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Content 7


The Doctor and the Pharmacist

Radio Show Articles:
March 3, 2012

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No Link Between Vitamin D Levels and Risk for COPD Exacerbations
Dieting and Unhealthy Weight Control Behaviors Predict Later Weight Gain
Up All Night Eating? Here's Why
FDA Exploring Expansion of Rx-to-OTC Switches
Added Warnings to Cholesterol-lowering Drugs
Statin Labels Updated to Include Diabetes, Memory, and Drug Interaction Risks
Statins and Protease Inhibitors May Interact, Causing Rhabdomyolysis
Making Smoking Cessation Stick: Nicotine-Replacement Patches in Pregnancy
Even Infrequent Use of Sleeping Pills Linked to Increased Mortality
No Safe Pattern of Alcohol Consumption During Pregnancy
Tattoos Can Be Removed in Fewer but Longer Laser Sessions
Duration of Risk for Clostridium difficile Infection After Antibiotic Use
Maneuverable Videocapsule Gastroscopy: Not Ready for Prime Time
Tai Chi vs. Other Exercises for Parkinson Disease

MM: I’ve stated many times that it is not sufficient to just read the headlines or even the abstracts. You have to read the entiire articles in many cases to see what the quality of the data is. Peer reviewed literature means only that it has been read and hopefully reviewed before it is accepted for print. The problem with these studies of Vitamin D is that they are considering extremely low blood levels of vitamin D,. I contend that an appropriate level of Vitamin D secondary to vitamin D3 administration is 60-8-ng/ml. The levels in this study look at <10-30ng/ml. Levels that are simply insufficient in my opinion.
Am J Respir Crit Care Med 2012 Feb 1; 185:286
No Link Between Vitamin D Levels and Risk for COPD Exacerbations
Two studies were consistent in showing a lack of association.
Low vitamin D levels are common in patients with chronic obstructive pulmonary disease (COPD). Two new studies examine the implications of vitamin D levels in patients with COPD.
Kunisaki and colleagues evaluated the link between baseline 25-hydroxyvitamin D (25-[OH]D) levels and risk for exacerbations among 973 COPD patients (mean FEV1, 1.12 L). At baseline, 33% of the patients had levels of 20–29 ng/mL, 32% had levels <20 ng/mL, and 8% had levels <10 ng/mL. No associations were seen between baseline vitamin D level and the time to first COPD exacerbation or the rate of exacerbations.
Lehouck and colleagues conducted a randomized, placebo-controlled trial of vitamin D supplementation (100,000 IU every 4 weeks for 1 year) among 182 patients with moderate-to-severe COPD (mean FEV1, 1.2 L) and recent exacerbations. Supplementation had no effect on time to subsequent exacerbations or on rates of hospitalization. Among patients with severe vitamin D deficiency at baseline (25-[OH]D levels <10 ng/mL), supplementation failed to reduce the time to subsequent exacerbation but led to significantly fewer exacerbations per patient-year (1.8 vs. 3.5).
Comment: Neither of these studies provides much support for a link between vitamin D levels and risk for COPD exacerbations, although the randomized trial suggests that vitamin D supplementation could reduce the number of exacerbations in patients with severe deficiency at baseline. Given that such patients already require vitamin D supplementation for prevention or treatment of bone disease, a possible relationship with COPD would not alter clinical management substantially.
Jamaluddin Moloo, MD, MPH Published in Journal Watch General Medicine February 28, 2012
Citation(s):Kunisaki KM et al. Vitamin D levels and risk of acute exacerbations of chronic obstructive pulmonary disease: A prospective cohort study. Am J Respir Crit Care Med 2012 Feb 1; 185:286. (http://dx.doi.org/10.1164/rccm.201109-1644OC)
Lehouck A et al. High doses of vitamin D to reduce exacerbations in chronic obstructive pulmonary disease: A randomized trial. Ann Intern Med 2012 Jan 17; 156:105. (http://www.annals.org/content/156/2/105.full.pdf+html)
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J Adolesc Health 2012 Jan; 50:80.
Dieting and Unhealthy Weight Control Behaviors Predict Later Weight Gain
Dieting and unhealthy weight control behaviors in adolescents are associated with excess increases in body-mass index 10 years later
Dieting and unhealthy weight control behaviors (e.g., skipping meals, using diet pills) are linked to excess weight gain during adolescence, but does this association continue into young adulthood? To find out, investigators analyzed longitudinal data from 1714 middle school and high school students (55% girls) in Minnesota. Mean age at baseline (1998–1999) was 12 years among the one third of participants who started in early adolescence and 16 years in the two thirds who started in middle adolescence.
Persistent "users" were participants who reported dieting or unhealthy weight control behaviors at baseline and 5 years later; 38% of girls and 10% of boys were persistent dieters and 44% of girls and 19% of boys reported persistent unhealthy weight control behaviors. In analysis adjusted for baseline body-mass index (BMI), girls who reported any dieting during the study had significantly greater weight gain after 10 years than girls who did not diet. Among girls and boys, persistent dieters had the greatest weight gain (mean, 4.33 and 6.96 BMI units, respectively) as did those who reported persistent unhealthy weight control behaviors (mean, 4.6 and 5.4 BMI units, respectively). Associations held true for adolescents who were and were not overweight at baseline. The most common behaviors associated with BMI increases were eating very little and skipping meals (in girls and boys), using food substitutes (boys), and using diet pills (girls).
Comment: Concerns about body image and weight are common during adolescence, especially — but not exclusively — among girls. Dieting, skipping meals, and cutting back drastically on calories might seem like good strategies (and could even work for a few days or weeks) but the data are clear — these behaviors are counterproductive in the long run. Armed with this information, we can steer adolescents away from these behaviors and help them adopt strategies that work: portion control, trading calorie-dense but nutrient-empty foods for those that promote satiety with fewer calories, and regular (but not excessive) exercise.
Alain Joffe, MD, MPH, FAAP Published in Journal Watch Pediatrics and Adolescent Medicine February 1, 2012
Citation(s):Neumark-Sztainer D et al. Dieting and unhealthy weight control behaviors during adolescence: Associations with 10-year changes in body mass index.
J Adolesc Health 2012 Jan; 50:80.
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J Clin Endocrinol Metab 2012 Jan 18;
Up All Night Eating? Here's Why
On seeing images of food, sleep-deprived men — regardless of their blood glucose levels — showed increased activation of a brain area involved in hunger motivation.
Sleep deprivation is associated with increased appetite and food intake — but why? Researchers in Europe have now explored this question, using functional magnetic resonance imaging to examine brain activations in response to images of low- and high-calorie food after a night of total sleep deprivation (TSD) and after 7 hours of sleep. The 12 participants (normal-weight men; mean age, 23) were used as their own controls, with sleep deprivation and normal sleep occurring in random order at least 2 weeks apart. A standardized dinner was provided before TSD or sleep; a standardized morning snack was provided before imaging.
Morning blood glucose levels were similar between the TSD and sleep conditions. However, the men reported significantly greater hunger after TSD, and they found 24% of the high-calorie food pictures (but none of the low-calorie ones) more appetizing after TSD than after a night's sleep. Compared with normal sleep, TSD was correlated with significantly greater activation of the right anterior cingulate cortex on seeing images of food.
Comment: The anterior cingulate cortex is involved in evaluating the potential reward from food and, through mesocorticolimbic connections, plays a role in hunger motivation. Independent of blood sugar, which can also influence appetite, sleep deprivation appears to activate this reward center, leading to greater reward from high-calorie foods — and, in turn, to calorie intake that overwhelms the somewhat increased energy expenditure that occurs with total sleep deprivation. Thus, people with chronic sleep deprivation may be more likely to overeat, and their preference for energy-dense foods may predispose them to weight gain and its complications.
Steven Dubovsky, MD Published in Journal Watch Psychiatry February 17, 2012
Citation(s):Benedict C et al. Acute sleep deprivation enhances the brain's response to hedonic food stimuli: An fMRI study. J Clin Endocrinol Metab 2012 Jan 18; [e-pub ahead of print]. (http://dx.doi.org/10.1210/jc.2011-2759)
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MM: I’m already uncomfortable with the Proton Pump Inhibitors (PPI’s) used for gastrointestinal upset, GERD and intestinal ulcers being available without a prescription. Making cholesterol, blood pressure and antibiotic medications available without professional supervision seems irresponsible. These are potentially dangerous medications; as the literature is reporting on a daily if not weekly basis. We need to be very circumspect as to whether we make these products indescriminately available. Without professional guidance and supervision people can hurt themselves. This is not casual stuff.
FDA Exploring Expansion of Rx-to-OTC Switches
The FDA has announced it will hold a public hearing on March 22 and 23 to discuss how technology can expand which drug products can be switched from prescription to over-the-counter status. The announcement stated:
These conditions of safe use would be specific to the drug product and might require sale in certain pre-defined healthcare settings, such as a pharmacy. For example, some conditions of safe use could be designed to assist patients in self-selection of an appropriate medication or provide for follow-up monitoring during continued use. The conditions of use could include requiring pharmacist intervention to ensure appropriate nonprescription use.
Other innovative technologies could include diagnostics approved for use in a pharmacy setting. The FDA stated:
For example, some diseases or conditions might require confirmation of a diagnosis or routine monitoring using a diagnostic test (e.g., a blood test for cholesterol levels or liver function) that could be available in a pharmacy.

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MM: This is one of the classes of drugs that are being considered for OTC status. As new potential dangers emerge we must not ignore them.
Added Warnings to Cholesterol-lowering Drugs
New warnings are to be added to the labels of widely used cholesterol-lowering drugs, such as Lipitor, to say they may raise levels of blood sugar and could cause memory loss. This includes the labels of statins such as Pfizer Inc.'s Lipitor, AstraZeneca's Crestor, and Merck & Co.'s Zocor that are taken by tens of millions of people.
More than 20 million Americans were taking some form of statin last year, according to IMS Health. "These are nuances, tiny little tweaks to the label, and the bigger picture doesn't change," said Steven Nissen, chief of cardiology at Cleveland Clinic. Asked what prompted the label changes, FDA spokeswoman Erica Jefferson said they were based on the agency's review of medical literature, clinical trial data, and reports of adverse events.
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Statin Labels Updated to Include Diabetes, Memory, and Drug Interaction Risks
The FDA is making several changes to the labels of statins following a comprehensive review, the agency announced on Tuesday:

SafetyAlertsforHumanMedicalProducts/ ucm293670.htm

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MM: *Note: Rhabdomylosis is a condition where there is significant muscle breakdown that ultimately leads to kidney failure since rhabdomylosis and its end products are toxic to the kidneys. This is a relatively common side effect of the statin drugs.
Statins and Protease Inhibitors May Interact, Causing Rhabdomyolysis
The FDA is warning again about interactions between protease inhibitors and certain statins that can lead to rhabdomyolysis. Protease inhibitors are used to treat HIV and hepatitis C.
In a safety communication, the agency published a list of statins that should either be avoided or whose dosing levels should be limited when coadministered with protease inhibitors. Atorvastatin, lovastatin, rosuvastatin, and simvastatin are either listed as contraindicated or have had limits put on dosages.
In particular, lovastatin and simvastatin exposures can increase beyond 10-fold when used with protease inhibitors, and rosuvastatin exposure can increase up to 3-fold, according to the FDA.
Earlier this week, the agency announced several changes to statin labels, including a warning to avoid lovastatin in combination with HIV protease inhibitors.
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MM: It’s a noble intention to decrease smoking but its important to use methods that work. The patch does not demonstrate consistent effectiveness. It provides drug replacement but does nothing for the learned habit associated with hand to mouth gratification and oral gratification that is obtained from the actual habit and act of smoking. Electric cigarettes demonstrate a better response than patches do but PRESCRIPTION NICOTINE LOLLIPOPS have demonstrated a superior response to long term smoking cessation in many patients. Call Mark Drugs for more information on this compounded prescription alternative.
N Engl J Med 2012 Mar 1; 366:808
Making Smoking Cessation Stick: Nicotine-Replacement Patches in Pregnancy
A randomized trial failed to show long-term benefit.
Smoking during pregnancy is the leading preventable cause of maternal and neonatal morbidity. Although nicotine-replacement therapy has been demonstrated to be safe and effective in nonpregnant women, its role in promoting smoking cessation in pregnant women remain unclear. A multicenter, randomized controlled trial was conducted to compare the use of standard-dose nicotine patches or placebo patches among 1050 pregnant smokers in the U.K., who also received behavioral counseling.
Women assigned to nicotine or placebo patches were equally likely to abstain from smoking between their quit date and delivery (9.4% vs. 7.6%), as measured by self-report and validated by exhaled carbon monoxide and salivary cotinine concentrations. Abstinence rates 1 month after the quit date were higher in the nicotine group than the placebo group (21% vs. 12%), but rates of adherence beyond the first month were low in both groups (7.2% and 2.8%). Gestational age, birth weight, and occurrence of perinatal death did not differ between groups.
Comment: Better strategies to curb tobacco use during pregnancy could reduce the burden of adverse pregnancy outcomes globally. In addition, longer-term abstinence would favorably affect the health of families more broadly. Unfortunately, rates of abstinence and adherence in this trial were woefully low. Whether higher doses of nicotine replacement might prove efficacious remains unknown, but the data do not support the use of standard-dose nicotine-replacement patches to promote smoking cessation during pregnancy. Clinicians should bear in mind that behavioral support for smoking cessation was provided to all women in this study; sadly, these proven interventions are neither uniformly accessible nor uniformly provided to pregnant women in the U.S.
Allison Bryant, MD, MPH Published in Journal Watch Women's Health February 29, 2012
Citation(s):Coleman T et al. A randomized trial of nicotine-replacement therapy patches in pregnancy. N Engl J Med 2012 Mar 1; 366:808. (http://dx.doi.org/10.1056/NEJMoa1109582)
Oncken C. Nicotine replacement for smoking cessation during pregnancy. N Engl J Med 2012 Mar 1; 366:846. (http://dx.doi.org/10.1056/NEJMe1200136)
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Even Infrequent Use of Sleeping Pills Linked to Increased Mortality
Adults who take hypnotics for insomnia even less than 20 times a year might face increased mortality risk, according to a study in BMJ Open.
Using a rural health system database, researchers matched more than 10,000 adults who used hypnotics with nearly 24,000 nonusers. The most commonly used hypnotics were zolpidem (e.g., Ambien) and temazepam (e.g., Restoril). During 2.5 years of observation, 6% of hypnotic users and 1% of nonusers died.
After adjustment for comorbidities, hypnotic use was associated with an elevated risk for death, with risk increasing with the number of doses used. However, even adults who took just 0.4 to 18 pills per year had a significantly increased mortality risk compared with nonusers (hazard ratio, 3.6). In addition, use of more than 18 pills per year was associated with increased cancer risk.
Asked to comment, Dr. Peter Roy-Byrne, editor-in-chief of Journal Watch Psychiatry, said, "While a provocative finding, it is hard to conceive of a mechanism that would account for increases in mortality with just a handful of sleeping pills taken annually."
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Alcohol Clin Exp Res 2012 Jan 17;
No Safe Pattern of Alcohol Consumption During Pregnancy
Risk was highest during the second half of the first trimester.
Since the first clinical description of fetal alcohol syndrome (FAS) nearly 40 years ago, no prospective study has examined the effect of various patterns of prenatal alcohol exposure on risk for the major dysmorphic features associated with the syndrome (smooth philtrum, thin vermillion border, short palpebral fissures, microcephaly, and growth deficiency). To explore this relation, researchers analyzed data from 992 pregnant women with a positive history of alcohol consumption during pregnancy who had enrolled in a prospective study conducted by the California Teratogen Information Service and Clinical Research Program. Data on exposure to 70 teratogens were collected at enrollment and every 3 months during pregnancy. A physical examination of all infants was performed by a dysmorphologist who was blind to prenatal history.
Mean gestational age at enrollment was 13 weeks (age range, 4.4–37.9 weeks). The median average number of binge drinking episodes and daily drinks during the first trimester were significantly associated with all alcohol-related birth outcomes on physical examination, with the exception of short palpebral fissures. The strongest associations were for exposure during the second half of the first trimester. Exposures during the second and third trimesters were also significantly associated with increased risk, but for fewer dysmorphic features. All associations were linear with no evidence of a threshold.
Comment: This is the first prospective study to quantify specific alcohol exposure patterns at various times during pregnancy and risk for dysmorphic facial features and growth deficiencies. An important finding was that there was no evidence for a safe threshold for drinking during pregnancy. The authors conclude decisively, ". . .women who are pregnant should abstain from alcohol throughout pregnancy."
Martin T. Stein, MD Published in Journal Watch Pediatrics and Adolescent Medicine February 29, 2012
Citation(s):Feldman HS et al. Prenatal alcohol exposure patterns and alcohol-related birth defects and growth deficiencies: A prospective study. Alcohol Clin Exp Res 2012 Jan 17; [e-pub ahead of print]. (http://dx.doi.org/10.1111/j.1530-0277.2011.01664.x)
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J Am Acad Dermatol 2012 Feb; 66:271
Tattoos Can Be Removed in Fewer but Longer Laser Sessions
Repeated exposures in one day with intervals between treatments effectively removed most tattoos.
Removal of unwanted tattoos is usually performed with Q-switched lasers. Many treatment sessions are needed (up to 20 for professional tattoos), and the results are often incomplete. These authors studied the efficacy of using four passes in a single treatment session with long intervals between treatments.
Twelve healthy white subjects with a total of 8 professional and 10 amateur tattoos were treated. Each tattoo was divided into two parts, and the parts were randomized to be treated with a single laser pass or by the so-called R20 method of four consecutive passes separated by 20 minutes. All passes were made by the same investigator using a Q-switched alexandrite laser (5.5 J/cm2, 755 nm, 100-nanosecond pulse duration, 3-mm spot size). Patients were followed for 6 months. At 3 months, results on a 5-point measure were significantly better on the R20 sides (P<0.01). In punch biopsy samples, more pigment had been removed from deeper areas with the new technique. Transient side effects included more epidermal injury and purpura on the R20-treated sides, but these did not translate into later adverse effects such as scarring.
Comment: With the R20 technique, many simple tattoos can be mostly removed in a single session. This is an exciting advance that may have an immediate effect on the standard of care. Though this study was performed with a Q-switched alexandrite laser, the results would almost certainly be similar with other Q-switched lasers. The mechanism of action is not known, but the authors hypothesize that immediate tattoo whitening after laser treatment is due to gas bubble formation that creates an optical blockage preventing the further penetration of light deep into the dermis, where the pigment particles are located; these gas bubbles appear to dissipate after a few minutes, allowing further, effective laser treatment to resume with subsequent passes. Unanswered practical questions remain: how to find staff and space for tattoo patients who will be receiving treatment for hours at a time, and how to price this service.
Murad Alam, MD, MSCI Published in Journal Watch Dermatology February 24, 2012
Citation(s):Kossida T et al. Optimal tattoo removal in a single laser session based on the method of repeated exposures. J Am Acad Dermatol 2012 Feb; 66:271.
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MM: This example of increased risk of C.diff demonstrates why appropriate Probiotic adjunctive therapy is necessaary with ALL antibiotic regimens. Its not sufficient to just use bacterial based probiotics with antibiotics. One must use a yeast based probiotic such as saccharomyces boulardii in conjunction with the antibiotics or you are simply getting a false sense of security and wasting your money. Call Mark Drugs for more informatyion about appropriate use of Probuiotics while using and after using antibiotics.
J Antimicrob Chemother 2012 Mar; 67:742
Duration of Risk for Clostridium difficile Infection After Antibiotic Use
Risk was increased 7- to 10-fold during the first month after antibiotic therapy, and nearly 3-fold for the next 2 months.
Antibiotic use is an established risk factor for Clostridium difficile infection (CDI). Less clear, however, are the degree and duration of CDI risk after cessation of antibiotic treatment.
To investigate this issue, researchers in the Netherlands performed a multicenter case-control study between March 2006 and May 2009. They examined antibiotic use — classes, as well as dosage and duration (expressed as "defined daily doses") — during the preceding 3 months in 337 patients with CDI and 564 controls matched for admission period and ward (337 without diarrhea, 227 with non-CDI diarrhea).
CDI risk rose with increasing dosage and duration of antibiotics and was highest (odds ratio, 8.5; 95% confidence interval, 4.6–15.9) when ≥14 defined daily doses had been prescribed during the preceding 3 months. All antibiotic classes except macrolides and first-generation cephalosporins were associated with CDI; carbapenems and second- and third-generation cephalosporins conferred the highest risk. Multivariate analysis showed CDI risk to be elevated 7- to 10-fold during antibiotic therapy and the first month after cessation of antibiotics, and nearly 3-fold for the next 2 months.
Comment: This study suggests that CDI risk remains elevated for at least 3 months after administration of antibiotics — at which point patients may not even remember having received such agents.
Thomas Glück, MD Published in Journal Watch Infectious Diseases February 29, 2012
Citation(s):Hensgens MPM et al. Time interval of increased risk for Clostridium difficile infection after exposure to antibiotics. J Antimicrob Chemother 2012 Mar; 67:742.
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MM: Although this is a very cool approach to looking inside the GI tract, it is costly in a number of ways. The actual cost of the procedure is significantly greater, the time involved takes practitioner and quality time away from other patients and the training necessary to perform the procedure is significantly greater. Plus, additional, very expensive equipment appears to be necessary to perform the procedure. If the procedure yielded better results it might be worth all the extra costs but at this point it does not. My inner geekdom says please but my reality says wait.
Gastrointest Endosc 2012 Feb; 75:373
Maneuverable Videocapsule Gastroscopy: Not Ready for Prime Time
Although diagnostic results were similar between this technique and standard high-definition endoscopy, capsule examination requires complicated preparation and sophisticated technology.
Capsule endoscopy has been used to evaluate the mucosa of the small and large bowel, but reliance on intrinsic bowel motility has impaired its use in the stomach. Investigators in France and Japan recently performed a comparative study of gastric examination with magnetically guided capsule endoscopy (MGCE) and with standard high-definition endoscopy. The lead author has received grants from the companies that developed the MGCE device.
The study involved 61 patients who required gastroscopy for evaluation of abdominal pain. Standard high-definition gastroscopy was performed, and the findings were noted. At least 24 hours later, MGCE was performed by an endoscopist who was blinded to the results of the earlier procedure. The endoscopist could maneuver the capsule by manipulating the magnetic field surrounding the patient or by changing the patient's position.
Capsule evaluation was considered complete in 88.5%, 86.9%, 93.4%, 85.2%, and 88.5% of patients for the pylorus, antrum, body, fundus, and cardia, respectively. A total of 108 pathological findings were noted, with 63 seen by both methods, 14 seen by gastroscopy only, and 31 seen by MGCE only. The average time required was 17.4 minutes for MGCE and 5.3 minutes for high-definition endoscopy.
The authors conclude that MGCE can evaluate the gastric mucosa and has the potential to become a screening tool in countries with incidence of gastric cancer.
Comment: This small pilot study demonstrates the technical capacity to perform gastric evaluation using this device. The number of lesions detected by capsule endoscopy alone might be explained by the longer duration of the procedure (>3 times as long as gastroscopy) and investigator bias toward more-careful examination using the new technique. The suggestion that MGCE might be a screening tool in countries with high incidence of gastric cancer seems premature: The sophisticated technology needed to create the magnetic field and manipulate the capsule is unlikely to be widely available in resource-limited settings. The benefits of unsedated endoscopy might be offset by the complicated protocol — ingestion of 900 mL of water in two doses, followed by light exercise and a 450-mL dose of warm water. Some patients with lesions discovered by capsule examination will need a subsequent endoscopy for biopsy.
David J. Bjorkman, MD, MSPH (HSA), SM (Epid.) Published in Journal Watch Gastroenterology March 2, 2012
Citation(s):Rey J-F et al. Blinded nonrandomized comparative study of gastric examination with a magnetically guided capsule endoscope and standard videoendoscope. Gastrointest Endosc 2012 Feb; 75:373.
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N Engl J Med 2012 Feb 9; 366:511
Tai Chi vs. Other Exercises for Parkinson Disease
A randomized comparison suggests potential benefits from both tai chi and resistance training.
Aiming to assess whether practicing tai chi improves measures of postural stability in patients with Parkinson disease (PD), researchers randomized 185 patients with PD ranging from early to late disease stages to be trained in tai chi, resistance training, or stretching. Training consisted of 60-minute sessions twice weekly for 24 weeks. In the resistance-training group, resistance was added at week 10 and gradually increased from 1% to 5% of body weight. The primary outcome was postural stability at 6 months, measured by maximum excursion and directional control on the limits-of-stability test. Secondary outcomes included measures of gait and knee strength, scores on the functional-reach and timed up-and-go tests, motor scores on the Unified Parkinson's Disease Rating Scale, and number of falls recorded in patient diaries.
At 6 months, the tai chi group performed significantly better than the other two groups on the primary outcome measures (vs. resistance training: maximum excursion, 5.55 percentage points better; directional control, 10.45 percentage points better; vs. stretching: 11.98 and 11.38 percentage points better, respectively). Compared with the resistance-training group, the tai chi group had similar performance on many of the secondary measures and reported nonsignificantly fewer falls. (They reported significantly fewer falls than the stretching group.)
Comment: Because much of the disability in PD arises from gait, balance, and motor dysfunction, and because many experts now prescribe exercise as an intervention, this study provides important insights. The findings add to the growing body of evidence suggesting benefits of various activities in patients with PD. However, it is important not to overinterpret the results. Patients at a wide range of disease stages were included, making generalization and interpretation of effects tricky. Better characterization of pre- and posttreatment falling in the advanced-stage patients, especially those with preexisting fall-related issues, would have been more relevant. Also, medications were quantitated by number, not dose.
Tai chi incorporates movements that enhance balance control through practicing volitional destabilization of the center of mass. Therefore, the tai chi group's better performance on balance measures makes sense. Resistance training prioritizes muscle strengthening and force development and has potential benefits that are distinct from those of tai chi. The resistance training in this study was not particularly intense, especially compared with previous studies (Parkinsonism Relat Disord 2009; 15:752 and Gait Posture 2012 Jan 20; e-pub ahead of print). Similarly, stretching is a very important part of the daily regimen for the PD patient. Therefore, modalities should be selected and tailored to meet the needs of the individual patient.
Michael S. Okun, MD Published in Journal Watch Neurology February 8, 2012
Citation(s):Li F et al. Tai chi and postural stability in patients with Parkinson's disease. N Engl J Med 2012 Feb 9; 366:511.

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