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Content 7


The Doctor and the Pharmacist

Radio Show Articles:
May 24, 2014

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New Approach to Treating Cancer
Prevention of Catheter-Associated Urinary Tract Infections
"Sluggish Cognitive Tempo" Is the New Kid on the Attention-Disorder Block
Are Dietary Fiber, the Gut Microbiome, and Asthma Connected?
A Big Salad Could Help You Live Longer
Do Patients Benefit from Healthcare Providers' Influenza Vaccination?
Dietary Fiber Intake Is Associated Inversely with Cardiovascular Risks
How Much Have Women — and Society — Benefited from the Women's Health
   Initiative Findings?
Alternative Menopausal Therapies Don't Cool Things Down
How Safe Is Lithium in Pregnancy?
Steroids for COPD: Less Is Probably More
Top 5 Neglected Parasitic Infections in the U.S.
Is Your Stethoscope Going to Join Your Typewriter in the Storage Closet?

MM: It would be very exciting if there was an approach to treating cancer that was tumor cell specific and highly limited in local toxicity. More research and cross testing is certainly necessary before we jump onto this particular bandwagon.
Nature 2014 Apr 10; 508:191
New Approach to Treating Cancer
Inhibiting a molecule that protects cancer cells prevents growth of tumors.
The identification of the genetic basis of cancer — the roles of oncogenes and defective tumor-suppressor genes that drive unrestricted cell growth — understandably has resulted in therapies that target these genes. Imatinib (Gleevec) is one example, yet few true breakthroughs have occurred.
Two international teams report a novel approach. Rapidly dividing tumor cells synthesize large amounts of DNA and RNA and ramp up production of reactive oxygen species (ROS). ROS damage nucleic acids directly and also damage the free bases that are incorporated into nucleic acids as they are being synthesized. The investigators discovered a protein called MTH1 that protects against oxidative damage of the free bases, thereby reducing the amount of defective DNA and RNA that is produced in tumor cells and prolonging their lifespan. When the teams treated tumor cell lines with small molecules that inhibit the action of MTH1, the cells had shorter life spans than untreated tumor cells. When human melanoma cells were transplanted into mice, treating the mice with MTH1 inhibitors restricted the growth rate of the tumors.
Comment: The investigators think they have identified molecules that selectively lead to the death of tumor cells, while not having apparent adverse effects on nonmalignant cells or on animals without malignancy. That latter claim, in particular, surely will be tested.
Citation(s): Gad H et al. MTH1 inhibition eradicates cancer by preventing sanitation of the dNTP pool. Nature 2014 Apr 10; 508:215. (http://dx.doi.org/10.1038/nature13181) Huber KVM et al. Stereospecific targeting of MTH1 by (S)-crizotinib as an anticancer strategy. Nature 2014 Apr 10; 508:222. (http://dx.doi.org/10.1038/nature13194) Dominissini D and He C.Damage prevention targeted. Nature 2014 Apr 10; 508:191.
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MM: Although it is a good practice to provide data that enhances the health and well-being of patients who are statistically at risk, alternative and complimentary treatments should not be ignored. One such treatment that has shown consistent success and has demonstrated few to no adverse effects for UTI's and especially for catheter-associated UTI's is D-Mannose. This is the extract of cranberry, blueberry and/or pineapple and works by preventing E.coli bacteria from attaching itself to the walls of the bladder and urethra. By taking frequent doses of D-mannose during an acute episode of a UTI or taking a maintenance dose continually when there is an indwelling urinary catheter present, patients may be able to avoid antibiotics for UTI's.
Infect Control Hosp Epidemiol 2014 May; 35:464
Prevention of Catheter-Associated Urinary Tract Infections
This document updates 2008 guidelines on prevention of catheter-associated urinary tract infections in acute care hospitals
Sponsoring Organizations: Society for Healthcare Epidemiology of America (SHEA), Infectious Diseases Society of America, American Hospital Association, Association for Professionals in Infection Control and Epidemiology, and The Joint Commission
Target Population: Clinicians, infection control departments, hospital epidemiologists, acute care hospitals
Key Points or Recommendations:
This document updates 2008 SHEA guidelines on the prevention of catheter-associated urinary tract infections (CAUTIs). Following a review of existing guidelines and recommendations and recent relevant literature, it outlines basic practices that should be implemented by all acute care hospitals, special approaches that could be considered for implementation, and strategies that should not be routinely used.
Key recommendations include:

What's Changed: The guidelines now include specific implementation strategies that institutions can use to improve practices, focusing on ways to engage healthcare providers, improve educational programs, and overcome resistance to practice changes.
Comment: Going forward, hospitals with high rates of catheter-associated urinary tract infections can be penalized by the Centers for Medicare and Medicaid Services — a ruling that has spotlighted the need for effective preventive measures.
A strength of these guidelines is the new section on implementation strategies. The document also highlights concerns with using device-days rather than patient-days as a denominator for determining CAUTI incidence (possibly masking substantial achievements of successful CAUTI-prevention programs), as well as with comparing the effects of prevention strategies among facilities (because the validity of the current CDC/National Healthcare Safety Network definition for CAUTIs has not been established for use in such comparisons).
Citation(s): Lo E et al. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014 May; 35:464.
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MM: When we consider many of the criticisms of the American system of schooling that seems to point at an inadequate approach to learning and teaching that tends to bore the student rather than stimulate their minds, I am personally very reluctant to identify and give credence to a condition that emphasizes boredom as its primary diagnostic characteristic. I would first look at the methods of education that we use in this country and compare them to those used in the multitude of educational systems that are leaving out schools in their dust and assess if there is a problem with the process and not our kids.
"Sluggish Cognitive Tempo" Is the New Kid on the Attention-Disorder Block
By Joe Elia
An emerging diagnosis, not yet in the DSM, seems poised to enter the family of attention disorders. Called "sluggish cognitive tempo," it's reported in the New York Times to be a seemingly ill-defined target for ADHD-related drugs.
Characterized by lethargy, daydreaming, and slow mental processing, SCT is estimated to affect some 2 million children (roughly 6 million have ADHD). One researcher with strong ties to an ADHD drug maker says that SCT "has become the new attention disorder," according to the Times. Others aren't so sure. One expert warned: "We haven't even agreed on the symptom list — that's how early we are in the process."
Asked to comment, Peter Roy-Byrne, editor-in-chief of NEJM Journal Watch Psychiatry, expressed concern that SCT "will be used as a convenient easy diagnosis in lieu of evaluating things more carefully, especially from a psychological and behavioral perspective."
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MM: Fiber, probiotics and digestive enzymes are all natural means of maintaining regularity, inhibiting inflammation and promoting the immune system through proper gut health and modulation. Mark Drugs provides a variety of products that all promote gut health while addressing other metabolic conditions, pain & inflammation.
Nat Med 2014 Feb; 20:159
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. (http://dx.doi.org/10.1038/nm.3472)
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MM: Whether it's a salad, raw fruits or vegetables, the reduction of red meat from the diet and the promotion of regularity seem to provide benefit in a number of general ways. This approach goes back at least 2000 years to Hippocrates who recommended a plant based diet to his patients.
A Big Salad Could Help You Live Longer
By Amy Orciari Herman
Eating just a couple of servings of fruits or vegetables daily is associated with reduced all-cause mortality, according to a study in the Journal of Epidemiology and Community Health.
Some 65,000 U.K. adults completed annual health surveys over an 8-year period. During nearly 8 years' follow-up, 7% of the sample died. Compared with participants who reported eating less than 1 serving of fruits and veggies daily, those who ate 1 to <3 servings had a 12% reduction in all-cause mortality. As consumption increased, so did the risk reduction, with those eating 7 or more servings daily experiencing a 33% risk reduction.
Significant reductions in cancer- and cardiovascular-related mortality were also seen with 3 or more servings daily.
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MM: Only 1 out of 1000 or 0.1% of the studies trying to justify HCP's receiving vaccines were worthy of supporting this practice. Yet, it is a practice that is required by all HCP students, nurses, physicians and others. We are stuck in the mindset that vaccines offer a magic power of protection yet the data simply does not support their prolific use in preventing injury to patients.
Clin Infect Dis 2014 Jan 1; 58:50
Do Patients Benefit from Healthcare Providers' Influenza Vaccination?
A literature review showed a reduction in all-cause mortality and influenza-like illness among the providers' patients, but the quality of evidence was moderate to very low.
Although influenza vaccination is recommended for healthcare providers (HCPs) in the U.S. and many other countries, whether it benefits patients remains controversial. The debate stems in part from the quality of evidence in previous studies.
To rectify this situation, researchers at the CDC conducted a review of randomized, controlled trials, cohort studies, and case-control studies published between January 1948 and June 2012 that reported on the association between influenza vaccination of HCPs and morbidity or mortality among patients of healthcare facilities. They evaluated evidence quality using the Grading of Recommendations Assessment, Development and Evaluation system, a methodology employed by more than 60 organizations worldwide. Out of 8790 articles identified by the literature search, only 8 (4 cluster-randomized trials and 4 observational studies) met the authors' inclusion criteria.
In the cluster-randomized trials, HCP vaccination was associated with a 29% (95% confidence interval, 15%–41%) reduction in all-cause mortality and a 42% (95% CI, 27%–54%) reduction in influenza-like illness among patients. Results of the observational studies also showed HCP influenza vaccination to be associated with decreased risk for influenza-like illness in patients. However, the quality of evidence from the randomized trials was only moderate for the effect of HCP vaccination on reducing mortality among patients and was low for reducing influenza-like illness. In addition, the quality of evidence from the observational studies for mortality and influenza-like illness was very low.
Comment: It is sobering that only 8 studies out of more than 8000 were of sufficient relevance and quality to be analyzed and that the strength of the data was no better than moderate. However, as an editorialist points out, we should not be slaves to statistical analysis. Given the known safety and efficacy of influenza vaccination in general, the current study offers additional evidence that we have reached the threshold of evidence regarding the benefit of immunizing healthcare providers to protect susceptible patients.
Citation(s): Ahmed F et al. Effect of influenza vaccination of healthcare personnel on morbidity and mortality among patients: Systematic review and grading of evidence. Clin Infect Dis 2014 Jan 1; 58:50.
Griffin MR.Influenza vaccination of healthcare workers: Making the grade for action. Clin Infect Dis 2014 Jan 1; 58:58.
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MM: Most of us have bought into the idea that adding dietary fiber on a daily basis is generally beneficial. The type of fiber that we consume may have distinct effects on our health and well-being. There has been no benefit demonstrated that psyllium or other non-dietary fiber has benefits other than relieving constipation or diarrhea so in general these should be avoided. There are also distinct differences in the effect on the body between soluble and non-soluble fiber. One is better for people with loose stool and the other for those with chronic constipation and should be avoided by those with the reciprocal condition. The bottom line is that we need to be informed consumers and know what and when to use different products and not just look at the abstracts. To do things correctly and obtain benefits from these activities we must have a more complete knowledge basis.
BMJ 2013 Dec 20; 347:f6879
Dietary Fiber Intake Is Associated Inversely with Cardiovascular Risks
Every 7-g increase in daily dietary fiber intake was associated with significantly lower risks for coronary heart disease and CV disease.
High dietary fiber intake is associated with lower risk for coronary heart disease (CHD). However, which fiber types are protective and whether a dose–response relation exists are unclear. In this meta-analysis of 22 observational cohort studies, investigators assessed associations between intakes of various dietary fiber types and risks for first CHD and cardiovascular disease (CVD) events.
Every 7-g daily increase in total dietary fiber intake (e.g., the amount in about 1 cup of bran flakes, 1 cup of raw green peas, or 2 apples) was associated significantly with lower risk for CHD and CVD events (risk ratio, 0.9 for both). Findings were similar for each of the various types of fiber (soluble, insoluble, vegetable, fruit, cereal), although the lowered risk just missed statistical significance for some subgroups.
Comment: In this study, higher dietary fiber intakes — from various sources — were associated with lower risks for coronary heart disease and cardiovascular disease in a dose–response pattern. Women and men should aim for total dietary fiber intakes of 25 g daily and 38 g daily, respectively. Finally, although these observational studies adjusted for confounding variables to some extent, some confounding remains possible (e.g., high dietary fiber intake is associated with other healthy behaviors).
Citation(s): Threapleton DE et al. Dietary fibre intake and risk of cardiovascular disease: Systematic review and meta-analysis. BMJ 2013 Dec 20; 347:f6879.
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MM: Perhaps the most useful portion of this article is what is missing. The authors have a very myopic view of HT.They fail to consider the effect(s) on quality of life. Bt any measure, that is a worthy outcome to consider.
Ann Intern Med 2014 May 6; 160:594
How Much Have Women — and Society — Benefited from the Women's Health Initiative Findings?
Disease-simulation analysis suggests substantial economic benefits but failed to consider other important outcomes.
After findings from the Women's Health Initiative (WHI) estrogen plus progestin (EPT) clinical trial — a $260 million undertaking — were published in 2002, use of EPT and estrogen-only hormone therapy (HT) by U.S. women plummeted. Now, investigators have estimated the clinical and economic effects of this trial from a payer perspective. They developed a disease-simulation model to evaluate the trial's impact from 2003 to 2012 on women (age range, 50–79) with an intact uterus and estimated outcomes of a “WHI scenario” (based on lower prevalence of HT use resulting from WHI findings) versus a “no-WHI” scenario (based on trends in HT use before the WHI).In the WHI scenario compared with the no-WHI scenario, 126,000 fewer cases of breast cancer, 76,000 fewer cases of cardiovascular disease, and 80,000 fewer cases of venous thromboembolism occurred, as well as 263,000 more fractures and 15,000 more cases of colorectal cancer. The authors estimated that the WHI resulted in $35.2 billion savings in medical expenditures (principally due to fewer prescriptions for EPT and associated office visits).
Comment: At first glance, the clinical and economic benefits of the Women's Health Initiative estrogen plus progestin trial seem enormous. However, I am surprised that the authors did not consider other key issues. Less use of systemic hormone therapy has resulted in many more women suffering from bothersome vasomotor and sleep-related menopausal symptoms. In addition, the authors did not account for the major decrease in use of estrogen-only therapy by women with hysterectomies. Given that ET lowers risk for breast cancer and cardiovascular disease, declines in its use have resulted in increased morbidity and mortality from these conditions. Lastly, because the profound reduction in use of systemic HT has not been accompanied by greater use of vaginal estrogen, a substantial increase in symptomatic vulvovaginal atrophy with attendant sexual dysfunction and impaired quality of life has resulted.
Citation(s): Roth JA et al. Economic return from the Women's Health Initiative Estrogen Plus Progestin Clinical Trial: A modeling study. Ann Intern Med 2014 May 6; 160:594. (http://dx.doi.org/10.7326/M13-2348)

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MM: Improvement of menopausal symptoms may be seen by a variety of alternative methods of treatment. Vasomotor symptoms seem to be most greatly improved with the use of hormone therapy and my preference from a safety and effectiveness approach are generally transdermal Bio-identical Hormone Replacement Therapy (BHRT). This predominantly applies to the use of estrogen and testosterone in women. Progesterone may be administered either orally or transdermally depending on the individual's symptoms and therapeutic goals. Other than the use of BHRT, I have seen only a couple of products that have consistently provided benefits to this patient group. These are NeuEve vaginal inserts for urogenital issues and Estrovera oral tablets for hot flashes, night sweats and a variety of other menopausally related concerns.
Both of these products are available at Mark Drugs.
Menopause 2014 Apr; 21:321
Alternative Menopausal Therapies Don't Cool Things Down
Exercise, yoga, and ω-3 supplements did not alleviate vasomotor symptoms, but both activity interventions improved sleep quality.
The search for effective, acceptable treatments for women with menopausal vasomotor symptoms (VMS) has taken many paths. Now, to explore the efficacy and tolerability of three alternative therapies for VMS (aerobic exercise, yoga, and ω-3 fish oil supplements), researchers have conducted a 12-week, 3-by-2 factorial, randomized, controlled trial involving 249 previously sedentary women in late perimenopause or postmenopause (age range, 40–62) who met criteria for frequency and severity of hot flashes and night sweats. Participants were randomized to one of three groups: weekly 90-minute yoga classes plus daily practice at home, thrice weekly individualized cardiovascular conditioning training sessions, or usual physical activity. Women in each group were further randomized to receive ω-3 fish oil supplements (1.8 g daily) or placebo. Frequency and bother of VMS were reported in diaries; sleep quality and mood were assessed with validated questionnaires.
At 12 weeks, no differences were found regarding relief of VMS among women in the exercise, yoga, or usual-activity groups (although white women reported experiencing less-frequent VMS, whereas black women reported no change). Participants who received ω-3 supplements showed no benefit compared with placebo in VMS or measures of sleep quality.
Compared with women in the usual-activity group, those in the exercise group reported greater improvement in insomnia symptoms and sleep quality, although between-group differences were modest. Participants in yoga also experienced better sleep; moreover, they were generally satisfied with this intervention, with the majority expressing a desire to continue yoga.
Comment: An editorialist mentions the lack of motivation in the general population to adhere to interventions such as exercise, noting that these study participants (355 out of 900,000 women who received recruitment letters) therefore may not be representative of all women who seek solutions to symptoms of menopause. Many women want a “natural” option for management of vasomotor symptoms, but the concept of working for it doesn't necessarily fit into the equation. As for ω-3 supplements, these results appear to place them among the failures in the search for a nonprescription pill for effectively warding off hot flashes. Taken together, however, the findings of this tripartite study provide more good evidence that physical activity in any form is a prescription for wellbeing in menopausal women.
Citation(s): Sternfeld B et al. Efficacy of exercise for menopausal symptoms: A randomized controlled trial. Menopause 2014 Apr; 21:330.
(http://dx.doi.org/10.1097/GME.0b013e31829e4089) Newton KM et al. Efficacy of yoga for vasomotor symptoms: A randomized controlled trial. Menopause 2014 Apr; 21:339. (http://dx.doi.org/10.1097/GME.0b013e31829e4baa) Cohen LS et al. Efficacy of omega-3 for vasomotor symptoms treatment: A randomized controlled trial. Menopause 2014 Apr; 21:347. (http://dx.doi.org/10.1097/GME.0b013e31829e40b8) Richardson MK.Menopause strategies: Finding lasting answers for symptoms and health: Eliminating hot flashes — still not a slam dunk! Menopause 2014 Apr; 21:321.
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Am J Psychiatry 2014 Apr 29
How Safe Is Lithium in Pregnancy?
A new study raises concerns about cardiovascular malformations and other adverse pregnancy outcomes.
Lithium has been associated with increased rates of cardiovascular anomalies, primarily Ebstein's anomaly. Researchers in Israel conducted a prospective, observational study to examine associations between lithium and adverse pregnancy outcomes among women seeking advice from a teratology information service. The study population was 183 lithium-exposed pregnancies (90% with first-trimester exposure), 72 lithium-nonexposed pregnancies of women with bipolar disorder, and 748 pregnancies without teratogen exposure.
Rates of miscarriage, elective termination, and preterm delivery were higher in the lithium-exposed group than in the nonteratogen group. The three groups had similar overall rates of major malformations. Cardiovascular malformations were significantly more common with first-trimester lithium exposure (4.1% vs. 0.6% in nonteratogen-exposed pregnancies), but not after exclusion of spontaneously resolved anomalies (2.4% and 0.3%). Elevated cardiovascular risk with lithium exposure persisted after adjustment for potential confounders (smoking, birth order, and bipolar disorder).
Comment: Although this study reports higher rates of miscarriage, preterm birth, and persistent cardiovascular anomalies with in utero lithium exposure, the small number of anomalies weakens the power of group comparisons. With few subjects having bipolar disorder but not lithium exposure, determining the effects of the underlying illness is difficult. Risks of lithium discontinuation and untreated bipolar disorder during pregnancy must be weighed against medication risks. Among the alternatives, mood stabilizers such as valproate and carbamazepine are teratogens; lamotrigine has unclear efficacy for mania. Clinicians should ensure that women of childbearing age who take lithium use appropriate birth control, should counsel them about potential risks in pregnancy, and could consider treatment with an antipsychotic during pregnancy, provided that it effectively treats the patient's illness.
Citation(s): Diav-Citrin O et al. Pregnancy outcome following in utero exposure to lithium: A prospective, comparative, observational study. Am J Psychiatry 2014 Apr 29; [e-pub ahead of print].
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MM: Here is another example of how a more moderate approach to a life threatening condition may be a more appropriate course of action.
Am J Respir Crit Care Med 2014 May 1; 189:1052
Steroids for COPD: Less Is Probably More
 Patients with chronic obstructive pulmonary disease exacerbations who require intensive care admission do better with low-dose steroids.
A 2010 observational study suggested that relatively low-dose oral corticosteroids were as good as — or better than — high-dose parenteral steroids in hospitalized patients with chronic obstructive pulmonary disease (COPD) exacerbations, but intensive care unit (ICU) patients were excluded from that study (NEJM JW Gen Med Jun 24 2010). Whether these results can be extrapolated to patients admitted to ICUs is unclear.
Researchers evaluated 17,239 patients (77% older than 60; 31% tobacco users) with COPD exacerbations who were admitted to ICUs at 473 U.S. hospitals. Nearly one third of patients received noninvasive ventilation; 15% were intubated. Almost all patients received antibiotics and bronchodilators. Methylprednisolone doses were categorized as either high (>240 mg) or low (≤240 mg), based on total methylprednisolone administered on hospital day 1 or 2; 11,083 patients (64%) received high doses.
Patients in the two groups were matched by propensity scoring. After adjusting for unbalanced covariates, the groups had similar in-hospital mortality. Compared with high-dose treatment, low-dose treatment was associated with shorter ICU and hospital lengths of stay, lower hospital costs, and shorter duration of mechanical ventilation. Low-dose patients were less likely to require insulin therapy or develop fungal infections.
Comment: This study strongly suggests that a moderate dose of steroids is more than adequate to treat ICU patients with severe COPD exacerbations. I would feel comfortable treating such patients with <240 mg of methylprednisolone (i.e., 80 mg to 160 mg), but a randomized trial is necessary to determine optimal dosing and duration of steroids.
Citation(s): Kiser TH et al. Outcomes associated with corticosteroid dosage in critically ill patients with acute exacerbations of chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2014 May 1; 189:1052. (http://dx.doi.org/10.1164/rccm.201401-0058OC)
Abroug F and Krishnan JA.What is the right dose of systemic corticosteroids for intensive care unit patients with chronic obstructive pulmonary disease exacerbations? A question in search of a definitive answer. Am J Respir Crit Care Med 2014 May 1; 189:1014.

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MM: We don't think too much about parasites in the U.S. but maybe we should be a little more cognizant of this health threat. As many as 25-35% of Americans may have parasitic infections at any given time. This is a number that we associate with third world nations that lack pure water and advanced sanitation facilities. It is a source of illness that may not be on the radar screen of many physicians. The take home is that if you are sick or not thriving and no other reason seems apparent then consider a parasitic infection.
Top 5 Neglected Parasitic Infections in the U.S.
By Kelly Young
The CDC is taking aim at five neglected parasitic infections in the U.S. based on the number of people affected, illness severity, and the ability to prevent and treat the illnesses. The infections, which are reviewed in the American Journal of Tropical Medicine and Hygiene, include:

CDC editorialists write that immediate interventions to prevent infections include deworming dogs and cats, picking up pet feces immediately, covering sandboxes to lower the risk for contamination with animal feces, and cooking meat thoroughly. The articles also cover clinical manifestations.
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MM: Technology can improve care or act as an obstacle. The readily available and relatively inexpensive aspect of ultrasound makes an interesting argument for its greater use. I have to question whether it will be an asset to EMT's or other first responders who have relied upon their stethoscopes for so long or perhaps I am merely being a curmudgeon and am reluctant to give up my old Littman.
Is Your Stethoscope Going to Join Your Typewriter in the Storage Closet?
By Joe Elia
Point-of-care ultrasound devices, available on eBay for roughly the price of a fancy digital camera, seem poised to be "the stethoscope of the 21st century," according to a review and commentary in Global Heart.
The review's authors praise ultrasound's advantages, especially in the emergency department and the ICU, where treatment decisions have often had to rely on other imaging devices that need to be scheduled and require radiation shielding. They argue for the earlier introduction of the technology into medical school curricula.
Editorialists echo those sentiments, reminding readers that ultrasound has been called a "disruptive technology," in that it's simpler, cheaper, more convenient, and more accessible than those other devices, which rely on highly trained subspecialists to interpret the images.

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