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Content 7


The Doctor and the Pharmacist

Radio Show Articles:
June 15, 2013

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Short Walks After Meals Could Help Control Glucose Levels in Older Adults
Atorvastatin (Lipitor), Rosuvastatin (Crestor), and Simvastatin (Zocor) Are
   Associated with Excess Risk for Diabetes
2012–2013 Flu Season Characterized as Moderately Severe
New Quadrivalent Flu Vaccine Approved
U.S. Supreme Court: Human Genes Can't Be Patented
More Evidence for Gluten-Sensitive Irritable Bowel Syndrome
More Evidence Links REM Sleep Behavior Disorder and Neurodegenerative Disease
Does Parental Sucking of Their Infant's Pacifier Reduce Risk for Allergy?
What Happens to Older Men After PSA Screening?
Should Hypertension Treatment Intensify with Age?
More Evidence of Increased Cancer Risks After Childhood CT Scans
Restless Legs Syndrome Seems an Independent Predictor of Mortality in Men

MM: An advantage of summer, daylight savings time and more moderate weather is that this is a wonderful time to start establishing healthy habits that can have long term benefits. Taking a short walk after a meal rather than plopping down in front of the TV set may be the perfect thing to do to improve your overall health. It doesn't have to be a marathon or anything too strenuous. Just get out and take a stroll and let today be the first day of this new activity. After all, there is no better time than the present!
Short Walks After Meals Could Help Control Glucose Levels in Older Adults
By Kelly Young
Short bouts of walking after meals may be more effective than a single longer walk in controlling postprandial hyperglycemia in older adults, according to a study in Diabetes Care.
Ten inactive adults (mean age, 69) with fasting blood glucose levels between 105 and 125 mg/dL completed three separate treadmill programs: walking for 15 minutes after every meal; for 45 minutes at 10:30 a.m.; and for 45 minutes at 4:30 p.m. Each program took place over 2 days in a laboratory, with the first day acting as the control and the second as the exercise day.
The 45-minute morning walk and the shorter, thrice daily walks similarly improved 24-hour glycemic control over the control day, but the shorter walks were more effective than the longer walks in reducing 3-hour postprandial glucose levels.
The authors call the effects of shorter, frequent walking bouts "substantial," noting that older adults may feel more comfortable with such a regimen.
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MM: In this study neither pravastatin or lovastatin exhibited a significantly increased risk of diabetes. Lovastatin is the same active ingredient found in Red Yeast Rice and in our Synergy Blends, Cholesterol Health product. It is unfortunate that most hospitals have as an SOP that when a patient enters the hospital environment they are almost universally administered a statin drug. The increased risk of a diabetic like condition, even transiently, also increases the risk of infection during a hospital stay.
BMJ 2013 May 23; 346:f2610
Atorvastatin (Lipitor), Rosuvastatin (Crestor), and Simvastatin (Zocor) Are Associated with Excess Risk for Diabetes
Using low doses of these drugs might mitigate the risk.
Studies in people and in animal models suggest that atorvastatin, rosuvastatin (Crestor), and simvastatin are associated with elevated risk for diabetes, whereas pravastatin is associated with lower risk. In this population-based cohort study, investigators in Canada used administrative databases to assess incident diabetes between 1997 and 2010 in 471,000 older patients (age, ≥66) who were newly treated with statins (median age at treatment onset, 73).
After adjustment for multiple confounders, with pravastatin as the reference drug, risk for new diabetes was 10%, 18%, and 22% higher in participants who received simvastatin, rosuvastatin, and atorvastatin, respectively. Corresponding numbers needed to harm were 363 (simvastatin), 210 (rosuvastatin), and 172 (atorvastatin). Fluvastatin and lovastatin were not associated with excess risk. Compared with low statin doses (pravastatin, fluvastatin, and lovastatin at all doses; atorvastatin, <20 mg; rosuvastatin, <10 mg; simvastatin, <80 mg), moderate and high statin doses were associated with higher diabetes risk.
Comment: In this study, compared with pravastatin, moderate- and high-potency statins (simvastatin, rosuvastatin, and atorvastatin) were associated with higher risk for incident diabetes. Using low doses of these drugs or low-potency statins (fluvastatin and lovastatin) might mitigate this risk. Notably, these results are biologically plausible: Simvastatin diminishes insulin secretion, whereas pravastatin improves insulin sensitivity and inhibits gluconeogenesis. An editorialist recommends: "When total cardiovascular risk favours statin treatment, a low dose, low potency agent should be used to begin with." However, some readers will disagree and will argue that, for some high-risk patients, benefits of high-potency statins outweigh the small absolute risk for incident diabetes.
Paul S. Mueller, MD, MPH, FACP  Published in Journal Watch General Medicine June 11, 2013
Citation(s):  Carter AA et al. Risk of incident diabetes among patients treated with statins: Population based study. BMJ 2013 May 23; 346:f2610.
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MM: Doesn't it seem a bit odd that with the increased availability of the flu vaccine at every corner drug store, clinic, airport and grocery store there is an upturn in serious adverse flu reactions? Maybe we need to re-think the ubiquitous recommendation of giving the flu vaccine. It doesn't seem to be getting the intended results.
2012–2013 Flu Season Characterized as Moderately Severe
By Cara Adler
The 2012–2013 influenza season saw more office visits, hospitalizations, and deaths than recent years, according to an MMWR article.
Among the findings of an analysis of CDC and WHO data:

The report provides recommendations for the components of the 2013–2014 influenza vaccine.
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MM:Based on the results of increased availability and subsequent administration of flu vaccines and the increase of flu related adverse effects, is this really a good thing?!? Will a broader spectrum vaccine help or ultimately hurt the population?
New Quadrivalent Flu Vaccine Approved
By the Editors
Fluzone Quadrivalent influenza vaccine has been FDA approved for people aged 6 months and up for the 2013–2014 flu season, according to the manufacturer. The intramuscular vaccine is the only quadrivalent flu immunization approved for use in very young children. It will contain two A and two B influenza strains.
Last year's intramuscular flu vaccine was trivalent.
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U.S. Supreme Court: Human Genes Can't Be Patented
By Kelly Young
The U.S. Supreme Court unanimously decided on Thursday that human genes that have merely been isolated cannot be patented. The case concerned Myriad Genetics' discovery of the location and sequence of the BRCA1 and BRCA2 genes. The company subsequently developed tests to detect mutations in the genes.
In the court's decision, Justice Clarence Thomas writes that merely isolating the genes was not enough to warrant a patent. However, altering a gene to make something not occurring in nature could qualify for a patent.
The price of the BRCA test — sometimes over $3000 — is expected to fall as a result of the decision, the New York Times reports.
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MM: The significant thing about this study is that these patients were tested negative for celiac disease yet they exhibited measurable changes in their guts and their gut permeability when they were exposed to gluten containing products. This dispels the notion that gluten sensitivity without evidence of celiac disease is not a real thing.
Gastroenterology 2013 May; 144:903
More Evidence for Gluten-Sensitive Irritable Bowel Syndrome
These patients share a genetic marker with celiac disease patients.
Some patients with diarrhea-predominant irritable bowel syndrome (IBS-D) but no evidence of celiac disease respond positively to gluten-free diets (JW Gen Med Jan 10 2013 and JW Gen Med Apr 5 2011). In a new trial, Mayo Clinic researchers randomized 45 patients with IBS-D to 4 weeks of gluten-containing or gluten-free diets; all patients had negative antibody tests for celiac disease.
The gluten-containing–diet group, compared with the gluten-free–diet group, exhibited the following significant abnormalities:

These findings occurred mainly in the subgroup of patients who were positive for HLA-DQ2 or HLA-DQ8 — the haplotypes seen in nearly all patients with celiac disease.
Comment: A growing body of evidence suggests that some patients with irritable bowel syndrome really are sensitive to gluten, despite the absence of serologic markers and histologic findings of celiac disease. Interestingly, the HLA haplotype findings in the current study suggest that gluten-sensitive IBS patients and celiac patients have a common genetic predisposition.
Allan S. Brett, MD  Published in Journal Watch General Medicine June 11, 2013
Citation(s): Vazquez-Roque MI et al. A controlled trial of gluten-free diet in patients with irritable bowel syndrome-diarrhea: Effects on bowel frequency and intestinal function. Gastroenterology 2013 May; 144:903.
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MM: This emphasizes how important sleep and dreaming is on a longitudinal basis. The supposition in the past that sleep/dream disruption can contribute to ill health finds greater support with this new data.
Lancet Neurol 2013 May; 12:443
More Evidence Links REM Sleep Behavior Disorder and Neurodegenerative Disease
Most patients diagnosed with idiopathic REM sleep behavior disorder advance to a neurodegnerative disease associated with alpha synuclein deposition (Lewy body disease) within a decade.
Several longitudinal studies have demonstrated a consistent association between idiopathic rapid eye movement (REM) sleep behavior disorder (IRBD) and the development of neurodegenerative disorders associated with alphasynucleinopathy, including Parkinson disease (PD), dementia with Lewy bodies (DLB), and multiple systems atrophy (MSA). In one previously described cohort of 44 patients with symptomatic IRBD for a median interval of 11 years and followed clinically for a median of 4.5 years, 45% met criteria for a neurodegenerative disorder. Now, the investigators report their findings in this cohort after an additional 7-year interval.
The conversion to a defined neurodegenerative diagnosis was 82% (16 PD, 14 DLB, 1 MSA, and 5 mild cognitive impairment). Four cohort members were lost to follow-up. Three patients in the cohort underwent autopsy during the period of study, which demonstrated characteristic pathological changes confirming diagnoses of PD in 2 and DLB in 1. Compared with healthy controls without IRBD, 4 patients who did not meet criteria for a neurodegenerative disorder demonstrated decreased striatal uptake of dopamine transporter, a biomarker associated with alphasynucleinopathies.
Comment: Although the sample size is relatively small, this report emphasizes the importance of longitudinal observations in slowly progressive neurodegenerative disorders. The findings highlight an opportunity to identify at-risk individuals and potentially intervene as disease-modifying therapies become available. However, clinicians should look carefully for other causes of dream-enactment behavior, such as medications or concomitant sleep disorders. In the absence of such factors, clinicians should confirm the diagnosis with polysomnography. As the authors suggest, idiopathic RBD may be more accurately termed isolated RBD. Patients who have REM sleep behavior disorder but are asymptomatic for parkinsonism or dementia should be made aware of the risk and the need for continued clinical follow-up.
Brandy R. Matthews, MD  Published in Journal Watch Neurology June 11, 2013
Citation(s): Iranzo A et al. Neurodegenerative disease status and post-mortem pathology in idiopathic rapid-eye movement sleep behavior disorder: An observational cohort study. Lancet Neurol 2013 May; 12:443.
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Pediatrics 2013 Jun 1; 131:e1829
Does Parental Sucking of Their Infant's Pacifier Reduce Risk for Allergy?
The surprising answer supports the "hygiene hypothesis."
The increasing prevalence of allergy among children in developed countries has been associated with reduced exposure to environmental microbes. The "hygiene hypothesis" is supported by a reduced risk for allergy in children living in poverty or crowded housing, or with early contact with animals and exposure to foodborne microbes. Researchers in Sweden examined whether pacifier cleaning practices affected risk for allergy in a prospective birth-cohort of 184 healthy full-term infants in an urban community (80% with at least one allergic parent).
Parents reported pacifier use and pacifier cleaning practices when children were age 6 months and kept a diary of food introduction, weaning, diseases, and medications during the first 6 months. At ages 18 and 36 months, the children were examined by a pediatric allergist who obtained blood eosinophil counts and allergen-specific IgE levels for inhalant and food allergens. Standard clinical criteria for eczema and asthma were used during a chart review and physical examination when allergy symptoms occurred.
During the first 6 months of life, 74% of infants used a pacifier. Almost all parents cleaned the pacifier by rinsing it in tap water, about half also boiled it, and half reported sucking it before giving it to the infant. Asthma, eczema or IgE sensitization at age 18 months were significantly less common among infants whose parents sucked on pacifiers. Protection against eczema persisted at age 36 months and vaginal delivery had an added protective effect against development of eczema. Although blood eosinophil counts were lower at age 18 months in infants whose parents sucked on the pacifier, the difference was not statistically significant. When infant saliva at age 4 months was analyzed by fingerprinting bacterial DNA, the microbial pattern in infants whose parents sucked the pacifier could be distinguished from the pattern in those whose parents did not.
Comment: Counterintuitive results such as these are challenging to clinicians. Can the passage of a parent's bacteria in saliva via a pacifier protect an infant's development of allergic disease? These results should stimulate a larger study. A recent review of the hygiene hypothesis by a talented nutrition journalist can be found in a recent article in the New York Times.
Martin T. Stein, MD  Published in Journal Watch Pediatrics and Adolescent Medicine June 12, 2013
Citation(s): Hesselmar B et al. Pacifier cleaning practices and risk of allergy development. Pediatrics 2013 Jun 1; 131:e1829.
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JAMA Intern Med 2013 Apr 15
What Happens to Older Men After PSA Screening?
Many biopsies performed, some cancers detected, complications common   
Amid the controversy surrounding use of prostate-specific antigen (PSA) testing to screen for prostate cancer, this longitudinal cohort study of PSA screening in 300,000 men (age, ≥65; mean age, 73; 90% white) in the Veterans Affairs (VA) health system provides some new perspectives of what happens in actual clinical practice. Men received PSA screening in 2003 and were followed for 5 years.
Of 25,208 patients with PSA levels >4.0 µg/L, 33% underwent prostate biopsies; of those with PSA levels >6.5 µg/L, 39% underwent biopsies; and, of those with PSA levels >10.0 µg/L, 42% underwent biopsies. Of men who underwent biopsies, 5220 (63%) were diagnosed with prostate cancer; of these, 4284 were treated with radical prostatectomy, radiation therapy, or hormone therapy. Among men who received prostate cancer treatment, 1172 (27.3%) experienced new-onset incontinence or erectile dysfunction.
Comment: A study published in 2012 (J Gen Intern Med 2012; 27:653) showed remarkably wide variation across the VA healthcare system in the rate of PSA testing in men with limited life expectancy, from a low of 25% to a high of 79%. That study and recent personal conversations with VA physicians suggest many reasons for this inappropriately high rate of PSA testing, including lack of system-wide guidance for evidence-based screening, routine ordering of test panels without physician involvement, perception that testing allows clinicians to meet quality performance standards, concerns about malpractice risk, and belief that more testing shows we're giving veterans the care they deserve. An editorialist asks why a healthcare system would continue to support what he considers low-value (at best) PSA testing with precious and finite resources that could better be used for high-value services.
Thomas L. Schwenk, MD  Published in Journal Watch General Medicine May 2, 2013
Citation(s): Walter LC et al. Five-year downstream outcomes following prostate-specific antigen screening in older men. JAMA Intern Med 2013 Apr 15; [e-pub ahead of print].
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Hypertension 2013 Jun; 61:1309
Should Hypertension Treatment Intensify with Age?
In a feasibility study, targeting antihypertensive treatment to 130/80 mm Hg rather than 140/85 mm Hg significantly increased cerebral blood flow in elderly patients.
Hypertension leads to reduced cerebral blood flow (CBF), which is associated with cognitive decline. However, aggressive blood pressure (BP) reduction in the elderly may produce cerebral hypoperfusion, resulting in falls and possibly stroke. In a proof-of-concept study, investigators recruited 37 primary-care patients aged ≥70 with uncontrolled clinical hypertension (defined as a systolic BP of >150 mm Hg as averaged from the second and third of 3 sitting measurements) while taking ≤1 antihypertensive medication. Patients were randomized to receive protocol-defined antihypertensive treatment to a target BP lower than either 130/80 mm Hg (intensive) or 140/85 mm Hg (usual). Magnetic resonance imaging to measure CBF and 24-hour ambulatory BP monitoring were performed at baseline and after 12 weeks of treatment.
At baseline, mean BP and mean CBF did not differ significantly between the two groups, and CBF did not correlate with any BP measure (clinical, ambulatory, aortic, systolic, or diastolic). At 12 weeks, mean clinical BP fell significantly from baseline in both groups; however, the reduction was significantly greater in the intensive group than in the usual group (26/17 vs. 15/5 mm Hg). Mean CBF did not change significantly from baseline in the usual group but increased significantly in the intensive-treatment group, regardless of baseline CBF. In both groups, the change in CBF correlated significantly with change in systolic BP.
Comment: In this small study, intensive blood-pressure treatment (targeted to <130/80 mm Hg) increased cerebral blood flow in elderly patients with hypertension. Whether increasing CBF by aggressive BP reduction slows cognitive decline or decreases cognitive impairment and — possibly — dementia compared with current, more conservative BP targets remains unclear. The latest revision of the National Heart, Lung, and Blood Institute's Joint National Committee guidelines is eagerly awaited and should shed light on BP goals in the elderly.
Joel M. Gore, MD Published in Journal Watch Cardiology June 12, 2013
Citation(s):  Tryambake D et al. Intensive blood pressure lowering increases cerebral blood flow in older subjects with hypertension. Hypertension 2013 Jun; 61:1309.
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More Evidence of Increased Cancer Risks After Childhood CT Scans
By Joe Elia
Evidence from six health plans adds to data showing that computed tomographic scanning during childhood increases the risk for subsequent tumors. The report appears in JAMA Pediatrics.
Using data from the HMO Research Network, researchers accumulated 4.9 million child-years of observation to characterize CT usage. Some 744 pediatric scans chosen at random were used to calculate radiation dosages. On the basis of previous exposure studies, the authors estimate that abdomen/pelvis scans, for example, cause roughly 30 solid tumors per 10,000 scans in girls and about 14 in boys.
Radiation doses varied, and reducing the highest 25% of doses to the median could prevent over 40% of the excess cancers, according to the researchers; that strategy, plus eliminating unneeded CT scans (an estimated one third of scans), could prevent almost two thirds of such cancers. Editorialists write that such changes would require a cultural shift "to become more tolerant of clinical diagnoses without confirmatory imaging."
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Restless Legs Syndrome Seems an Independent Predictor of Mortality in Men
By Amy Orciari Herman
Relatively healthy men with restless legs syndrome have nearly twice the risk for death as those without RLS, according to a prospective study in Neurology.
Over 18,000 male health professionals in the U.S. answered questions about RLS symptoms and then were followed for roughly 8 years. Four percent had RLS at baseline (symptoms at least five times monthly). Overall, 15% died during follow-up.
After adjustment for confounders including age and lifestyle risk factors, men with RLS had a 30% increased likelihood of death. In a subgroup of men without major chronic conditions such as cancer and cardiovascular disease, RLS increased risk nearly twofold. The increase in mortality was primarily attributed to deaths from respiratory illnesses; blood diseases; and endocrine, metabolic, and immunity disorders.
The authors speculate that "the nocturnal blood pressure variations associated with RLS could be among potential underlying mechanisms for the observed association between RLS and mortality."

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