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Content 7


The Doctor and the Pharmacist

Radio Show Articles:
June 8, 2013

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Older Drugs More Effective than New Drugs
The Hypothalamus Strongly Influences Body Aging
Scaling Back: Effects of Weight Loss on Psoriasis Severity
Diarrhea-Predominant IBS May Respond to a Gluten-Free Diet
Treatment of Pediatric Acne
Preparing for Extreme Heat Might Reduce Deaths
Potential Drawbacks of Breast Implants
Is Menopausal Hormone Therapy Associated with Excess Risk for Ovarian Cancer?
MDs vs. NPs in Primary Care . . . The Conflict Continues
New PSA Screening Guideline from the American Urological Association
Knee Arthritis Guidelines Issued
The Agony of the Feet
Anxiety Common in Long-Term Cancer Survivors and Their Spouses
Gestational Flu Increases Offspring's Risk for Bipolar Disorder
Does Yoga Improve Mental Health?
Fast-Food Restaurant Patrons Underestimate Calorie Contents of Their Meals
Vegetarians May Have Lower Mortality Risk

Older Drugs More Effective than New Drugs
Even after spending more than $50 billion annually since the mid-2000s to discover new medications, PHARMA companies have barely improved on old standbys developed decades ago. Newly published research shows that the effectiveness of new drugs, as measured by comparing the response of patients on those treatments to those taking a placebo, has plummeted since the 1970s. The consequences for the pharmaceutical industry could get worse under the new healthcare law that established an independent research institute to compare the effectiveness of different treatments for the same condition. If the study is correct, then "comparative effectiveness research" could conclude that older drugs, which are more likely to be generics, are better than pricey new brand names that deliver the most profits for drug makers.
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MM:I found it interesting that the hypothalamus may be responsible for a portion of the aging process and this same organ is largely credited with part of the success of HCG and maintenance of the body's "weight set point" and possibly with the pain/inflammation reducing aspects of the HCG weight loss protocol..
Nature 2013 May 9; 497:211
The Hypothalamus Strongly Influences Body Aging
Two master molecules influence aging histology in mice.
Do all body tissues age independently, or does some central process affect the pace with which tissues age? A team from the Albert Einstein College of Medicine found that, as mice age, levels of two molecules that initiate the inflammatory response rise gradually in the brain, particularly in the hypothalamus. Along with increases in these two molecules — I{kappa}B kinase-β (IKK-β) and nuclear factor {kappa}B (NF-{kappa}B) — the concentration of the proinflammatory cytokine tumor necrosis factor α also rises. Increases in IKK-β and NF-{kappa}B directly cause a decline in gonadotropin-releasing hormone (GnRH).
Mice that were genetically engineered to underproduce IKK-β and NF-{kappa}B in the hypothalamus created more new neurons and solved mazes more quickly, had greater muscle strength, and exhibited a 20% longer lifespan. The opposite effects occurred in mice that overproduced IKK-β and NF-{kappa}B. Injecting GnRH into the brain ventricles promoted neurogenesis in the brain. Injecting GnRH intravenously prevented aging histology in normal mice and abolished the premature aging that occurred in mice that overproduced IKK-β and NF-{kappa}B.
Comment: At least in mice, expression of master molecules that promote inflammation in the hypothalamus increases the pace of aging. Inhibiting expression of those molecules slows aging, as does increasing brain and systemic levels of gonadotropin-releasing hormone, which suggests that this molecule might have biological effects beyond those associated with sex hormone production. Yet another pathway that influences aging has been elucidated.
Anthony L. Komaroff, MD  Published in Journal Watch General Medicine June 4, 2013
Citation(s):Zhang G et al. Hypothalamic programming of systemic ageing involving IKK-β, NF-{kappa}B and GnRH. Nature 2013 May 9; 497:211.
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JAMA Dermatol 2013 May 29
Scaling Back: Effects of Weight Loss on Psoriasis Severity
It seems appropriate to suggest a weight-loss program as part of the treatment plan.
Psoriasis is associated with obesity. Does weight loss improve Psoriasis Area and Severity Index (PASI) scores? To address this question, 60 overweight patients (body-mass index, >27) with psoriasis were enrolled in a prospective Danish comparison study. Thirty subjects underwent intensive weight-loss therapy (WLT; formula diets of 800–1200 kcal/day), and the nonintervention group continued "standard routine dietary guidance." All subjects were older than 18 and in good health and had stable weight and plaque-type psoriasis. Antipsoriatic treatments were allowed if treatment had been stable for 3 months. Patients were instructed not to change psoriasis treatments, amount of tobacco use, or levels of physical exercise. Psoriasis severity was determined using the PASI by the unblinded primary investigator.
Patients randomized to WLT lost a mean of 15.4 kg; the control group lost a mere 0.4 kg (95% confidence interval, 12.3–18.5 kg; P<0.001). The WLT group had a mean decrease in PASI score of 2.3 compared with a 0.3 decrease in the control group (95% CI, –4.1–0.1, P=0.06). In individual participants, improvement in PASI score correlated with amount of weight loss irrespective of group allocation (P<0.001).
Comment: Many previous studies have shown mutual associations between obesity and psoriasis. Proinflammatory mechanisms induced by obesity might exacerbate psoriasis, but the process is probably more complicated than that. It is worth noting that the primary endpoint (a significant reduction in Psoriasis Area and Severity Index score) was not quite reached (P=0.06). The 16-week trial was short, the primary investigator was unblinded, the effect of weight loss on patients with severe psoriasis was not studied, and treatment doses were not reduced as weight was lost.
It seems appropriate to suggest a weight-loss program as part of the treatment plan to overweight and obese patients with psoriasis. In addition to helping the psoriasis, such a plan might help reduce risks for cardiovascular disease, diabetes, hypertension, and hyperlipidemia.
Mark V. Dahl, MD  Published in Journal Watch Dermatology June 7, 2013
Citation(s): Jensen P et al. Effect of weight loss on the severity of psoriasis: A randomized clinical study. JAMA Dermatol 2013 May 29; [e-pub ahead of print].
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Gastroenterology 2013 May; 144:903
Diarrhea-Predominant IBS May Respond to a Gluten-Free Diet
Patients randomized to a gluten-free diet had decreased bowel movement frequency.
It is well known that some patients without celiac disease develop symptoms in response to gluten. This syndrome is often called gluten intolerance. Based on preliminary evidence, patients with diarrhea-predominant irritable bowel syndrome (IBS-D) may respond to a gluten-free diet, especially those with human leukocyte antigen (HLA) markers associated with celiac disease (HLA-DQ2 and HLA-DQ8), although the mechanism is unclear.
To investigate this issue further, researchers randomized 45 patients with IBS-D to a gluten-free diet or a gluten-containing diet for 4 weeks. Half of the patients in each group were positive for HLA-DQ2 or HLA-DQ8, and the other half were negative for these markers.
Stool frequency decreased in patients on the gluten-free diet compared with those on the gluten-containing diet (P=0.04). This effect was greater in HLA-DQ2/8-positive patients compared with HLA-DQ2/8-negative patients (P=0.019). The gluten-containing diet increased small bowel permeability, which was greater in HLA-DQ2/8-positive patients compared with HLA-DQ2/8-negative patients. The diet groups did not differ in colonic permeability, transit time, or histology.
Comment: A gluten-free diet improved bowel movement frequency in patients with diarrhea-predominant IBS, especially in patients with HLA markers for celiac disease but without celiac disease. Gluten also induced increases in small bowel permeability, and this effect was greater when celiac HLA antigens were present. Overall, these findings support attempts at gluten withdrawal in patients with IBS-D.
Douglas K. Rex, MD  Published in Journal Watch Gastroenterology June 7, 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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Pediatrics 2013 May; 131:S163
Treatment of Pediatric Acne
The first evidence-based guideline for management of pediatric acne.
Sponsoring Organization: The American Acne and Rosacea Society, reviewed and endorsed by the American Academy of Pediatrics (AAP)
Purpose and Objective: An evidenced-based clinical guideline for management of pediatric acne
Key Points

1. Sebaceous hyperplasia influenced by increasing androgen levels
2. Alterations in follicular growth and differentiation
3. Colonization of the follicle with Propionibacterium acnes
4. Immune response and inflammation

Recommended Prescription Treatment Regimens

The Journal Watch Pediatric and Adolescent Medicine Perspective
These guidelines provide a general roadmap for treatment of pediatric acne. Treatment considerations are also affected by previous treatment history, cost and insurance coverage, and vehicle preference (cream, gel, etc.). Fixed-dose combination topical therapies simplify treatment regimens, and hormonal contraceptives may be particularly appropriate for young women with dysmenorrhea or who are sexually active. The guideline includes concise flowcharts detailing treatment regimens according to acne severity.
The Journal Watch Dermatology Perspective
The AAP report also provides a concise review of oral antibiotic complications and controversies in isotretinoin use. In general, the recommendations are consistent with the 2012 European evidence-based guidelines for the treatment of acne (J Eur Acad Dermatol Venereol 2012 Feb; 26 Suppl 1:1). The European guidelines state the following three objectives: reduction of serious sequelae and scarring, promotion of patient adherence, and reduction of antibiotic resistance. Although not exclusive for pediatrics, the European guidelines recommend that treatment strategy be influenced by the presence of scarring and other poor prognostic indicators (including family history, truncal acne, and past infantile acne) and dictated by acne morphologic type and severity (comedonal, mild to moderate papulopustular, severe papulopustular/moderate nodular, or severe nodular). One variation from the AAP recommendations is that tropical azelaic acid is included as an option for comedonal and moderate papulopustular acne.
My take home messages for acne management include the following:

Eichenfield LF et al. Evidence-based recommendations for the diagnosis and treatment of pediatric acne. Pediatrics 2013 May; 131:S163.
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Preparing for Extreme Heat Might Reduce Deaths
By Cara Adler
Planning for periods of extreme heat and targeting interventions to vulnerable populations seems to reduce heat-related deaths, according to an MMWR article.
The report describes 32 heat-related deaths in Maryland, Ohio, West Virginia, and Virginia during a 2-week period in the summer of 2012, when temperatures topped 100 degrees and a storm knocked out power. Decedents' median age was 65; most were men living alone, and most died at home, without air conditioning.
The death rate was much lower than during comparable periods in the previous 20 years. The authors report that the development of heat response plans in the four states, along with targeting interventions to vulnerable populations, may have contributed to the lower rate. Interventions included home visits to elderly and socially isolated people, restoration of power to vulnerable populations first, and public health messages about heat exposure risks.
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MM: We already know that breast implants may lead to fibromyalgia (FMS), Chronic fatigue Syndrome (CFS) and a host of other problems. Now it appears that they may increase the risk of breast cancer. Yet, a large portion of the population opts for these dangerous cosmetic surgeries. Sometimes we do the most baffling things or maybe it's simply a case of denial.
BMJ 2013 Apr 30; 346:f2399
Potential Drawbacks of Breast Implants
Review and meta-analysis suggest implants are associated with delayed breast cancer detection and higher breast cancer mortality.
Although most epidemiologic studies have not shown an association between cosmetic breast augmentation and excess risk for breast cancer, concerns persist that implants (which are radio-opaque) may impair mammographic detection of early-stage malignancies. In a review and meta-analysis, investigators evaluated breast cancer stage distribution and survival among women with and without cosmetic breast implants.
Breast augmentation was associated with marginally higher likelihood of having a nonlocalized breast cancer at diagnosis (odds ratio, 1.26; 95% confidence interval, 0.99–1.60; P=0.058). The statistical significance of the association was strengthened when the analysis was limited to studies that only included cases of invasive breast cancer. Five cohort studies that evaluated survival showed that breast augmentation was associated with significantly higher risk for breast cancer death (OR, 1.38; 95% CI, 1.08–1.75).
Comment: More than 300,000 women undergo cosmetic breast augmentation annually in the U.S. The authors speculate that impaired visualization of breast tissue, insufficient breast compression, and capsular contraction can lessen mammographic accuracy in women with implants. Although breast magnetic resonance imaging may be helpful for screening such women, evidence is insufficient to support routine use of this expensive technology. These findings should be shared with women who have received or are considering cosmetic implants.
Andrew M. Kaunitz, MD  Published in Journal Watch Women's Health May 16, 2013
Citation(s): Lavigne E et al. Breast cancer detection and survival among women with cosmetic breast implants: Systematic review and meta-analysis of observational studies. BMJ 2013 Apr 30; 346:f2399.
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MM: It is important to clarify that this data refers to the WHI study that focused on Premarin(R) and not Bio-identical Hormone Replacement Therapy (BHRT).
J Clin Oncol 2013 May 6
Is Menopausal Hormone Therapy Associated with Excess Risk for
Ovarian Cancer?

Temporal analysis of ovarian cancer incidence before and after the initial report of WHI risk–benefit data suggests a possible relation.
Epidemiologic studies have indicated an association between menopausal hormone therapy (HT) and ovarian cancer risk (Cancer 2009; 115:531); thus, investigators used information on 171,142 incident ovarian cancers in the North American Association of Central Cancer Registries database to estimate incidence rate changes before and after publication in 2002 of the Women's Health Initiative (WHI) report on risks and benefits of combined HT (JAMA 2002; 288:321), at which time HT use declined markedly.
In women 50 and older, age-standardized ovarian cancer incidence declined by 0.8% annually before the WHI report and by 2.4% after the report. Incidence of ovarian cancer in younger women decreased steadily (by 2.2%) throughout the study period. The change in incidence among older women was greatest in those most likely to use HT (i.e., aged 50–69 years, white, and living in U.S. regions where HT use was most prevalent), and was most pronounced for the endometrioid histologic subtype.
Comment: The authors suggest that these data are consistent with the hypothesis that menopausal hormone therapy raises risk for ovarian cancer, noting that similar data for breast cancer incidence (N Engl J Med 2007; 356:1670) support the broader idea of a link between HT and hormonally sensitive cancers. Undoubtedly, the development of these cancers involves multiple factors; furthermore, alternative explanations that are not immediately apparent may emerge. To me, this analysis is not sufficiently persuasive to convince me to alter my administration of HT, which remains indicated for those with severe menopausal symptoms who have no other contraindications.
Robert W. Rebar, MD  Published in Journal Watch Women's Health June 6, 2013
Citation(s): Yang HP et al. Ovarian cancer incidence trends in relation to changing patterns of menopausal hormone therapy use in the United States. J Clin Oncol 2013 May 6; [e-pub ahead of print].
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N Engl J Med 2013 May 16; 368:1898
MDs vs. NPs in Primary Care . . . The Conflict Continues
Societal needs should supersede the disparate self-perceptions of physicians and nurse practitioners.
Advanced-practice nurses (including nurse practitioners [NPs], clinical nurse specialists, certified registered nurse anesthetists, and certified nurse midwives) have become commonplace within the U.S. healthcare delivery system since their inception in the 1960s. Now, the clinical workforce is estimated to include >180,000 NPs, approximately 35% of whom provide primary care. But how do NPs and physicians view their respective roles? Researchers analyzed responses to a survey (conducted from November 2011 to April 2012) of 505 primary care physicians and 467 NPs to evaluate their attitudes about healthcare delivery, compensation, and collaboration. Questions included topics such as scope of practice, hours worked, compensation, and attitudes toward NPs in a primary care role.
Three quarters of NPs believed that they were practicing to the full extent of their training and education. Fully 82% of NPs (vs. 17% of physicians) agreed with the statement that NPs should have the authority to lead medical homes. Two thirds (64%) of NPs (vs. 4% of physicians) believed that they should receive equal pay for the same services. Two thirds (66%) of physicians believed that they provided higher quality of care than NPs; 75% of NPs disagreed with this statement.
These results, taken together with an accompanying Health Policy Report, provide insight into the evolution of the NP's role in the face of economic and political influences. NP certification programs were initially developed — and continue — to fill a healthcare gap for a largely uninsured, underserved population. These "certificate-prepared" NPs work in large clinics serving both urban and rural populations. With the projected shortage of primary care physicians (an estimated 33,100 by 2015), NPs again occupy an ideal position to address a healthcare deficit.
Today's NP is a formally educated clinician: In addition to being a registered nurse, the NP graduate must now have — at minimum — a master's degree in nursing and should hold national certification in a practice domain. Doctor of Nursing Practice (DNP) programs are burgeoning. Many NPs are trained as primary care providers in family, adult, or pediatric care. The Institute of Medicine (IOM), in a 2010 report, supported the mission to eliminate barriers to advanced-practice nursing, stating that nurses should be free to "practice to the full extent of their education and training."
With the assistance of the Federal Trade Commission (FTC), the IOM sought to promote advanced-practice nursing as a safe alternative to physician-delivered care. The American Medical Association (AMA) disapproved of this effort, accusing the FTC of "aggressive advocacy." The Robert Wood Johnson Foundation drafted a document entitled "Common Ground: An Agreement between Nurse and Physician Leaders on Interprofessional Collaboration for the Future of Patient Care," coauthored with representative leaders of national physician and nursing organizations. However, the AMA, upon learning of the document's existence, garnered support from the American Association of Family Practice, and American Osteopathic Association, and the American Association of Pediatrics to withdraw support from the dialogue, essentially halting the document's progression.
Comment: An editorialist notes that the U.S. has fewer primary care physicians per capita (30 per 100,000) than any other industrialized nation, and that an adult in this country typically waits ≥6 days to see a primary care doctor. Given the multiple stakeholders, financial incentives and disincentives, and egocentrism, one wonders, "What happened to the patient?"
Many studies have shown that NPs achieve outcomes at least equivalent (and sometimes superior) to those of MDs for management of the most common chronic conditions (diabetes, hypertension, and asthma); in some studies, patients were more satisfied with NP-provided care than with MD-provided care (Cochrane Database Syst Rev 2004;4:CD001271). NPs are legally authorized to diagnose, treat, and prescribe without mandated relationships with MDs in at least 18 states and the District of Columbia (N Engl J Med 2011; 364:193). In a good example of collaboration, the American College of Obstetricians and Gynecologists and the American College of Nurse-Midwives have issued a joint statement to foster practice relations.
Perhaps the real question is how best to train the broad spectrum of primary care providers our population needs, given the range and complexity of diseases and comorbidities patients may have. It's in patients' best interests for physicians and nurses to abandon the issue of "who does it better?" and instead move forward with "how can we get everyone the best healthcare possible?"
Anne A. Moore, DNP, APRN, FAANP, Diane E. Judge, APN/CNP, and Diane J. Angelini, EdD, CNM, FACNM, FAAN, NEA-BC
Published in Journal Watch Women's Health June 6, 2013
Citation(s):  Donelan K et al. Perspectives of physicians and nurse practitioners on primary care practice. N Engl J Med 2013 May 16; 368:1898.
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J Urol 2013 May 7
New PSA Screening Guideline from the American Urological Association
The target range for "routine" prostate-specific antigen screening has been narrowed to ages 55 to 69.
The American Urological Association (AUA) has published a new guideline on prostate-specific antigen (PSA) screening. The guideline has five summary recommendations:

Comment: This guideline supplants a 2009 AUA "Best Practice Statement," which stated that screening ". . . should be offered to healthy, well-informed men 40 years of age or older" (J Urol 2009; 182:2232). The new guideline narrows the age range for "routine" screening to 55 to 69, because that was the core age group in the European screening trial (JW Gen Med Mar 14 2012). Still, the guideline makes for some frustrating reading: Phrases such as "no routine screening" (my italics) are ambiguous, and many clinicians find difficulty in navigating the interplay between a patient's "values and preferences" and the complexity of potential benefits and harms of screening.
Many media reports publicized the new guideline as evidence that urologists are backing off from aggressive PSA screening. However, some urologists have criticized the AUA for not presenting screening more favorably. And finally, this guideline differs substantially from that of the U.S. Preventive Services Task Force, which recommends against PSA screening for all age groups (JW Gen Med Jun 7 2012).
Allan S. Brett, MD  Published in Journal Watch General Medicine June 6, 2013
Citation(s): Carter HB et al. Early detection of prostate cancer: AUA guideline. J Urol 2013 May 7; [e-pub ahead of print].
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Knee Arthritis Guidelines Issued
By Joe Elia
The American Academy of Orthopaedic Surgeons has released revised guidelines for treating osteoarthritis of the knee. The document is large, running over 1200 pages, but it's accompanied by a 13-page summary of recommendations.
The AAOS recommends that patients engage in self-management programs including low-impact aerobic exercise. The group says it can't recommend use of acupuncture or chondroitin and glucosamine. Nor can it recommend the use of hyaluronic acid or arthroscopy with lavage and/or debridement in patients whose primary diagnosis is symptomatic osteoarthritis.
Evidence on the usefulness of electrotherapy and manual therapies was found to be inconclusive
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The Agony of the Feet
By Amy Orciari Herman
Several new studies, including one in the Journal of Applied Physiology, have found that running barefoot or in minimalist footwear does not result in greater physiologic efficiency or injury prevention, according to the New York Times "Well" blog.
Indeed, it seems that when it comes to running, one style does not fit all. The Times quotes one expert: "I always recommend that runners run the way that is most natural and comfortable for them.... Each runner runs a certain way for a reason, likely because of the way they were physically built. Unless there is some indication that you should change things, such as repeated injury, do not mess with that plan."
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Anxiety Common in Long-Term Cancer Survivors and Their Spouses
By Amy Orciari Herman
Cancer survivors face increased risk for anxiety years after their diagnosis, and their spouses might be at even greater risk, according to a meta-analysis in the Lancet Oncology.
Researchers examined data from 43 studies comparing mood disorders between long-term cancer survivors and healthy controls or spouses. They found that 2 years or more after cancer diagnosis, depression prevalence did not differ significantly between survivors and their spouses or controls.
When anxiety was assessed, however, differences emerged: anxiety's prevalence was 18% among survivors and 14% among controls, with the greatest difference more than 10 years after diagnosis. In a separate analysis, anxiety was found in 28% of survivors and 40% of spouses — a difference that became significant when one outlier study was excluded.
"Efforts should be made to improve recognition and treatment of anxiety in long-term cancer survivors and their spouses," the researchers conclude.
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MM: Please be careful when you hear these numbers presented in the lay press. Although the data is sensitive and dramatic, there is little support to make it a definitive conclusion. If indeed this data has a true origin, then it reinforces the support for aggressive Vitamin D3 supplementation during pregnancy. The dosing being a conservative 5,000-10,000IU daily.
JAMA Psychiatry 2013 May 8
Gestational Flu Increases Offspring's Risk for Bipolar Disorder
Is it time for large public health efforts to vaccinate all women of childbearing age?
Knowledge of the relationship between maternal influenza during pregnancy and bipolar disorder (BD) in offspring is limited. To learn more, investigators used comprehensive case-finding methods, including medical databases on all pregnancies and flu diagnoses in a large healthcare system from 1959 to 1996. Infection was not validated by serologic testing.
Possible BD cases were identified in the health system's database, in county health records, and from surveys mailed to participants in an ongoing study of prenatal effects on development. Diagnoses of BD I, II, or not otherwise specified, or BD with psychosis were obtained through direct interviews using a structured research scale. Participants were 92 individuals with BD (age range, 15–22 years) and 722 age- and sex-matched controls from the same population.
After adjustment for covariates (e.g., maternal age, education level, race, psychiatric history), offspring whose mothers experienced influenza while pregnant had a fourfold greater risk for BP (odds ratio, 4.21). Results were similar in separate analyses of offspring with BP I or BP with psychosis. In analyses by trimester, only third-trimester flu exposure was significantly associated with elevated BD risk (OR, 5.68). These findings, however, while statistically significant, were not robust, because confidence intervals had wide ranges and the lower limits were close to 1.
Comment: These findings — and those associating gestational viral exposure with increased risk for schizophrenia (JW Psychiatry Mar 1 2010) and autism (Physicians First Watch Nov 13 2012) — strongly argue for large public health efforts to vaccinate women of childbearing age. Because influenza occurred significantly more frequently among mothers with psychiatric illness, providing vaccinations in psychiatric treatment settings would be an important preventive measure.
Barbara Geller, MD  Published in Journal Watch Psychiatry June 3, 2013
Citation(s):  Parboosing R et al. Gestational influenza and bipolar disorder in adult offspring. JAMA Psychiatry 2013 May 8; [e-pub ahead of print].
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Front Psychiatry 2013 Jan 25
Does Yoga Improve Mental Health?
Possibly, according to this careful review, which highlights numerous problems with the few studies conducted.
Given that relaxation, mindfulness, controlled breathing, and physical activity all have benefits in various mood and anxiety disorders, it seems likely that yoga, which incorporates many of these practices, would be similarly beneficial. In a systematic review, these researchers identified 16 published, randomized, controlled trials of sufficient quality that examined the effects of yoga in depression, schizophrenia, attention-deficit/hyperactivity disorder (ADHD), sleep disturbance, and eating and cognitive disorders.
Although there was "suggested" (Grade B) evidence of "potential benefit" of yoga for depression and as a treatment adjunctive to medication for schizophrenia and ADHD, the reviewers rated these studies as "low quality" for various reasons. For example, the studies enrolled mildly ill, nondiagnosed subjects (e.g., self-reported depressive symptoms) and used crossover designs (ADHD), wait-list controls (depression and schizophrenia), or inactive controls (ADHD). Some studies were not double-blinded (ADHD) or enrolled small samples, and studies rarely described how randomization occurred.
Comment: The flaws in these studies are consistent with the fact that none were published in high-impact journals and only a few in moderate-impact journals. Although the authors spin the reviews as providing "emerging evidence" to support popular beliefs about yoga, the evidence is meager and poor-quality. Nonetheless, it is likely that some patients will benefit from yoga and very unlikely that any will suffer harm or adverse effects. More-rigorous trials in diagnosed depression are now under way, so stay tuned.
Peter Roy-Byrne, MD  Published in Journal Watch Psychiatry May 6, 2013
Citation(s): Balasubramaniam M et al. Yoga on our minds: A systematic review of yoga for neuropsychiatric disorders. Front Psychiatry 2013 Jan 25; [e-pub ahead of print].
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BMJ 2013 May 23; 346:f2907
Fast-Food Restaurant Patrons Underestimate Calorie Contents of Their Meals
Especially for larger meals and especially at Subway
In experimental settings, people underestimate the calorie contents of typical restaurant meals (JW Cardiol Sep 20 2006). But whether the same is true of people dining in actual restaurants is unclear. In this study, 3400 people were asked to estimate calorie contents of meals they purchased at six fast-food chain restaurants (McDonald's, Burger King, Subway, Wendy's, KFC, and Dunkin' Donuts). Adults and adolescents provided their own estimates; adults provided estimates for younger children.
On average, actual meal calorie content was 733 kcal for children, 756 kcal for adolescents, and 836 kcal for adults. Participants underestimated these calorie contents by 175, 259, and 175 kcal, respectively. Underestimation of meal calorie contents increased as actual meal calorie contents increased; underestimates of meal calorie contents were larger among adolescent and adult diners at Subway than at other chains; adults with higher body-mass index were less likely to underestimate calorie content; and noticing posted calorie information at restaurants did not affect the accuracy of calorie estimates.
Comment: People who purchased meals at fast-food restaurants generally underestimated the calorie contents of their meals. Notably, Subway diners underestimated calorie content by more than diners at other chains; the authors attribute this finding to Subway's positioning as a "healthier" fast-food option. The authors recommend more accessible and useful information about food at these restaurants (e.g., an "anchoring" statement on menus about total daily calorie requirements) and a social marketing campaign to explain the concept of calories.
Paul S. Mueller, MD, MPH, FACP  Published in Journal Watch General Medicine June 4, 2013
Citation(s): Block JP et al. Consumers' estimation of calorie content at fast food restaurants: Cross sectional observational study. BMJ 2013 May 23; 346:f2907.
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MM: Definitions are a funny thing. When we typically refer to vegetarians we think of a person who eats a predominant diet of fruits, vegetable, nuts and grains and possibly some dairy or egg components. This article refers to a vegetarian lifestyle that consists primarily of these preceding components but may also include a limited amount of fish, fowl and mammal meat. How this can be construed as a vegetarian diet is beyond my comprehension. This is especially poignant when the data suggests that the most beneficial diet combination emphasizes fish as a significant portion in addition to the traditional "vegetarian" components.
Vegetarians May Have Lower Mortality Risk
By Kelly Young
Eating a vegetarian diet is associated with a reduced mortality risk, according to a study in JAMA Internal Medicine.
Researchers studied 73,000 Seventh-day Adventists, who were asked about details of their diet at baseline. About 52% were classified as vegetarian, including some who ate meat or fish occasionally. Over a median follow-up of 6 years, vegetarians had a 12% lower overall mortality risk than nonvegetarians, after adjustment for confounders. The benefits of a vegetarian diet were more pronounced in men than in women. Of the subgroups of vegetarians, those who also ate fish had the lowest mortality risk.
A commentator who is vegetarian offers this advice to clinicians: "Our debates about the superiority of one diet over another have not served the public well. It is time to acknowledge the common features of diets associated with good clinical outcomes and to focus our attention on helping patients avoid the intense commercial pressures to eat otherwise."

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