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Content 7


The Doctor and the Pharmacist

Radio Show Articles:
April 6, 2013

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More ADHD Diagnoses; Can Parental Interventions Trump Drugs?
Higher Blood Levels of Omega-3s Linked to Lower Mortality Risk
Dementia the Most Expensive Health Condition in the U.S.
Male Pattern Baldness and Heart Risk: Location Matters
FDA Approves Novel Diabetes Drug
Sunshine and Tuberculosis: Is There a Relationship?
Is Light Therapy Underused?
Does Race Affect Perceptions of Healthy Body Weight?
A Parent-Focused Intervention to Reduce Childhood Obesity

More ADHD Diagnoses; Can Parental Interventions Trump Drugs?
By Joe Elia
Over 10% of U.S. school-age children have received a medical diagnosis of attention-deficit/hyperactivity disorder, according to an analysis of federal data by the New York Times. The prevalence is almost 20% among high school boys.
One concern is that an estimated two thirds of those with ADHD receive prescriptions for stimulants. CDC Director Thomas R. Frieden told the Times: "The right medications for ADHD, given to the right people, can make a huge difference. Unfortunately, misuse appears to be growing at an alarming rate." Sales of those drugs have more than doubled since 2007, to $9 billion in 2012.
Another concern is that, according to one expert, "we have kids out there getting these drugs to use them as mental steroids — that's dangerous."
Meanwhile, a review in Pediatrics concludes that training parents to help address children's behavioral problems has "greater evidence of effectiveness than methylphenidate for treatment of preschoolers at risk for ADHD.
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MM: Finally we get long term data that demonstrates the cardiac benefits of fish oil and omega 3 fatty acids. As a practitioner I read this and give a sigh of relief that my recommendations that I truly believe in have more scientific support behind them.
Higher Blood Levels of Omega-3s Linked to Lower Mortality Risk
By Amy Orciari Herman
High plasma levels of long-chain omega-3 fatty acids are associated with reduced mortality, especially cardiovascular mortality, according to an Annals of Internal Medicine study.
Some 2700 older U.S. adults without heart disease underwent serum measurements of omega-3 fatty acids and then were followed for about 15 years. During that time, there were 1625 deaths. In adjusted analyses, participants with the highest baseline levels of omega-3s had a 27% reduction in total mortality risk, relative to those with the lowest levels. A decrease in cardiovascular mortality — and, in particular, arrhythmic cardiac mortality — accounted for most of the risk reduction.
The researchers note that "the observed mortality differences corresponded to approximately 2.2 more years of remaining life after age 65 years" in those with the highest omega-3 levels. They say their findings suggest that dietary omega-3s in older age might reduce overall mortality.
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MM: OK, we have now seen that increased levels of omega 3's have an impact on mortality. Will we soon see longitudinal, confirmatory data that demonstrates a positive effect on dementia? Maybe I'm just a romantic but I still believe that there are ways to reverse some of the trends that we have seen in the diminished state of health in western society over the past several decades. I truly believe that many of our problems are due to negative life style changes and therefore they may be reversed without resorting to the use of dangerous drugs.
Dementia the Most Expensive Health Condition in the U.S.
By The Editors
Dementia tops heart disease and cancer in terms of overall spending in the U.S., and costs will likely continue rising as the population ages, according to a study in the New England Journal of Medicine.
Researchers calculated that dementia care (including out-of-pocket spending, nursing home costs, Medicare costs, and formal and informal home care) cost $41,000 to $56,000 annually per case in the U.S. in 2010, with a total cost of $159 billion to $215 billion. By 2040, researchers estimate that dementia costs could increase nearly 80% per adult.
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Male Pattern Baldness and Heart Risk: Location Matters
By Amy Orciari Herman
Male pattern baldness — in particular, baldness at the crown of the head — is associated with increased risk for coronary heart disease, according to a meta-analysis in BMJ Open.
Researchers examined data from six observational studies that included nearly 37,000 men. After adjustment for age, smoking, and other cardiac risk factors, severe baldness was associated with a significant increase in risk for CHD, relative to no baldness (relative risk, 1.3). When the location of baldness was taken into account, vertex baldness (even mild in nature) was significantly associated with CHD, while frontal baldness was not.
The authors write that traditional cardiac risk factors, such as hypertension and smoking, might affect both baldness and heart disease, making baldness a potential marker of atherosclerosis. They add: "It has also been postulated that baldness is linked to CHD by mechanisms such as hyperinsulinemia, chronic inflammation and increased peripheral sensitivity to androgens."
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MM: Cautious optimism is how I would look at this new drug. We've learned in the past that drugs that aggressively treat diabetes tend to have incredibly nasty side effects. Additionally, drugs that focus on a single parameter may not have the long term net positive effect that that indicator references. For example, we have seen that drugs that raise cholesterol HDL, the "happy cholesterol" do not necessarily improve morbidity nor mortality. A drug that solely alters HbA1c may not have the effect of reversing diabetes. A little more time is needed before we can rejoice that this is a miracle drug.
FDA Approves Novel Diabetes Drug
By Kristin J. Kelley
The FDA has approved the first oral inhibitor of sodium glucose cotransporter 2 (SGLT2) to treat adults with type 2 diabetes. Canagliflozin (Invokana) lowers blood sugar by blocking the kidneys' urinary reabsorption of glucose, resulting in increased urinary excretion.
In nine studies comprising over 10,000 patients, the SGLT2 inhibitor improved hemoglobin A1c levels and blood sugar levels. Canagliflozin has been studied as a stand-alone treatment and in combination with metformin, sulfonylurea, pioglitazone, and insulin.
Common side effects include urinary tract infection and vaginal yeast infection. Dizziness or fainting could occur during the first 3 months of treatment due to the tablet's diuretic effect, which can lead to orthostatic or postural hypotension. The drug should not be used in patients with type 1 diabetes, diabetic ketoacidosis, severe renal impairment, or end stage renal disease.
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MM: This British study discusses the observation that TB is less frequently present in areas and seasons that have an abundance of sunlight. Part of this may be attributed to higher vitamin D levels but it may also be influenced by general full spectrum sunlight exposure. Could Full Spectrum Light Bulbs year round have a beneficial effect on diseases such as TB? It is an interesting question and one that should be further investigated.
PLoS ONE 2013 Mar 6; 8:e57752
Sunshine and Tuberculosis: Is There a Relationship?
What does a seasonal variation in TB incidence mean with regard to sun exposure and vitamin D status?
An estimated 9 million cases of tuberculosis occur each year, worldwide, with 1.7 million associated deaths. Vitamin D has been reported to contribute to host defenses against TB, and sun exposure is an important source of vitamin D. Investigators evaluated the relationship between fluctuations in sun exposure and incidence of TB in Birmingham, England.
From 1980 to 2010, 9739 new cases of pulmonary and extrapulmonary TB were reported. Reports of new cases were 24% higher in the summer than in the winter (95% confidence interval, 15.8–32.8; P<0.001). Winter dips in sunshine correlated with peaks in TB incidence 6 months later (4.7% increase in incidence for each 100 hours decrease in sunshine, P<0.001). This variation in seasonal incidence was significant in both pulmonary and extrapulmonary TB, and among U.K.-born patients. A similar trend was seen in individuals born outside the U.K., although there were too few such cases to assess statistical significance.
Comment: Seasonal occurrence of tuberculosis has been reported by other investigators. It is tempting to conclude that this phenomenon is related to sun exposure. In fact, one of the first Nobel Prizes in Medicine was given to Niels Finsen for his discovery that ultraviolet radiation was an effective therapy for cutaneous TB. However, it is important to emphasize that these findings identify an association between sun exposure and TB incidence, rather than cause and effect. It is common but incorrect to conclude that any association of a disease with season or sun exposure is caused by variations in vitamin D status. Many other factors can cause seasonal variation in disease. As the authors point out, a hypothesis generated by these observations should be followed by further investigation. The bottom line is that a seasonal variation in TB incidence exists; whether this variation is related to aspects of sun exposure or vitamin D is unclear.
Craig A. Elmets, MD Published in Journal Watch Dermatology April 5, 2013
Citation(s): Koh GC et al. Tuberculosis incidence correlates with sunshine: An ecological 28-year time series study. PLoS ONE 2013 Mar 6; 8:e57752.
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Neuropsychopharmacology 2013 Jan 31
Is Light Therapy Underused?
An animal study provides even more data on the neurobiology of this antidepressant treatment.
Light therapy is a proven therapy for seasonal depression, but the neurobiology has been unclear. To further understand how light affects serotonin pathways, investigators examined a subset of retinal ganglion cells that project to serotonin neurons in the dorsal raphe.
Gerbils were housed in total darkness for 14 days, while matched controls had usual light–dark cycles. All animals underwent laboratory protocols similar to those used to test drugs for antidepressant efficacy by measuring helplessness, despair, and anhedonia.
Darkness produced worse outcomes than normal light exposure in gerbils on depression tests, and these effects were alleviated with fluoxetine or imipramine. Destroying retinal ganglion cells that project to the dorsal raphe nucleus, or preventing them from firing, also produced depression-like outcomes. Serotonin levels in the dorsal raphe increased with lower depression scores and decreased with higher depression scores. Surprisingly, destroying rods and cones did not alter the depressive effects of ablating the ganglion cells.
Comment: These data further bolster the plausibility for light therapy improving depression.
How much light can affect mood was recently highlighted by data that even nocturnal artificial light is depressogenic (JW Psychiatry Aug 6 2012) and can affect hippocampal and brain-derived neurotrophic factor pathways. In a randomized trial, light therapy and antidepressants were equivalent (although the study lacked a double-placebo comparison arm; JW Gen Med May 9 2006). Given the accumulating preclinical and clinical evidence, is light therapy underused?
Barbara Geller, MD Published in Journal Watch Psychiatry March 25, 2013
Citation(s):  Ren C et al. Direct retino-raphe projection alters serotonergic tone and affective behavior. Neuropsychopharmacology 2013 Jan 31; [e-pub ahead of print].
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Menopause 2013 Mar; 20:269
Does Race Affect Perceptions of Healthy Body Weight?
Black women were less likely than white women to perceive their weight as unhealthy, irrespective of actual body-mass index.
Obesity-related chronic disease can be avoided or mitigated by weight loss. However, to pursue weight loss, women must perceive that their current weight is too high. In the Do Stage Transitions Result in Detectable Effects (STRIDE) study, investigators examined perceptions of body weight in a cohort of women (age range at enrollment, 40–65) by assessing answers to the question "Do you think your current weight is healthy?" in relation to participants' body-mass index (BMI).
In this cohort of black and white women, mean BMI was higher in blacks (33.1 kg/m2 vs. 29.2 kg/m2; P<0.0001). The majority of both black and white women (about 71%) perceived their weight as too high. However, 6.2% of black women (9 of 145) versus 1.1% of white women (6 of 544) viewed their weight as too low. Overall, higher BMI and greater educational attainment were associated with the perception of weighing too much, whereas lower BMI and poor emotional well-being were associated with the perception of not weighing enough.
Comment: Obesity is more common in black than in white women in the U.S. and carries higher mortality risk. As an editorialist observes, obesity may be deemed more acceptable in the black community than in the overall U.S. population. Most black women who participated in the STRIDE study recognized their weight as excessive, but as participants in an ongoing health study, they might have been unusually receptive to viewing their weight from the standpoint of health. In addition, the finding that black women were more likely than white women to perceive their weight as too low should be interpreted with caution, given the rarity of this opinion in either group. We should remain sensitive to the effects of culture on weight perception (and therefore motivation to lose weight). Motivational interviewing, the "5 A's" (Ask, Advise, Assess, Assist, Arrange; used for smoking cessation), and peer counseling are all weight-loss strategies that are widely beneficial while acknowledging cultural and individual differences.
Diane E. Judge, APN/CNP  Published in Journal Watch Women's Health April 4, 2013
Citation(s): Thomas S et al. Racial differences in perception of healthy body weight in midlife women: Results from the Do Stage Transitions Result in Detectable Effects study. Menopause 2013 Mar; 20:269.
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MM: The short term data shows promise and I feel very positive that if training and lifestyle modification becomes regular day to day habit, then we will see the longitudinal benefits of these practices.
Pediatrics 2013 Apr; 131:652
A Parent-Focused Intervention to Reduce Childhood Obesity
Children of parents who received dietary counseling during the first 15 months of life ate less sweetened foods and watched less television.
An estimated 43 million children younger than 5 years worldwide are overweight or obese, and obesity in toddlers predicts overweight during adolescence. In a cluster randomized trial, researchers examined the efficacy of an obesity prevention intervention aimed at first-time parents from different geographic areas in Australia. The intervention stressed knowledge, skills, and social support regarding infant feeding during six 2-hour sessions delivered by dieticians at first-time parents' group meetings over 15 months. The groups were run by nurses hired by the government and about 66% of first-time parents participate.
Parents of 241 children received the intervention and parents of 239 children received usual care. Children in the intervention group had significantly lower intake of sweetened drinks midway through the intervention, and by the end of the intervention, they consumed 25% fewer sweet snacks and were watching 25% less television. No differences were noted in body-mass index z-scores or physical activity at age 20 months. The intervention cost was about AUD$ 500 per family.
Comment: A recent study of a mother-focused anticipatory guidance intervention to improve infant feeding delivered at scheduled well-child visits reported similar results (Pediatrics 2012 Sep; 130:e507). Early infant and childhood interventions that focus on parents appear to have some short-term effects, but long-term follow-up studies are needed. Both studies suggest that focusing on parents during early childhood is fertile ground for slowing the obesity epidemic.
Louis M. Bell, MD  Published in Journal Watch Pediatrics and Adolescent Medicine April 3, 2013
Citation(s): Campbell KJ et al. A parent-focused intervention to reduce infant obesity risk behaviors: A randomized trial. Pediatrics 2013 Apr; 131:652.

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