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Content 7


The Doctor and the Pharmacist

Radio Show Articles:
March 9, 2013

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Telomere Length Predicts Vulnerability to the Common Cold
Robosurgery Injuries and Death Reports Increase
Extending the Benefits of a Smoke-Free Environment to Those Still In Utero
Birth in America — By the Numbers
Macrosomia (oversized newborns): A Growing Global Problem
High Supplemental Calcium Intake Is Associated with Cardiovascular Death
High Calcium Intake Is Associated with Earlier Mortality in Women
Top Five Recommendations to Reduce Unnecessary Medical Expenses
Newer Sleep Meds Raise Hip Fracture Risk in Nursing Home Residents

MM: None of us want to grow old and feeble.It's the feeble part that is the unpopular aspect of aging. This article describes how shortening of telomeres decrease our level of immunity and thereby diminish our health. Peer reviewed studies have demonstrated that higher systemic levels of vitamin D will serve to slow the shortening of telomeres! This is equivalent to a nutritional fountain of youth! Therefore, the use of Vitamin D3 appears to have another reinforcement for supplementation. As we have said many times in the past, it's not enough to merely have a "sufficient" level of vitamin D (30ng/ml) You are much better served to have a blood level of 60-80ng/ml.
JAMA 2013 Feb 20; 309:699
Telomere Length Predicts Vulnerability to the Common Cold
In young adults, shorter telomeres were associated with weaker viral immunity.
With each division of a healthy cell, telomeres (the ends of chromosomes) get shorter. Thus, the length of a cell's telomeres is a measure of its biological age. Older adults, whose leukocytes have shorter telomeres, are more likely to develop chronic age-related diseases, including cancer and heart disease (JW Gen Med Jul 20 2010 and JW Gen Med Jan 25 2007).
A multicenter team recruited 152 healthy young adults (age range, 18–55) and prospectively determined telomere length in several lymphocyte subsets (CD8+CD28–) that play an important role in containing viral infections. Then, they inoculated the volunteers with rhinovirus, quarantined them, and monitored them for 5 days. Participants with shorter CD8+CD28– telomeres were significantly more likely to develop virologically confirmed infections and were nearly 70% more likely to develop symptoms of upper respiratory infections. This association was independent of many potential confounders.
Comment: This study suggests that telomere length in leukocytes not only predicts vulnerability to chronic diseases in older adults but also predicts vulnerability to acute minor infectious illnesses in younger adults. No immediate clinical practice implications of this work are evident. But one day, all our patients might not only have their genomes sequenced; they also might have their telomere length monitored, and those with shorter telomeres could be targeted for certain preventive interventions.
Anthony L. Komaroff, MD  Published in Journal Watch General Medicine March 7, 2013
Citation(s): Cohen S et al. Association between telomere length and experimentally induced upper respiratory viral infection in healthy adults. JAMA 2013 Feb 20; 309:699.
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Robosurgery Injuries and Death Reports Increase
With nimble robotic instruments doing the delicate work usually performed by doctors hands-on, patients are told there will be less pain and bleeding. Robot systems made by Intuitive Surgical Inc. are linked to at least 70 deaths since 2009, according to a review by Bloomberg News. The robots cost $1.5 million each. The number of U.S. procedures done with the robots has grown to about 367,000 in 2012, compared with 292,000 in 2011, and 228,000 in 2010. Most of last year's procedures involved gynecological treatments; others involved prostate and gall bladder removals, as well as heart surgery.
Tough new questions about safety have been raised; they come as the technology is already facing criticism for raising surgical costs at a time when few large, randomized trials document significant health benefits for the robots, compared with standard less-invasive operations
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BMJ 2013 Feb 14; 346:f441
Extending the Benefits of a Smoke-Free Environment to Those Still In Utero
Successive public smoking bans in Belgium were associated with reductions in incidence of preterm deliveries.
Both maternal smoking and exposure to second-hand smoke affect pregnancy outcomes (JW Womens Health Apr 9 2009). To determine whether legislation to limit public smoking can lower risk for preterm delivery, investigators analyzed data on >606,000 singleton live births at 24 to 44 weeks' gestation in Flanders from 2002 through 2011. Smoke-free legislation in Belgium was implemented in phases, with all public places and workplaces (except for restaurants) becoming smoke-free in January 2006, restaurants becoming smoke-free in January 2007, and bars serving food becoming smoke-free in January 2010; thus, it was possible to assess changes in rates of spontaneous preterm delivery over time.
Overall, 7.2% of spontaneous deliveries occurred before 37 weeks' gestation. The preterm birth rate was relatively stable at 7.4% before the first smoke-free legislation, then began to fall during the year thereafter. The largest drops in preterm birth rates followed the smoking bans in restaurants and bars serving food, and by 2011, the rate was 6.8%. In all, the declines during the 5 years after 2007 corresponded to a reduction of 6 preterm births per 1000 deliveries.
Comment: Although the authors admit that an epidemiologic study such as this cannot prove causality, the association is compelling and cannot be accounted for by the many potential confounders that they considered (even air pollution and influenza epidemics). This "good news" study adds to the already impressive body of evidence about the dangers of cigarette smoking.
Robert W. Rebar, MD Published in Journal Watch Women's Health March 7, 2013
Citation(s): Cox B et al. Impact of a stepwise introduction of smoke-free legislation on the rate of preterm births: Analysis of routinely collected birth data. BMJ 2013 Feb 14; 346:f441.
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Pediatrics 2013 Feb 11
Birth in America — By the Numbers
U.S. teen birth rates reached a historic low in 2011, but racial disparities persisted.
U.S. vital statistics data for 2011 show that the crude birth rate was the lowest ever reported. Teen birth rates dropped steadily during the preceding 5 years among all racial/ethnic subgroups and also reached a historic low, although teen births remained twice as common in blacks and Hispanics as in whites. Since 1990, the number of pregnancies affected by diabetes more than doubled. Prevalence of preterm birth fell slightly but varied greatly by state (8.8 per 1000 live births in Vermont vs. 16.9 per 1000 in Mississippi).
Although the proportion of infants dying within 1 year of birth declined between 2005 and 2011, infant mortality rates also varied by state (3.8 per 1000 live births in Alaska vs. 10.0 per 1000 in Mississippi) and mortality among black infants was more than twice that among white infants.
Comment: Vital statistics provide important measures of the efficacy of a country's health policy and public health efforts. The finding that teen births have hit a record low is a credit to recent efforts to promote comprehensive sexual health education as well as use of highly effective contraception. Although it's good to see this progress on many fronts, persistent health disparities demand concerted efforts to improve the prenatal and general health status of our minority populations.
Eleanor Bimla Schwarz, MD, MS  Published in Journal Watch Women's Health March 7, 2013
Citation(s): Hamilton BE et al. Annual summary of vital statistics: 2010–2011. Pediatrics 2013 Feb 11; [e-pub ahead of print].
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MM: Fetal macrosomia is used to describe a newborn who's significantly larger than average. This is consistent with a birthweight greater than 8lbs,13 oz.(4000gms) however the real problems may start when the infant is 9lbs, 15 oz (4500gms). Macrosomia puts the baby at risk and makes vaginal delivery more difficult.
Lancet 2013 Feb 9; 381:476
Macrosomia (oversized newborns): A Growing Global Problem
The prevalence of macrosomia is increasing in developing countries in conjunction with rising rates of obesity and diabetes.
Macrosomia is associated with maternal and neonatal complications such as shoulder dystocia, birth trauma, cesarean delivery, and postpartum hemorrhage. Rates of macrosomia have increased in developed countries, paralleled by the rise in maternal obesity and diabetes. Although macrosomia may be less common in developing countries, its consequences in these resource-poor settings are likely to be greater. Investigators reviewed World Health Organization data to estimate prevalence of macrosomia (defined as >4000 g and >90th percentile for birth weights in the region) in 23 developing nations in Africa, Asia, and Latin America.
Prevalence of birth weight >4000 g varied widely from a low of 0.5% in India to a high of 14.9% in Algeria. Macrosomia was associated with multiparity, older maternal age, high maternal body mass index and diabetes. Risks for cesarean delivery as well as maternal morbidity and death were universally higher in the presence of macrosomia. After adjustment for other risk factors, macrosomia was associated with greater perinatal morbidity and mortality in African countries.
Comment: The burden of macrosomia is not borne solely by women in developed countries. The obesity epidemic is global, and the associated threats to perinatal and maternal health vary by healthcare setting. These findings raise questions about the relative value of improving access to technologies available in the developed world (e.g., screening tools for gestational diabetes, ultrasound to detect macrosomia antenatally, facilities for safe operative delivery when indicated) in regions where resources are scarce and competing needs are many.
Allison Bryant, MD, MPH  Published in Journal Watch Women's Health March 7, 2013
Citation(s): Koyanagi A et al. Macrosomia in 23 developing countries: An analysis of a multicountry, facility-based, cross-sectional survey. Lancet 2013 Feb 9; 381:476. (http://dx.doi.org/10.1016/S0140-6736(12)61605-5)
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JAMA Intern Med 2013 Feb 4
High Supplemental Calcium Intake Is Associated with Cardiovascular Death
But elevated risk was only in men and only for death from heart disease.
Calcium intake, both dietary and supplemental, is encouraged to improve bone health, and many older adults take calcium supplements. Recent randomized trials of supplementation suggest an association with cardiovascular disease (CVD), but the studies are heterogeneous, and results are mixed. In this prospective cohort study, U.S. researchers assessed baseline calcium intake — including dietary recall and calcium supplements and calcium-containing antacids and multivitamins — in 390,000 older adults (mean age, 61). About 50% of men and 70% of women used calcium-containing supplements. Median daily dietary intake of calcium in both men and women was 700 mg.
During 12 years of follow-up, researchers identified 12,000 CVD-related deaths. In analyses adjusted for multiple CVD risk factors, supplemental calcium was associated significantly with CVD-related death in men but not in women: In men, daily calcium supplementation of >1000 mg, compared with no supplement use, was associated with 20% higher risk for CVD-related death, with the excess risk entirely attributable to heart disease. Calcium intake was not associated with death from cerebrovascular disease.
Comment: The lack of an association between CVD-related death and calcium supplementation in women is puzzling, in light of at least some recent randomized trials (JW Gen Med Aug 31 2010). Although more study is needed to clarify these risks, a safe recommendation for both men and women is to eat a healthful diet of calcium-containing vegetables, legumes, and low-fat dairy products rather than take supplements.
Thomas L. Schwenk, MD  Published in Journal Watch General Medicine February 26, 2013
Citation(s): Xiao Q et al. Dietary and supplemental calcium intake and cardiovascular disease mortality: The National Institutes of Health–AARP Diet and Health study. JAMA Intern Med 2013 Feb 4; [e-pub ahead of print].
Larsson SC. Are calcium supplements harmful to cardiovascular disease? JAMA Intern Med 2013 Feb 4; [e-pub head of print].
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BMJ 2013 Feb 13; 346:f228
High Calcium Intake Is Associated with Earlier Mortality in Women
Higher death rates occurred with daily intakes exceeding 1400 mg.
Oral calcium supplementation is associated with elevated risk for adverse cardiovascular (CV) events such as myocardial infarction (e.g., JW Gen Med May 12 2011). Moreover, in a recent study (JW Gen Med Feb 26 2013), high-dose calcium supplementation was associated with excess CV-related mortality in men. In this prospective cohort study, Swedish investigators assessed the associations between long-term calcium intake and all-cause and CV-related death in 61,000 women born between 1914 and 1948.
Researchers estimated dietary, supplemental, and total calcium intake from food-frequency questionnaires that were completed at baseline (1987–1990) and in 1997. Median follow-up was 19 years. Compared with dietary calcium intakes of 600 to 999 mg daily, daily intakes of ≥1400 mg were associated with significantly higher rates of death from all causes (multivariate adjusted hazard ratio, 1.4), CV disease (AHR, 1.5), and ischemic heart disease (AHR, 2.1), but not from stroke. Similar results were obtained for total calcium intake. Vitamin D intake did not modify the associations.
Comment: In this study, high calcium intake was associated with excess risk for all-cause and CV-related mortality but not from stroke-related death. Although these results do not prove causality, they — along with the results of prior studies — suggest that people avoid excessive calcium intake (i.e., ≥1400 mg daily) and that high calcium intake should be reserved for situations in which benefits clearly outweigh risks.
Paul S. Mueller, MD, MPH, FACP  Published in Journal Watch General Medicine February 28, 2013
Citation(s): Michaëlsson K et al. Long term calcium intake and rates of all cause and cardiovascular mortality: Community based prospective longitudinal cohort study. BMJ 2013 Feb 13; 346:f228.
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Neurology 2013 Feb 20
Top Five Recommendations to Reduce Unnecessary Medical Expenses
The American Academy of Neurology provides evidence-based guidelines for practitioners and patients with the aim of reducing costs.
To reduce wasteful practices in medicine, the American Board of Internal Medicine and Consumer Reports developed the "Choosing Wisely" campaign. As a participant in the campaign, The American Academy of Neurology (AAN) selected a diverse panel with experience in evidence-based guidelines and practice parameters. The AAN sought from its members recommendations of practices that are common in neurology yet have strong evidence of lacking benefit (or causing harm) and are costly. From 178 submissions, the AAN selected 5 as having strong supporting rationales and obtained input from relevant subspecialty experts and patient advocacy groups. These practices are as follows:

Comment: Patients have expectations for testing and treatment, and clinicians can feel obliged to reassure patients and reduce legal risk. The Choosing Wisely campaign seeks to inform patients and lend credence to clinicians to act more conservatively. Insurance providers are increasingly creating such guidelines, but guidelines created through the AAN may be more valid and accepted.
These recommendation are useful, especially the limitations on opioids for migraine. DMTs should not be started for primary or nonrelapsing, secondary progressive MS. However, some patients on a DMT long-term may have transitioned to secondary progressive MS with no relapses for 3 years, but may still relapse or worsen upon DMT withdrawal. Knowing the CEA complication rate for each surgeon in your center is a good idea, but these data are not always available, despite the long-standing recommendation that they should be.
Robert T. Naismith, MD  Published in Journal Watch Neurology March 5, 2013
Citation(s): Langer-Gould AM et al. The American Academy of Neurology's Top Five Choosing Wisely recommendations. Neurology 2013 Feb 20; [e-pub ahead of print].
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Newer Sleep Meds Raise Hip Fracture Risk in Nursing Home Residents
By Cara Adler
Use of nonbenzodiazepine hypnotic drugs — zolpidem (marketed as Ambien), eszopiclone (Lunesta), or zaleplon (Sonata) — increases the risk for hip fracture by 66% in elderly nursing home residents, according to a JAMA Internal Medicine study.
Researchers used Medicare claims data to study some 1700 nursing home residents with hip fracture whose doctors had prescribed nonbenzodiazepine hypnotics within 149 days before the fracture. For each patient, the researchers compared use of these drugs within 30 days before the fracture with use during two earlier periods. They found a 66% increase in risk for hip fracture within 30 days of using the drugs. This risk was higher in new users and in patients who needed limited assistance with transfers.
A commentator notes that this study leaves us with "the nagging question" of whether it's the use of these drugs or the sleep disorders they're given for (or both) that accounts for the elevated fracture risk.

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