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Content 7


The Doctor and the Pharmacist

Radio Show Articles:
April 21, 2012

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Prostate Cancer: High-Intensity Focal Ultrasound Promising in Small Study
Physical Activity in Advanced Age Associated with Lower Alzheimer's Risk
Primary Care Interventions Can Promote Physical Activity
Bariatric Surgery Outperforms Medical Therapy in Obese Diabetic Patients
Drug Shortages Causing Deaths
Proton-Pump Inhibitor Use Associated with Spontaneous Bacterial Peritonitis
Broccoli & Cousins May Fight Breast Cancer
U.S. Has Worst Measles Year in Over a Decade
AHA Casts Doubt on Gum Disease as a Cardiovascular Risk Factor

MM: This is amazing! Here is more science fiction coming to reality in medicine. Imagine treating prostate cancer with ultrasound! What‘s next; pancreatic and breast cancer? How exciting are the possibilities?
Prostate Cancer: High-Intensity Focal Ultrasound Promising in Small Study
Focal ablation for prostate cancer could move treatment strategies away from the current whole-gland approach, according to a small study in the Lancet Oncology.
Researchers followed 41 men with localized (unifocal or multifocal) cancers who had received no previous treatment. All underwent MRI to locate the cancers, and all were treated with high-intensity focused ultrasound.
By 12 months, 84% had leak-free and pad-free urinary continence, normal sexual function, and no evidence of clinically significant disease.
Commentators say that with better standardization and patient-selection criteria, focal therapy could become mainstream.
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Physical Activity in Advanced Age Associated with Lower Alzheimer's Risk
Daily physical activity is associated with reduced risk for Alzheimer disease among the elderly, according to a Neurology study.
Roughly 700 adults (average age, 82) free of dementia wore actigraphs on their wrists 24 hours a day for up to 10 days to measure their daily physical activity. Over a mean 3.5 years' follow-up, 10% were diagnosed with Alzheimer disease.
Participants in the lowest decile of physical activity had more than twice the Alzheimer's risk as those in the highest decile. The results remained significant after adjustment for self-reported physical, social, and cognitive activities. More physical activity on actigraphy was also associated with less cognitive decline.
Editorialists conclude: "In a world that is becoming progressively sedentary, and in the context of very limited success of the currently available medications to treat or delay AD, physical activity provides a promising, low-cost, easily accessible, and side-effect-free means to prevent AD."
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MM: Primary care Physicians are some of the most hard-working doctors there are. Many of them have little time for their own personal health and find it almost impossible to carve out time to exercise. None the less, they should still recommend to their patients that they get exercise, eat right and take time to reduce stress and enjoy life. Doctors, its just as important to “Do as I do”, as it is to encourage patients to “Do as I say.”
BMJ 2012 Mar 26; 344:e1389
Primary Care Interventions Can Promote Physical Activity
Among some sedentary adults, self-reported activity increased after counseling or exercise referrals.
Most adults lead sedentary lives. In a meta-analysis of 15 randomized trials that involved 8745 sedentary adults, investigators determined whether primary care–based promotion of physical activity had a salutary effect on physical activity.
Most interventions included written materials, multiple face-to-face counseling sessions about physical activity, and telephone-delivered advice. In most studies, counseling and advice was given by at least two professionals from different disciplines (e.g., physicians, nurses, exercise facilitators). Three studies involved referrals to exercise programs, with control groups who received either no intervention or brief sessions on physical activity or nutrition. At 12 months, participants who were randomized to exercise interventions were significantly more likely than controls to report exercising at levels consistent with guidelines (150 minutes of moderate-intensity exercise weekly). Overall, 12 patients needed to receive exercise interventions to get 1 to adhere to guidelines. Referrals to exercise programs were not superior to counseling and advice. In four trials, interventions had a positive, although nonsignificant, effect on cardiovascular fitness.
Comment: Primary care–based promotion of physical activity can have a salutary effect on self-reported physical activity in some sedentary patients. However, whether such promotion is associated with improved fitness and fewer adverse outcomes (e.g., early death) is unclear. Nevertheless, these results support the time-honored strategy of advising sedentary patients to increase their physical activity.
Paul S. Mueller, MD, MPH, FACP Published in Journal Watch General Medicine April 19, 2012
Citation(s):Orrow G et al. Effectiveness of physical activity promotion based in primary care: Systematic review and meta-analysis of randomised controlled trials. BMJ 2012 Mar 26; 344:e1389. (http://dx.doi.org/10.1136/bmj.e1389)
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MM: The bottom line is not that bariatric surgery is the be all and end all to improving diabetes but than losing weight no matter how it is accomplished is the number one weapon against type 2 diabetes.
Bariatric Surgery Outperforms Medical Therapy in Obese Diabetic Patients
Laparoscopic sleeve gastrectomy in morbidly obese patients with diabetes is more effective than medical therapy in controlling diabetes, according to an Archives of Surgery study.
Researchers followed 60 patients for 18 months; half underwent gastrectomy, and the others received best-available medical therapy. Before treatment, patients' BMIs averaged roughly 40.
By 18 months, surgical patients had lost more weight than medical-therapy patients (final BMI: 28 with surgery vs. 40 with medical therapy). Diabetes was in remission in 80% of the surgical patients and in none of the medical-therapy patients.
An editorialist points out that less than 1% of eligible patients undergo bariatric surgery. He calls for a partnership with primary care physicians to educate the public about surgery's benefits. (The study's authors, meanwhile, plan longer-term studies on the persistence of the benefit.)
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Drug Shortages Causing Deaths
Shortages of prescription drugs have been a growing concern for the past six years (2005 to 2010), nearly tripling and reaching record levels of 267 drugs in 2011 as manufacturers ceased operations or ran into production problems. In some cases, lifesaving treatments have been delayed, sending patients on desperate searches for needed medicines. Shortages have also caused injuries from mistakes and at least 15 deaths around the country since mid-2011, according to the ISMP. The mistakes included confusion about dosing and preparation of substitutes. Handling the shortage problem is very, very time consuming and involves a lot of people. It has a tremendous impact on pharmacy operations. Of the drugs in short supply, the majority are generic injectable medications.
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MM: Why is this article important? Because many chronically ill patients or those with compromised immune systems who enter the hospital are routinely placed on PPI’s. This is a dangerous practiceand should be challenged by caregivers and patients. There is no clinically proven benefit to routinely place patients on these medications upon hospital admission and this article illustrates a good reason why it should be abandoned.
Clin Gastroenterol Hepatol 2012 Apr; 10:422
Proton-Pump Inhibitor Use Associated with Spontaneous Bacterial Peritonitis
A higher rate of recent PPI use was seen in patients with cirrhosis who had SBP versus those who did not.
Spontaneous bacterial peritonitis (SBP) is a common complication in cirrhosis. High rates of spontaneous bacterial translocation and compromised host defenses in patients with cirrhosis seem to play a major role in the development of SBP. Use of acid-suppressive therapy, with its predisposition to bacterial overgrowth and bacterial translocation, might heighten the risk for developing SBP.
To assess whether proton-pump inhibitor (PPI) use was associated with SBP in hospitalized patients with cirrhosis, investigators conducted a retrospective case-control study. Among 1309 patients admitted to a single tertiary care center during a 4-year period, researchers identified 65 cases (patients with cirrhosis and SBP) and 65 controls (patients with cirrhosis and ascites but no evidence of SBP) and assessed their previous use of PPIs.
Use of PPIs in the previous 7 days was higher in cases than in controls (71% vs. 42%; P<0.001). Notably, 68% of cases had no documented indication for PPI use. After adjusting for Child-Pugh-Turcotte score, multivariate analysis demonstrated a 70% lower likelihood of developing SBP among patients with no PPI use in the previous 90 days versus patients with PPI use in the previous 7 days (odds ratio, 0.29; P=0.005).
Comment: This study, although retrospective, suggests that proton-pump inhibitor use is associated with higher rates of spontaneous bacterial peritonitis in patients with cirrhosis. The overutilization of PPIs continues to be an issue, especially for long-term and high-dose use, which have been linked to such adverse outcomes as ventilator-associated pneumonia in ICU patients (Ann Intern Med 1994; 120:653). Randomized controlled trials are needed to validate the association between PPI use and SBP. Meanwhile, clinicians should be vigilant in making sure PPIs are used appropriately.
Atif Zaman, MD, MPH Published in Journal Watch Gastroenterology April 20, 2012
Citation(s):Goel GA et al. Increased rate of spontaneous bacterial peritonitis among cirrhotic patients receiving pharmacologic acid suppression. Clin Gastroenterol Hepatol 2012 Apr; 10:422.
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Broccoli & Cousins May Fight Breast Cancer
U.S.-Chinese study supports the idea that diets rich in cruciferous vegetables can fight breast cancer
by Craig Weatherby

Can broccoli and its botanical cousins increase the chances of surviving breast cancer? The results of a joint U.S.-Chinese study found that breast cancer patients who ate more broccoli or other cruciferous vegetables enjoyed improved survival rates.

Broccoli belongs to a family whose members are called cruciferous vegetables. The botanical name of this plant family – Cruciferae (AKA Brassicaceae) – comes from the cross-like marking on the flower-buds of some species. Members include cabbage, kale, chard, collards, kohlrabi, Brussels sprouts, turnip, rutabaga, bok choy, cauliflower, mustard greens, and wasabi. Cruciferous vegetables are rich in sulfur compounds called glucosinolates, which enzymes convert into compounds – isothiocyanates (ITCs) and indoles – that display anti-cancer effects. As the authors of the new study wrote, “These bioactive compounds have many anti-cancer properties that may influence cancer development, progression and survival. For example, ITCs and indole-3-carbinol have been shown to reduce tumor proliferation in human breast cancer cells.” (Nechuta SJ et al 2012)

Population study reinforces crucifers’ anti-cancer reputation
The study looked at women in China, and was presented by Sarah Nechuta, Ph.D., MPH, at the American Association for Cancer Research Annual Meeting in Chicago (Nechuta SJ et al 2012). Nechuta and her colleagues compared the reported intake of cruciferous vegetables among breast cancer patients. The women were participating in the Shanghai Breast Cancer Survival Study … a prospective study of 4,886 Chinese women aged 20-75 who were diagnosed with breast cancer (stage 1 to stage 4) from 2002 to 2006. The international team’s analysis linked higher cruciferous vegetable intake during the first 36 months after breast cancer diagnosis to a reduced risk for death from any cause, breast cancer-specific death, and disease recurrence. Women’s survival rates varied in a persuasive “dose–response” pattern … as women consumed more cruciferous vegetables, their risk of death or cancer recurrence decreased. By about five years after diagnosis, the women whose self-reported intake of cruciferous vegetables ranked in the top one-fifth – an average of 150 grams (five ounces) a day – were 42 percent less likely to have died from breast cancer. (One cup of cooked broccoli, cauliflower, Brussels sprouts, mustard greens, cabbage, or kale provides about 150 grams.)

These women were also 58 percent less likely to die from any cause compared to women in the bottom fifth, who ate less than 54 grams a day. Further, the women in the top fifth of cruciferous vegetable consumption were also 19 percent less likely to see their breast cancer return. Dr. Nechuta noted that cruciferous vegetable consumption habits differ between China and the United States, and suggested this fact be considered when generalizing these results to U.S. breast cancer survivors. “Commonly consumed cruciferous vegetables in China include turnips, Chinese cabbage/bok choy and greens, while broccoli and Brussels sprouts are the more commonly consumed cruciferous vegetables in the United States and other Western countries,” she said. “The amount of intake among Chinese women is also much higher than that of U.S. women.” (VICC 2012)

Dr. Nechuta called for studies to measure the levels of active compounds in cruciferous vegetables, and characteristics in women that may influence their effects. In the meantime, as Dr. Nechuta said, “Breast cancer survivors can follow the general nutritional guidelines of eating vegetables daily and may consider increasing intake of cruciferous vegetables, such as greens, cabbage, cauliflower and broccoli, as part of a healthy diet.” (VICC 2012)

To learn more, see “Broccoli Chemical Stems Breast Cancer Cells”, “Broccoli and Company vs. Cancer and Aging”, “Broccoli Curbs Breast Cancer like Chemo Drugs”, and “Broccoli & Buddies Help Keep Arteries Clear”.

Sources: Dong JY, He K, Wang P, Qin LQ. Dietary fiber intake and risk of breast cancer: a meta-analysis of prospective cohort studies. Am J Clin Nutr. 2011 Sep;94(3):900-5. Epub 2011 Jul 20. Keck AS, Finley JW. Cruciferous vegetables: cancer protective mechanisms of glucosinolate hydrolysis products and selenium. Integr Cancer Ther. 2004 Mar;3(1):5-12. Nechuta SJ et al. Cruciferous vegetable intake after diagnosis of breast cancer and survival: a report from the shanghai breast cancer survival study. Abstract Number LB-322, Poster Section 40. Tuesday, April 3, 2012. McCormick Place West (Hall F). Vanderbilt-Ingram Cancer Center (VICC). Cruciferous Vegetables and Breast Cancer. April 6, 2012. Accessed at http://www.vicc.org/news/2012/04/breast-cancer-study-points-to-cruciferous-vegetables-benefit/ Zhang CX, Ho SC, Cheng SZ, Chen YM, Fu JH, Lin FY. Effect of dietary fiber intake on breast cancer risk according to estrogen and progesterone receptor status. Eur J Clin Nutr. 2011 Aug;65(8):929-36. doi: 10.1038/ejcn.2011.57. Epub 2011 May 4.
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U.S. Has Worst Measles Year in Over a Decade
The U.S. saw its highest number of confirmed measles cases in over a decade in 2011, with 222 cases and 17 outbreaks, according to an article in MMWR. In comparison, the U.S. had a median of 60 cases and 4 outbreaks annually from 2001 to 2010.
Roughly 90% of last year's cases were linked to importation from other nations, and 86% of patients were not vaccinated against measles or had unknown vaccination status. Nearly a third were hospitalized with the illness.
The CDC reminds clinicians to:

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AHA Casts Doubt on Gum Disease as a Cardiovascular Risk Factor
Periodontal disease, although often associated with atherosclerotic vascular disease, does not necessarily cause it, according to a statement from the American Heart Association published online in Circulation. (The Clinical Conversations podcast has a brief interview with the paper's lead author.)
An AHA committee examined the published evidence associating the two conditions. They point to the many factors contributing to gum disease that are also seen in atherosclerosis: for example, smoking, diabetes, obesity, and the presence of inflammatory markers, such as C-reactive protein.
The committee concludes that high-level evidence for causation of atherosclerosis by periodontal disease does not exist. They add that claims implying that therapeutic periodontal interventions could lower risks or affect cardiovascular disease outcomes are "unwarranted."

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