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Content 7


The Doctor and the Pharmacist

Radio Show Articles:
March 8, 2014

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CDC Seeks safer Healthcare Through Better Antibiotic Prescribing in Hospitals
Melanoma in IBD: Everyone Is at Increased Risk
Parents, Turn Down Those White Noise Machines
Can Mixed Feelings About Your Spouse Harden Your Arteries?
Touch and Existential Anxiety
Are Dietary Fiber, the Gut Microbiome, and Asthma Connected?
Rare, Diabetes-Sparing Gene Mutation Identified
Television Removal, Active Videogaming Have salutary Effect on Kids' Weight
Higher BPA Levels Associated with Prostate Cancer
18-Year Follow-Up Confirms benefit of Prostatectomy Over Watchful Waiting in Early Cancer
FDA Proposes Food Label Changes

MM: The excessive use of antibiotics is a problem both in the hospital and in the community setting. New strategies need to be employed so that clinicians will prescribe them more appropriately in order to attempt to curtail the ever growing problems of super-infection and opportunistic infection as demonstrated by the increase of C. difficile infections.
CDC Seeks safer Healthcare Through Better Antibiotic Prescribing in Hospitals
By Joe Elia
Roughly a quarter of Clostridium difficile infections could be prevented if hospital prescriptions for high-risk antibiotics were cut by a third, the CDC says in a Vital Signs issue entitled "Antibiotic Rx in Hospitals: Proceed with Caution."
The risky antibiotics include fluoroquinolones, beta-lactams with beta-lactamase inhibitors, and extended-spectrum cephalosporins. The CDC estimates that some 250,000 C. difficile infections occur each year in hospitalized patients, causing 14,000 deaths.
The fact that physicians in some hospitals prescribe up to three times as many antibiotics as physicians in others suggests the need for reforms. To that end, the CDC is encouraging "antibiotic stewardship programs" in which, for example, a single pharmacist would be appointed to support a hospital's improved prescribing.
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MM: Non-specific IBD is effected by the micro-organism balance in the gut. This imbalance is known as dysbiosis. Dysbiosis may frequently be reversed through the use of probiotics. The combination and number of microorganisms are some of the most important factors that affect this recovery. In severe dysbiosis we recommend 100-200 BU daily of a mixed bacterial probiotic and to this may be adder 500mg daily of Saccharomyces Boulardii.
Clin Gastroenterol Hepatol 2014 Feb; 12:210
Melanoma in IBD: Everyone Is at Increased Risk
In a meta-analysis, risk for melanoma was elevated in patients with IBD, irrespective of use of thiopurines or anti–tumor necrosis factor agents
Recent evidence shows that patients treated with thiopurines for inflammatory bowel disease (IBD) are at increased risk for nonmelanoma skin cancers (basal cell and squamous cell carcinoma). Also, some evidence indicates that patients treated with anti–tumor necrosis factor agents for IBD are at increased risk for melanoma.
To evaluate the overall risk for melanoma in patients with IBD, investigators conducted a meta-analysis of 12 cohort studies comprising 172,837 patients. Overall, 179 cases of melanoma were reported between 1940 and 2009. Compared with the general population, the incidence of melanoma was 37% higher in patients with IBD, 51% higher in patients with Crohn disease, and 23% higher in patients with ulcerative colitis. In a subanalysis, the elevated risk for melanoma in patients with IBD was limited to studies performed before the introduction of biologic therapies (1998), although only two studies were performed during or after 1998.
Comment: These findings suggest that the risk for melanoma is increased in all patients with inflammatory bowel disease, and it seems reasonable to warn these patients of this risk. These data also cast doubt on whether anti–tumor necrosis factor agents truly increase the risk for melanoma, necessitating further study of that issue.
Citation(s): Singh S et al. Inflammatory bowel disease is associated with an increased risk of melanoma: A systematic review and meta-analysis. Clin Gastroenterol Hepatol 2014 Feb; 12:210.

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MM: Just when new parents thought that they had a sure way to get those little ones asleep and to stay asleep we discover a significant potential downside. Hearing loss or inappropriate development of the hearing system. The recommendation that machines be turned off when the child falls asleep is obviously made by someone who either has never had children or it's been so long since they had small kids they've forgotten that as soon as you walk in the room, the kids wake-up.
Parents, Turn Down Those White Noise Machines
By Amy Orciari Herman
Infant sleep machines — designed to emit white noise or other ambient sounds to promote better sleep — can produce sound levels that might damage a baby's hearing, a Pediatrics study finds.
Researchers played 14 commercial infant sleep machines at maximum volume, and measured the output at various distances to simulate the likely distance between the machine and infant. They found that all machines, if attached to a crib or placed on a bedside table, would exceed the maximum sound level recommended for hospital nurseries; three would exceed occupational limits for adults.
The researchers conclude that sleep machines "may place infants at risk of developing noise-induced hearing loss or maldevelopment of the auditory system." For safer use, they recommend that the machines be kept as far from the baby as possible, be set at the lowest volume possible, and be shut off after the baby falls asleep.
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MM: Although this is an interesting concept, further examination of the data is necessary before making any definitive conclusions. The quality of this study is somewhat suspect. There was no reference to diet, exercise/activity level or other lifestyle confounders. Here is an example of how we have to cast a wary eye on research and just because it is published does not indicate that it is valid.
Psychol Sci 2014 Feb 5
Can Mixed Feelings About Your Spouse Harden Your Arteries?
In long-term married couples, mutual perceptions of each other as “helpful and upsetting” are associated with elevated coronary artery calcification scores.
Studies linking measures of marital satisfaction with health outcomes have yielded variable results. Recognizing that real-life marital relationships are often characterized by perceptions of one's spouse as both helpful and upsetting (i.e., ambivalence), investigators examined spouses' ratings of social relationship and marital adjustment and used standard scans to assess coronary artery calcification.
The 136 couples were married for a mean of 36 years (97% non-Hispanic white; mean age, 63; median household income, $50,000–$75,000); none had cardiovascular disease histories. Overall, 30% of spouses were viewed as primarily positive, and 70% were viewed ambivalently.
Studied variables included gender, age, body mass, blood glucose, plasma lipids, and self-reported smoking, alcohol use, and activity level. In analyses adjusting for age, sex, and body mass, coronary artery calcification scores were highest in individuals who both viewed and in turn were viewed by their spouses as both helpful and upsetting. In an ancillary analysis, this finding was not accounted for by marital dissatisfaction per se.
Comment: These intriguing preliminary findings invite studies that have larger samples, use more-precise delineations of interpersonal interactions, and explore additional factors such as inflammatory markers, other illness conditions, medications, diet, and exercise. Reciprocally ambivalent states, not just unidirectional negative mood states, might generate specific physiological distress phenomena that contribute to cardiovascular pathology. Ambivalent relationships may generate interpersonal stress and decrease mutual support. Also meriting study is the question of how much these attitudes result from individuals' pre-existing personality traits or attachment styles or from evolving transactional marital processes. Overall, these findings suggest that individual and couples therapies may have value in helping individuals prone to cardiovascular disease (or other diseases) deal with ambivalent feelings about their spouses.
Citation(s): Uchino BN et al. Spousal relationship quality and cardiovascular risk: Dyadic perceptions of relationship ambivalence are associated with coronary-artery calcification. Psychol Sci 2014 Feb 5; [e-pub ahead of print].
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MM: There is no question in my mind that the value of human touch is an incalculable asset to healing. Not just physical but emotional and psychological healing as well. Studies have demonstrated that pre-mature infants in the NICU grow faster, sleep better and have fewer co-morbid conditions when they experience periods of "human touch". If a person is saddened, a hug may be just what is needed to make them feel better. A child who has been hurt yearns for physical comfort. Why would we be at all surprised that touch would have a beneficial effect on anxiety?
Psychol Sci 2014 Jan 1; 25:30
Touch and Existential Anxiety
Brief human touch reduces death anxiety and increases a sense of social connectedness in low self-esteem subjects — at least in the experimental laboratory.
According to clinical lore, teenage girls with borderline traits need lots of hugs for reassurance, and they bring pillows and teddy bears along on overnight trips, basically as tactile transitional objects. Investigators in the Netherlands studied relationships between psychological traits and the impact of touch on the experience of “death anxiety” in several studies involving paid student volunteers in their early 20s.
In one study (N=61), a 1-second touch on the back by the female experimenter administering the questionnaires substantially reduced self-ratings of death anxiety among individuals with low self-esteem. Another study (N=120) repeated this experiment with similar results. The subjects then completed a distractor task, followed by a questionnaire on feelings of social connection; among low self-esteem subjects only, the touch was associated with higher ratings of social connection. In related experiments, after death anxiety was provoked, low self-esteem subjects rated teddy bears as having greater monetary value than low self-esteem subjects without provoked death anxiety or high self-esteem subjects (N=50); when allowed to hold one, the provoked, low-self-esteem group reported less psychological defensiveness on ethnocultural issues (N=80). On all tests, high self-esteem subjects were not affected by the touch. No differences by sex were seen.
Comment: These findings are consistent with others showing that being touched can reduce anxiety and further demonstrate that touch might be particularly valuable for low self-esteem individuals. The authors hypothesize that real or simulated touch can alleviate the terrors of existential anxiety. Oxytocin and endorphin systems may underlie these phenomena. Further studies are required to delineate the durability of these findings and to contextualize them. Although these data support therapeutic hugs, their positive effects must be weighed against the high propensity of teenagers to find enhanced emotional and/or sexual meanings in physical contact.
Citation(s): Koole SL et al. Embodied terror management: Interpersonal touch alleviates existential concerns among individuals with low self-esteem. Psychol Sci 2014 Jan 1; 25:30. (http://dx.doi.org/10.1177/0956797613483478)
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MM: Intestinal motility and inflammation are related to each other. Fiber improves the motility and inflammation decreases. Since the gut modulates over 70% of all inflammatory processes and asthma is an inflammatory event, it makes a lot of sense that asthma conditions would improve with a better GI status.
Nat Med 2014 Feb 6; 20:120
Are Dietary Fiber, the Gut Microbiome, and Asthma Connected?
Mice that were fed a diet high in soluble fiber were more resistant to developing airway hyperreactivity.
An association exists between more dietary fiber (particularly soluble fiber) and fewer gut inflammatory disorders. A Swiss team has identified some mechanisms by which high–soluble fiber diets might protect against gut inflammation and another inflammatory disease: allergic airway disease.
The team raised mice on low-, regular-, or high-fiber diets; the three groups of mice were exposed repeatedly to dust mite allergens. The high-fiber group produced the most short-chain fatty acids (SCFAs) in the gut, with consequently higher levels in the blood. Particular species of gut microbes (particularly in the Clostridium genus) were responsible for digesting soluble fiber into SCFAs. Increased blood levels of SCFAs were associated with decreased airway levels of eosinophils, interleukin-4 and -5, and total IgE, and with less mucus production and airway hyperreactivity. The high-fiber diet was associated with higher numbers of bacteria that digested soluble fiber into SCFAs. Low-fiber diets led to the opposite results — and to a higher incidence of allergic airway disease.
Comment: This study incriminates the gut microbiome in another important human disease. As Western diets have evolved to include less soluble fiber, rates of asthma have risen. A causal connection might exist: Low-fiber diets might lead to more inflammation outside the gut because of diminished levels of circulating short-chain fatty acids.
Citation(s): Trompette A et al. Gut microbiota metabolism of dietary fiber influences allergic airway disease and hematopoiesis. Nat Med 2014 Feb; 20:159.
Huffnagle GB.Increase in dietary fiber dampens allergic responses in the lung. Nat Med 2014 Feb 6; 20:120.
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MM: It will be a long time before we see this "raw" science develop any real-life effects but in the mean time, it is interesting data. Since diabetes associated with obesity has become the number one health problem in western society, the possibility that research on this topic may be grossly accelerated is a great possibility due to the tremendous financial potentials that this research could generate.
Rare, Diabetes-Sparing Gene Mutation Identified
By Joe Elia
A rare mutation is associated with a 65% reduced risk for type 2 diabetes.
Researchers mined genetic data on 150,000 people and found 70 in Iceland and Sweden with the gene variant, according to a New York Times report. The researchers report in a a letter to Nature Genetics that the variant, in a gene known as SLC30A8, truncates a protein — ZnT8 — that transports zinc in the islet cells of the pancreas. The faulty protein results in lower glucose levels and lower diabetes risks.
The Times says a vice president for one of the two drug-company sponsors "cautioned it can take 10 to 20 years to get a drug to market after discovering something new about human genetics and disease."
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MM: The use of gaming increases physical activity by a very small amount. The nominal 8 minutes a day of activity, according to the study, does not even come close to the hours spent by previous generations riding bicycles, playing sports or doing other outdoor activities. I suppose that gaming is better than being a pure couch potato but I question how much better is it?
Television Removal, Active Videogaming Have salutary Effect on Kids' Weight
By Joe Elia
Two studies in JAMA Pediatrics offer U.S. parents evidence to back their attempts at limiting sedentary screen time in their homes.
The first study reports that adding a physically active videogaming component to a weight management program increases physical activity significantly (if modestly). In a 16-week trial, researchers provided overweight children with active gaming devices in addition to the weight loss program given to the controls. The gamers had an average increase in moderate-to-vigorous activity of about 8 minutes per day relative to controls. That translates to about 4 pounds of fat over the course of a year.
The other study simply asked whether children between ages 10 and 14 had televisions in their bedrooms. The researchers then measured BMI 2 and 4 years later. Having a TV (60% did) was associated with an excess BMI of almost 0.6 at year 2 and almost 0.8 at year 4 relative to not having one.
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Higher BPA Levels Associated with Prostate Cancer
By Amy Orciari Herman
Higher urinary levels of bisphenol A (BPA) are linked to early-onset prostate cancer, according to a PLoS ONE study.
Researchers measured urinary BPA concentrations in 60 urology patients, about half of whom had prostate cancer. Concentrations were significantly higher in patients with than without cancer, particularly among those younger than 65.
In addition, when prostate cancer cells were treated in vitro with low doses of BPA, there was a significant increase in the proportion of cells with three or more centrosomes (untreated cells showed no such increase). This "centrosome amplification," the researchers say, commonly occurs in human tumors and "may contribute to neoplastic transformation of the prostate."
BPA, found in many plastics and food and beverage containers, is detectable in the urine of over 90% of Americans, the researchers note.
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18-Year Follow-Up Confirms benefit of Prostatectomy Over Watchful Waiting in Early Cancer
By Amy Orciari Herman
Prostatectomy is associated with lower prostate-cancer mortality than watchful waiting even after nearly 20 years of follow-up, according to long-term results from the Scandinavian Prostate Cancer Group Study Number 4, published in the New England Journal of Medicine.
Some 700 men with early prostate cancer were randomized to radical prostatectomy or watchful waiting. The cumulative incidence of disease-specific mortality at 18 years was reduced in the surgery group versus the observation group (18% vs. 29%). The reduction was significant only for men younger than 65, in whom the number needed to treat to prevent one prostate cancer death was four.
Among men aged 65 and older, prostatectomy was associated with significantly lower risks for metastases and need for palliative therapy.
In terms of morbidity, the groups had similar rates of erectile dysfunction (roughly 80%), but the surgery group had a higher incidence of urinary leakage than the watchful-waiting group (41% vs. 11%).
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FDA Proposes Food Label Changes
By Amy Orciari Herman
The FDA has proposed changes to the format of the "Nutrition Facts" portion of food labels. The changes reflect the current understanding of diet and chronic disease and place more emphasis on calories and serving size.
Among the changes proposed:

The updates apply to all packaged foods except some meat, poultry, and processed egg products, which are overseen by the Department of Agriculture.

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