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Content 7


The Doctor and the Pharmacist

Radio Show Articles:
May 18, 2013

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Wisdom on Flu Vaccination Questioned
Doctors Still Reject Medicaid
Physicians and Nurse Practitioners Perceive Differing Primary Care Roles
Warts Are Transmitted in Homes and Schools
Ranbaxy Pleads Guilty in Federal Case
How Beneficial Is 3D Mammography with Tomosynthesis?
Will New USDA School Meal Standards Reduce Obesity?
IOM Report Notes Doubts on Dietary Sodium Recommendations
Is the Incidence of MS Increasing in Black Americans?
2012 a Record Year for West Nile Virus Deaths in the U.S.
Vitamin D and Calcium: What Women Need at Midlife and After

MM: The debate rages on when it comes to universal mandatory treatments and I am glad that it does. I do not feel that it is appropriate that everyone should be considered to have the same risk for a condition. We all have different genetic make-ups and live different lifestyles. This means that we are all very different people with different levels of risk. If there was a definitive set of circumstances that could determine which people were best suited to a specific set of risk factors and therefore would benefit the most from a vaccine then I'd say go for it. In the meantime, the present guidelines are biased and inaccurate and the general population(s) that are recommended to receive vaccines such as the flu , chicken pox or even Hepatitis B are too broad and have as great a risk from the vaccine as the potential benefits that they should provide.
Wisdom on Flu Vaccination Questioned
By Joe Elia
Influenza has been oversold as a disease, and the most widely promoted preventive measure — vaccination — rests on shaky scientific foundations, according to a BMJ essay.
In an attack that could draw mention around water coolers, the author says much of the measured benefit of vaccination owes to "healthy user bias." That is, healthier people are most likely to get vaccinated. And, he says, the CDC acknowledges this bias in its guidelines document.
Scoffing at the idea that "now we are all 'at risk'" and needing to get vaccinated, the essayist notes that deaths due to influenza decreased rapidly in the U.S. starting in the mid-20th century, well before aggressive promotion of flu vaccination.
Asked to comment, Stephen Baum of Journal Watch Infectious Diseases wrote: "While the BMJ article raises questions about the relative efficacy of influenza vaccination, it seems clear that vaccination saves many lives. If I told you I could prevent even 20% of cases of a cancer with a nontoxic drug or vaccine, the world would be lining up to get it."
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MM: This situation is only going to get worse. The Affordable Care Act is going to magnify this problem along with the decreasing number of primary care practitioners. One possible solution would be an increased number of physician assistants (PA's) and Nurse Practitioners (NP's). These professionals require a shorter educational process that is less expensive than a medical degree. This does not mean that they are less qualified to practice general medicine , only that their scope of practice may be narrower by necessity but can still accommodate a majority of patients in the general population. An added advantage is that these practitioners will likely be coming out of school with less debt than MD's and DO's so they can possibly afford to accept the lower reimbursement levels that Medicaid is able to pay.
Doctors Still Reject Medicaid
Fewer than half of U.S. doctors and other healthcare professionals accept Medicaid patients because of low payments, according to a recent study. For those that do accept Medicaid patients, getting an appointment sometimes can take months because of the high demand. The situation is worse in rural areas and 77% of the nation's 2,000-plus rural counties are designated as health professional shortage areas, according to the National Conference of State Legislatures. The lack of doctors is a growing problem nationwide that will only worsen as some 27 million people get health coverage by 2016 as part of the Patient Protection and Affordable Care Act. The Association of American Medical Colleges projects a shortage of 29,800 primary care doctors and 33,000 specialty doctors in 2015 alone.
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Physicians and Nurse Practitioners Perceive Differing Primary Care Roles
By Joe Elia
When asked about their respective roles in primary care, physicians and nurse practitioners seem to "inhabit different universes, at least perceptually," according to an editorial on a New England Journal of Medicine study.
Nearly 1000 clinicians — half primary care physicians and half primary care nurse practitioners — were surveyed on the role of nurse practitioners in primary care. The groups differed widely. For instance, 4% of physicians agreed that nurse practitioners "should be paid equally for providing the same services," versus 64% of nurse practitioners. On the statement that physicians provide a "higher quality of examination and consultation," 66% of physicians agreed, as opposed to 25% of nurses.
Editorialists note that the U.S. has a shortage of primary care clinicians in the face of the Affordable Care Act and that neither group can afford the impression that they are merely defending "narrow professional interests."
The same edition carries a useful history of the controversy
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MM: Simply cover it! That is the summary of this article. If contact is prevented, then there is a lower chance of transmission. It's a pretty simple concept. If it works...
Pediatrics 2013 May; 131:928
Warts Are Transmitted in Homes and Schools
School classrooms and family members are important reservoirs for transmission of human papillomavirus.
An estimated one third of school-age children develop cutaneous warts. Previous studies of human papillomavirus (HPV) transmission have focused on exposures in the home environment and in public places (e.g., communal showers), but have not assessed risk for wart acquisition over time or by degree of exposure or the role of classroom exposure.
Researchers prospectively followed 1000 children (age range, 4–12 years) in three primary schools in the Netherlands for 2 years and monitored them for the presence and acquisition of warts on hands and feet. Data on degree of HPV exposure included family, school, public, and environmental factors. The overall incidence rate of wart acquisition was 29 per 100 person-years. Plantar warts were more prevalent than common warts (14% vs. 9%). In multivariate analysis, exposure to warts in family and school settings was significantly associated with wart acquisition. Use of public pools, showers, and sports facilities did not significantly increase risk for wart acquisition.
Comment: Warts are common in school-age children, and this study indicates that exposure at home and school poses greater risks for transmission than previously recognized. Measures to curb transmission among family members and schoolmates (by covering lesions) might reduce the spread of warts.
Deborah Lehman, MD  Published in Journal Watch Pediatrics and Adolescent Medicine May 15, 2013
Citation(s): Bruggink SC et al. Warts transmitted in families and schools: A prospective cohort. Pediatrics 2013 May; 131:928.
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Ranbaxy Pleads Guilty in Federal Case
Ranbaxy pleaded guilty to federal drug safety violations and will pay $500 million in fines to resolve claims that it sold inferior drugs and made false statements to the FDA about its manufacturing practices at two factories in India. The settlement is the largest in history involving a generic manufacturer and drug safety.
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Lancet Oncol 2013 Apr 25
How Beneficial Is 3D Mammography with Tomosynthesis?
Three-dimensional imaging increased sensitivity and lowered false-positive rates, but isn't currently appropriate for routine screening.
Three-dimensional (3D) mammography with tomosynthesis uses a moving x-ray source to construct a series of thin-section images of the breast. Although this imaging mode has been recommended for high-risk women and those with radiologically dense breast tissue, few studies have addressed its use in routine screening. In a manufacturer-funded prospective study in Italy, women aged ≥48 were invited to receive both 2D and 3D mammography (performed during a single compression of the breast) as part of their routine screening. Each radiologist interpreted images sequentially, first using standard 2D mammography, then (on the same day) using an integrated 2D/3D image. Radiologists determined whether to recall women for additional evaluation after reading the standard image and again after analyzing the integrated imaging.
Among 7292 participants (median age, 58), 52 invasive cancers and 7 cases of ductal carcinoma in situ were detected. Of these 59 malignancies, 39 were detected with both 2D and integrated 2D/3D imaging, 20 were detected only with integrated 2D/3D imaging, and none were detected with 2D imaging alone. Cancer detection rates per 1000 screens were 5.3 with 2D only and 8.1 with integrated screening (P<0.0001). Of 395 false-positive screens (5.5%), 181 resulted from both screens, 141 resulted only from 2D, and 73 only from integrated screens.
Comment: These findings that integrated 2D/3D screening enhances sensitivity while lowering false-positive rates parallel those of an ongoing Norwegian trial (Radiology 2013 Jan 3 [e-pub ahead of print]). The authors suggest that 3D imaging should not be performed independent of 2D imaging and noted that integrated screening roughly doubles radiation exposure. I agree with their conclusions that these results do not warrant an immediate change in breast-screening practices, and that randomized trials to compare 2D with integrated 2D/3D screening are needed.
Andrew M. Kaunitz, MD Published in Journal Watch Women's Health May 16, 2013
Citation(s): Ciatto S et al. Integration of 3D digital mammography with tomosynthesis for population breast-cancer screening (STORM): A prospective comparison study. Lancet Oncol 2013 Apr 25; [e-pub ahead of print].
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JAMA Pediatr 2013 Apr 8
Will New USDA School Meal Standards Reduce Obesity?
Weight status was better in students who received subsidized school lunches in states that exceeded nutrition standards.
In January 2012, the U.S. Department of Agriculture (USDA) released new nutrition standards for school meals requiring more fruits, vegetables, and whole grains; low-fat milk; and less trans fat. To examine whether these changes have the potential to reduce childhood obesity, researchers used nationally representative longitudinal data from 2007 to compare weight status between 600 eighth-grade children in 10 states that had laws that exceeded USDA standards at that time (similar to the new 2012 standards) with that of 4270 children in 30 states that met the less-healthy school meal standards. To address state-level bias (e.g., states with higher rates of obesity might be more likely to implement healthier school meal standards), differences in outcomes were compared between students who received free or reduced-price school lunch and students who did not.
States that exceeded the USDA standards did in fact have a higher prevalence of childhood obesity than states that did not (16.5% vs. 15.2%). Overall, the adjusted prevalence of obesity was 3.7 percentage points higher in students who received subsidized school lunch than in those who did not. However, this difference was 12 percentage points lower in states that exceeded standards than in states with lower standards, and the difference in adjusted mean body-mass index was 11 points lower. Although students receiving subsidized lunch tended to buy and consume more junk food and sugary beverages than students who did not, this difference did not vary by state school lunch laws.
Comment: This creatively designed study suggests that the 2012 USDA nutrition standards for school meals might attenuate differences in obesity prevalence between students who receive free or reduced-price lunch (generally from lower socioeconomic groups and more likely to be obese) and students who do not. Another interesting finding is that laws mandating healthier school lunches did not necessarily drive students to buy and consume more junk food and sugary beverages. An editorialist praises school nutrition standards as a promising public health intervention that could reach tens of millions of children, stressing that improving school meals is an appropriate way to address childhood obesity.
Cornelius W. Van Niel, MD  Published in Journal Watch Pediatrics and Adolescent Medicine May 15, 2013
Citation(s): Taber DR et al. Association between state laws governing school meal nutrition content and student weight status: Implications for new USDA school meal standards. JAMA Pediatr 2013 Apr 8; [e-pub ahead of print].
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MM: I am thrilled that the IOM is finally realizing that sodium is not the poison that it has been made out to be. Sodium is necessary for stomach acid production and digestion. It has to be in balance for proper tear production, muscle function and brain function. Moderation is most likely the key here but apparently elimination is not.
IOM Report Notes Doubts on Dietary Sodium Recommendations
New research supports the health benefits of lowering sodium intake from very high levels to more moderate levels (i.e., 2300 mg/day), according to an Institute of Medicine (IOM) report, but reducing intake too much might actually be detrimental to one's health.
Current guidelines recommend a 2300 mg daily limit for those at average risk, and a 1500 mg limit for higher-risk individuals such as blacks, adults over age 50, and those with diabetes or kidney disease. The new IOM report concludes that evidence is insufficient to determine whether lowering intake below 2300 mg raises or lowers cardiovascular risk in the general population. In addition, there's not enough evidence to indicate that higher-risk adults should have lower targets than those at average risk; in fact, some research points to possible harms with lower intake among higher-risk individuals.
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MM: This is an interesting article in that a typically held perception that blacks are not as susceptible as European whites to develop MS is actually quite false. The statistics are indicating that just the opposite is true, that blacks are at greater risk than whites of developing MS and possibly other auto-immune conditions. This is especially true in women. Unfortunately we do not have a definitive reason so we can't come up with a universally preventative solution. I feel, however, that I can safely recommend increased Vitamin D3 consumption as a preventive and Low Dose Naltrexone (LDN) as a treatment. These may not take care of 100% of the problems but I feel strongly that they may improve the conditions of a significant portion of those who suffer or are potentially susceptible to developing this condition as well as a wide variety of others.
Neurology 2013 May 7; 80:1734
Is the Incidence of MS Increasing in Black Americans?
Black women in the U.S. are newly diagnosed in proportionally higher numbers than white women.
Studies from past decades suggested that multiple sclerosis (MS) was less common in black Americans than in white people of European descent. To provide current data on MS by race, researchers in one Southern California healthcare system analyzed almost 10 million person-years' worth of data from 2008 through 2010.
Race/ethnicity distribution within the entire health system was 37.5% white, 10.4% black, 39.9% Hispanic, 9.4% Asian/Pacific Islander, and 2.8% other/mixed. Among the 496 individuals newly diagnosed with MS, 52.0% were white, 21.4% black, 23.4% Hispanic, and 2.6% Asian. There was no difference in time from first symptoms to diagnosis for the different races. Thus, the proportion of black people with a first diagnosis of MS was higher than expected (21.4% vs. 10.4%) and was attributable entirely to women (risk ratio for black vs. white women, 1.59). The MS rates in black and white men were similar. In contrast, compared with the rate of MS in white people, the rate was lower in Hispanic (0.42) and Asian peoples (0.20).
The incidence of MS was higher in black people than white people (10.2 vs. 6.9 cases per 100,000 person-years). Similarly, the incidence among black versus white women was 14.7 versus 9.3 per 100,000 person-years. If the incidence rates for this region are similar to the rest of the country, the authors estimate 19,014 newly diagnosed MS cases in the U.S. annually, based on U.S. census data.
Comment: Despite prior studies suggesting that multiple sclerosis was less common in black people than in white people of European descent, black women are being diagnosed more often than white women, according to demographic data. Genetics may be part of the equation, but environment can also provide important clues. Other studies have suggested potential roles for vitamin D (JW Neurol Jan 17 2012), Epstein-Barr virus (JW Neurol Jun 29 2010), cigarette exposure (JW Neurol Aug 3 2005), and obesity (JW Neurol Jan 30 2013). Future studies on ethnicity should investigate whether MS diagnosis trends are changing over time and should assess more details about gene–environment interactions. Such investigations may lend insights into the permissive factors leading to MS.
Robert T. Naismith, MD Published in Journal Watch Neurology May 14, 2013
Citation(s):  Langer-Gould A et al. Incidence of multiple sclerosis in multiple racial and ethnic groups. Neurology 2013 May 7; 80:1734.
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2012 a Record Year for West Nile Virus Deaths in the U.S.
By Kelly Young
Last year set a record for the number of U.S. deaths caused by West Nile virus, the CDC reports. A total of 5674 people contracted the virus, which led to 286 deaths.
Half the cases reported to the CDC were classified as neuroinvasive. The number of infections increased eightfold over 2011. This is the highest number of reported cases since 2003.
The CDC says the increase was likely attributable to higher temperatures affecting mosquito and bird populations, viral replication in host mosquitos, and bird-mosquito interactions in regions disproportionately affected, according to an NBC News report.
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Vitamin D and Calcium: What Women Need at Midlife and After
Both nutrients are important for bone health.
With conflicting nutritional information available from multiple sources, it's hard to decide not only what to eat, but what, if any, supplements to take. It's commonly recommended that women — especially as they get older — should take calcium and vitamin D supplements to help strengthen bones and protect against future fractures (broken bones). However, the U.S. Preventive Services Task Force (USPSTF) recently concluded that there isn't enough proof that taking these supplements before or after menopause prevents fractures in women who never had fractures before, and that the possible harm supplements may cause is unknown.
So what should you do? Here's what we know right now about calcium and vitamin D for midlife and older women.
What It Is: Vitamin D is not a true vitamin. It's considered a "prohormone," a substance from which hormones are made. It comes in two forms: vitamin D2 (ergocalciferol) and vitamin D3 (cholecalciferol). If you are buying a vitamin D supplement, you may see both forms on the shelf. Unlike other vitamins, vitamin D can be made by the body: Your skin manufactures it when exposed to sunlight.
What It Does: Vitamin D works in the small intestine to help absorb calcium into the bloodstream, so that the calcium can help build bone. Vitamin D also helps strengthen muscles and the immune system and helps reduce inflammation. The bone-health benefits of vitamin D have been clearly shown. Some studies have suggested that vitamin D plays a role in preventing cardiovascular disease or some cancers. However, there is not yet enough information to prove that any dose of vitamin D can protect against these conditions, and its use for this purpose is not recommended.
How Much You Need: If you are regularly exposed to sunlight even for a short amount of time (as little as 15–30 minutes twice a week), you might have enough vitamin D. However, as you age, your body may be less efficient at making vitamin D; also, many women avoid sun exposure to protect against skin cancer and wrinkling. The recommended daily amount of vitamin D is:

A blood test can determine if you are getting an adequate amount of vitamin D (or too much). This test is not routinely recommended but can be helpful if you have malabsorption (decreased ability to absorb nutrients), osteoporosis, fractures, or another condition that makes having adequate vitamin D especially important. Your clinician (doctor, nurse practitioner, nurse midwife, or physician assistant) might have an individualized recommendation about vitamin D for you if you have certain health conditions.
How Much Is Too Much: Very high doses of vitamin D can increase calcium levels in the blood, causing kidney and heart damage. Unlike many other vitamins, D can build up in the body over time. Some ongoing studies are looking at exactly how much vitamin D is too much; for now, it is recommended that you not use supplements over 4000 IU for an extended period. If you are taking several different dietary supplements, check the labels on all of them to be sure you are not overdoing it. Don't worry about getting too much vitamin D from sun exposure or foods; that's not likely to happen.
How to Get It: Vitamin D occurs naturally in very few foods: egg yolks, fatty fish (mackerel, salmon, tuna), and beef liver. Some foods are fortified with vitamin D (and say so on the label): milk and other dairy products, cereals and grains, orange juice. If you can't get enough vitamin D from sunshine and your diet, many forms of nonprescription vitamin D supplements are available in various doses; some calcium supplements have vitamin D added as well. Many regular daily multiple vitamin supplements contain the recommended amounts of vitamin D, so check the label. As with all vitamins, inexpensive generic vitamin D supplements purchased at a pharmacy or grocery store work just as well as expensive name-brand ones advertised as "natural" or in some way superior. Look for "USP verified" on the label. Manufacturers of supplements are not required to follow the same strict guidelines as for prescription drugs. However, they may choose to have the USP agency check their products. "USP verified" means the supplement actually contains the ingredients on the label, does not contain harmful chemicals, will be released into the body in a specified amount of time, and has been manufactured according to strict guidelines.
For your body to absorb vitamin D well, take it with a meal that contains some fat — preferably "good fats" found in avocados, olive oil, fatty fish, or nuts.
What It Is: Calcium is a mineral that is essential to health in many ways.
What It Does: Calcium makes up most of your bones and teeth. It also plays a role in clotting blood and helping nerves, muscles, and the heart to work properly. Getting an adequate amount of calcium is necessary for bone health. Some studies have suggested that calcium, like vitamin D, may play a role in preventing some cancers or cardiovascular disease, but it's too early to say whether this is true.
How Much You Need: The recommended daily amount of calcium from food and — if necessary — supplements, is:

How Much Is Too Much: Taking too much calcium from supplements can cause kidney stones and heart disease. Don't worry about getting too much calcium from your diet, though; this does not seem to be a health problem and in fact might be beneficial. If you're using supplements, don't take more than the recommended amount.
How to Get It: Calcium is found in many foods, such as dairy products (milk, yogurt, cheese), some fish (such as sardines and salmon), tofu, calcium-fortified juices, and some dark green vegetables. If you eat three to four 8-ounce servings of dairy products a day, you are probably getting enough calcium from your diet. If you don't get enough dietary calcium, consider a supplement only to bring the total amount up to the recommended level. Supplements are available in various forms, including tablets, capsules, liquids, and candy-like chews. Some calcium supplements also contain vitamin D. As with vitamin D, inexpensive generic supplements are just as effective as expensive, well-advertised name brands, but look for the term "USP verified" on the label.
Vitamin D and calcium are essential to bone health. If possible, get adequate amounts from your diet and, for vitamin D, from sun exposure. Talk with your clinician or a nutritionist about supplements and bone health. If you have health problems that affect your ability to absorb nutrients, to get sun exposure, or to eat foods containing calcium and vitamin D — or if you are taking medications that affect your bone health or you have already had a fracture — different guidelines may apply to you.
And, of course, don't forget that a healthful diet, regular exercise, and good habits such as avoiding or quitting smoking and excessive alcohol also contribute to your overall wellbeing.
Nutrition http://www.womenshealth.gov/fitness-nutrition/nutrition-basics/index.html
Food Sources of Vitamin D and Calcium 
U.S. Preventive Services Task Force Information on Vitamin D and Calcium
Choosing and Using Supplements
Diane E. Judge, APN/CNP  Published in Journal Watch Women's Health February 28, 2013

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