also were advised to bathe twice weekly in a tub of dilute bleach — a difference that did not reach statistical significance (P=0.15). Results were similar when methicillin-sensitive and methicillin-resistant infections were considered separately. Severity of recurrence, as indicated by need for incision and drainage, was not affected by bleach bathing.
Recurrence rate was affected significantly by age, with children younger than 22 months experiencing about twice as many recurrences as older children did. Number of sites colonized with staph at study entry also influenced recurrence rate (16% for those not colonized in nose, throat, or groin vs. 30% for those colonized at all three sites).
Comment: This study did not have sufficient power to deliver a conclusive finding that bleach helps prevent recurrence of pediatric staph infections, although the authors suspected that it did. A larger study might bolster the statistics behind that conclusion, but assessing how bleach performs with concomitant use of chlorhexidine (prohibited in this study), mupirocin, or both also will require additional evaluation.
Citation(s): Kaplan SL et al. Randomized trial of “bleach baths” plus routine hygienic measures vs routine hygienic measures alone for prevention of recurrent infections. Clin Infect Dis 2014 Mar 1; 58:679.
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MM: We are a society of high tech. We have many diagnostic tests available to us but just because we have them, does it mean that it's appropriate to use them? Large volumes of tests for conditions that can be largely confirmed by observation should not be used. They are expensive and frequently offer little if any benefit or changes to treatment options. Why are they used? Because they are available and physicians are afraid of litigation accusing them of missing something or of not having corroborative data to support their diagnosis. Fear should not be a valid reason for financially undermining or knee-capping our healthcare payment system.
More Common Tests and Treatments That Pediatricians Should Question
By Kelly Young
The American Academy of Pediatrics has published a new list of five tests and treatments for children that may not be necessary, as part of the Choosing Wisely campaign. They include:

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MM: It always fascinates me when these studies come out. It is typical for doses administered to be less than what is considered to be therapeutic by most integrative medicine practitioners. This study is no different. The recommended dose of omega 3 fatty acids (fish oil) is 1000mg/50 lbs of body weight in order to see a clinical response. The dose that was administered in these studies was a simply 1000mg or the amount appropriate for a 50 pound person. I don't know of too many adults that are in that weight range. So, before we start telling patients that fish oil is of no value, we should do some studies under the same rigorous conditions that utilize appropriate doses and see what kind of clinical lab results we obtain.
Studies Provide Little Support for Guidelines on Dietary Fats and Supplements
By Larry Husten
Two new studies demonstrate the shaky underpinnings of guidelines that encourage the intake of omega-3 fatty acids.
The first, a large meta-analysis in the Annals of Internal Medicine, examined dietary fatty acid consumption, fatty acid biomarkers, and fatty acid supplements. Among the chief findings:

In the second study, published in JAMA Internal Medicine, 4200 patients with age-related macular degeneration were randomized to omega-3 fatty acids; lutein/zeaxanthin (carotenoids found in the eye); both; or placebo. After roughly 5 years, there was no significant reduction in cardiovascular outcomes in the treatment groups.
Commentators say it's now clear that omega-3 supplements "with daily doses close to 1 g in patients with or without established CVD shows no clear, considerable benefit." They conclude that for now, omega-3s should be prescribed only for patients with severe hypertriglyceridemia, "an extreme minority of the general population."
Adapted from CardioExchange
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MM: It is claimed that 1 out of 8 women in America are likely to be diagnosed with breast cancer in their lifetime. This statistic has been challenged in recent years, at least in part, by the claim of over-diagnosis through the misreading of mammograms. At the same time we are poisoning our bodies and our environment, many times in unknown ways, and increasing our risk of dementia and Alzheimer's disease. As more information is obtained and we get better at observing, perhaps we will be able to determine what the underlying cause of this cognitive deterioration is and address the root rather than merely the palliative treatment of the condition. The fact that more women than men are susceptible to this cognitive deterioration may press us in the direction of looking at estrogen and progesterone hormones. On the other hand, as more men are identified with low testosterone, there may be an evening of the numbers.
Women in their 60's are More Likely to Face Alzheimer's Than Breast Cancer
Women in their 60s are twice as likely to develop Alzheimer disease as breast cancer, according to the 2014 "Facts and Figures" report released by the Alzheimer's Association. In addition, at age 65, a woman has a 1 in 6 chance of developing Alzheimer's in her lifetime, nearly twice as high as the 1 in 11 chance among men.
In addition to offering a special section on women and Alzheimer's this year, the report includes proposed criteria and guidelines for diagnosing Alzheimer's, state-by-state prevalence and mortality stats, and analyses of caregiver burden and healthcare costs.
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Blood test Shows Early Promise in Identifying People at Risk for
Alzheimer Disease

By Kelly Young
An experimental blood test has used 10 phospholipid biomarkers to accurately predict preclinical Alzheimer disease in cognitively normal adults, according to a research letter published in Nature Medicine.
Researchers tested blood samples from community-dwelling adults aged 70 and older. Three years later, 53 had amnestic mild cognitive impairment or mild Alzheimer's, 18 of whom had developed their impairment over the course of the study. Blood test results for these adults were matched with those of 53 cognitively normal participants.
The researchers identified 10 different metabolites that were depleted in patients who later became impaired. In a validation phase, the test was over 90% accurate in predicting which people would develop mild cognitive impairment or Alzheimer's within 2 to 3 years.
The authors emphasize that their panel requires external validation before it is ready for clinical use.
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Loss of Protective Protein Linked to Alzheimer's
By Joe Elia
A protein that protects neurons against oxidative stress and amyloid beta-protein toxicity goes missing in mild cognitive impairment and Alzheimer disease, according to a study in Nature.
The protein, abbreviated as REST, was measured in the prefrontal cortex regions of young adults and elderly subjects without Alzheimer's. As expected, REST levels were low in the young and rose with age. When the brains of patients with mild cognitive impairment or Alzheimer's were examined, the REST levels in the nuclei of their neurons were dramatically lower than those among the healthy, non-impaired aged.
Commentators wonder whether stimulating REST activity might prevent neurodegeneration. They say that the results provide "the first detailed investigation of molecular markers in the brain that differentiate between populations of the young, the aged and those with Alzheimer's."
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MM: Excessive use of any chemical substance may have a deleterious effect on cognitive function. Teen-agers are at potentially greater risk of chemical damage as many parts of their brains are still developing compared to older adults. Areas that control limits, risk and other qualitative judgment activities are not fully developed until most people are in their 20's or 30's.
Am J Psychiatry 2014 Feb 28
How Heavy Marijuana Use May Hurt the Developing Brain: An Animal Study
In adolescent monkeys, 6 months of daily intravenous THC impaired spatial working memory, but not object memory, and did not increase tolerance to its acute effects.
With legalization of recreational marijuana use accomplished in two states and likely in many more, concerns about how it may affect youth are becoming more prominent than ever. To examine cognitive issues, investigators intravenously administered vehicle or Δ9-tetrahydrocannabinol (THC) at a dose equivalent to one or two marijuana cigarettes 5 days per week for 6 months to seven matched pairs of male adolescent rhesus monkeys.
The monkeys were repeatedly assessed for spatial memory (i.e., recalling the quadrant of a computer touch screen in which a square appeared) and object memory (i.e., recalling the color and shape of an object presented on the screen). With THC, improvement in accuracy (expected because of age and practice effects) was impaired both acutely and chronically on the spatial working memory task, with neither tolerance nor increased sensitivity to the marijuana effects seen over time. Object memory was not affected.
Comment: In rodent research, THC has been shown to decrease developmental neuroplasticity through glutamatergic pathways. The present study clearly demonstrates acute and persistent effects of chronic marijuana use on developing brains in adolescent monkeys — findings that are consistent with reports of a decline in IQ among human teenagers who persistently smoke marijuana. An editorialist notes that IQ declines might be reversible in even heavy marijuana users who stop early enough in their teens. However, a recent large cohort study from childhood to middle adulthood showed declines in adult IQ with persistent marijuana use that did not reverse with cessation of marijuana, especially if heavy marijuana use began in adolescence (NEJM JW Psychiatry Sep 17 2012). Clinicians, public health officials, and users: Be advised.
Citation(s): Verrico CD et al. Repeated Δ9-tetrahydrocannabinol exposure in adolescent monkeys: Persistent effects selective for spatial working memory. Am J Psychiatry 2014 Feb 28; [e-pub ahead of print].
Corcoran C.Marijuana and adolescence: What can we learn from primates? Am J Psychiatry 2014 Feb 28; [e-pub ahead of print].

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