• Is Metabolically Healthy Overweight or Obesity a Myth?
• Health Spending Growth in 2012 Remained Under 4% for 4th Year
• Medicaid Access Increases Use of Emergency Departments by 40%
• Vitamin E Outpaces Memantine in Mild-to-Moderate Alzheimer Disease
• Vitamin E Supplementation Linked to Better Functional Outcomes in Alzheimer's Patients
• Mediterranean Diet Protects Against Diabetes, Regardless of Weight Loss.
• Some States Making it Harder for Parents to Opt Out of Vaccination
• Magnetizing Depression
• Gene Therapy For Parkinson's Improves Motor Symptoms in Early Study
• Can Probiotics Prevent Asthma?
• Antiepileptic Drugs, Weight Loss, and Pregnancy
• Is Teenage Milk Consumption Good for the Hips?
• FDA Warns of Risks from Overdose of OTC Sodium Phosphate for Constipation
• Implantable Device Reduces Episodes of Obstructive Sleep Apnea
• Tamiflu Oral Suspension in Short Supply
• Only 1 in 6 Patients Have Talked with Their Providers About Drinking
• Mixed Long-Term Results with Smoking Cessation Drugs
• U.S. Cancer Death Rates Drop by 20% over Two Decades
• Assessing and Managing Depression in Multiple Sclerosis
MM: The important thing is that a person needs to become metabolically healthy. This may be by eating a healthier diet, losing weight, exercising more or decreasing stress in their lives. Whatever it takes! I have found that the majority of my patients find that by losing weight as a first step they are better motivated to long term metabolic health improvement. This is often the first step to changing dietary habits and maintaining them or establishing a successful exercise regimen. There is rarely a single answer to the question of improving life and longesity but weight loss seems to be a pretty universal first step to those who start out overweight.
Ann Intern Med 2013 Dec 3; 159:758
Is Metabolically Healthy Overweight or Obesity a Myth?
Metabolically healthy obesity was associated with adverse cardiovascular outcomes; overweight was not.
For years, people have debated whether high body-mass index (BMI) is itself an independent risk factor for adverse cardiovascular outcomes or whether such adverse outcomes are mediated by metabolic abnormalities that often accompany high BMI. In other words, are metabolically healthy overweight (BMI, 25–30 kg/m2) or obese (BMI, ≥30 kg/m2) people at greater risk for adverse outcomes than normal-weight people (BMI, 18–25 kg/m2)? To address this question, researchers performed a systematic review and meta-analysis of 12 observational studies (67,127 participants) in which metabolic status and cardiovascular outcomes were reported. Study participants were classified as metabolically unhealthy if they exhibited components of the metabolic syndrome, such as large waist circumference, elevated triglycerides, low HDL cholesterol level, hypertension, diabetes, or elevated fasting glucose level.
In studies with at least 10 years of follow-up, metabolically healthy overweight people and metabolically healthy normal-weight people had similar risk for all-cause mortality and adverse cardiovascular events, whereas metabolically healthy obese people had excess risk (relative risk, 1.24). Metabolically unhealthy normal-weight, overweight, and obese people all had excess risk for all-cause mortality and adverse cardiovascular events (RRs, 3.14, 2.70, and 2.65, respectively, compared with healthy normal-weight people).
Comment: These researchers found that normal weight doesn't protect metabolically unhealthy people and that even metabolically healthy obesity is associated with excess risk for all-cause mortality and adverse cardiovascular events. However, excess risk was not observed in metabolically healthy people who were overweight (i.e., BMI, 25–30 kg/m2) but not obese.
Citation(s): Kramer CK et al. Are metabolically healthy overweight and obesity benign conditions? A systematic review and meta-analysis of the effect of body mass index and metabolic status phenotypes on all-cause mortality and cardiovascular events. Ann Intern Med 2013 Dec 3; 159:758.
(http://annals.org/article.aspx?articleid=1784291)
http://www.ncbi.nlm.nih.gov/pubmed/24297192?access_num=24297192&link_
type=MED&dopt=Abstract
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MM: At the risk of being negative when it comes to these numbers, I have to wonder what will happen once the Affordable Care Act (ACA) has had a year or two of being in place.
Health Spending Growth in 2012 Remained Under 4% for 4th Year
The government's estimate of U.S. healthcare spending for 2012 shows an increase of some 3.7%, to $2.8 trillion, according to a Health Affairs report. Health-spending's share of the gross domestic product held steady at about 17%.
Expressed in per-capita terms, 2012's health bill came to $8915 for each of the 313 million Americans.
http://content.healthaffairs.org/content/33/1/67.abstract
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Medicaid Access Increases Use of Emergency Departments by 40%
By Joe Elia
Increased availability of Medicaid coverage is associated with higher use of emergency departments (EDs), according to a Science article.
Oregon modestly widened Medicaid access among low-income adults in 2008 through a lottery. The randomized nature of the lottery enabled researchers to compare ED use among lottery winners with use among those who applied but didn't win (controls).
During an 18-month observation period, ED visits increased by 40% among those covered by Medicaid relative to those without coverage: overall, Medicaid enrollees had an average of 1.43 ED visits, versus 1.02 among controls. Coverage increased ED use for all types of nonemergency visits, including those rated as "primary care treatable." The proportion of visits resulting in hospital admission, however, did not increase.
A commentator writes that under the Affordable Care Act, "we have good reason to anticipate a large increase — and almost surely not a decrease — in traffic to already overburdened emergency departments across the country."
http://www.sciencemag.org/content/early/2014/01/02/science.1246183.abstract
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MM: Results of nutritional products on chronic conditions have been mixed. Undoubtedly we will see a knee jerk reaction to this study from the pharmaceutical industry disputing and challenging its relevancy. My recommendation is to provide 2000 IU of combinations including natural gamma tocopherol daily to patients exhibiting mild to moderate forms of dementia or AD, keeping in mind that vitamin E may increase bleeding in patients taking blood thinners such as warfarin.
Vitamin E Outpaces Memantine in Mild-to-Moderate Alzheimer Disease
High-dose vitamin E modestly slows functional decline without associated increase in mortality, but clinical relevance is unclear.
Both memantine and vitamin E have demonstrated benefits in patients with moderate-to-severe Alzheimer disease (AD). However, multiple studies of memantine in mild AD revealed no clear benefit, and vitamin E used in normal cognition and mild cognitive impairment does not affect progression to AD. Now, researchers have tested the effects of vitamin E and memantine in more than 600 veterans (97% men; 86% white) diagnosed with mild-to-moderate AD (Mini Mental State Examination score range, 12–26) already treated with stable doses of acetylcholinesterase inhibitor therapy (donepezil, 65%; galantamine, 32%; rivastigmine, 3%). Participants were randomized to receive 2000 IU vitamin E, 20 mg memantine, 2000 IU vitamin E plus 20 mg memantine, or placebo daily. The primary outcome measure was functional decline, measured with the Alzheimer's Disease Cooperative Study–Activities of Daily Living (ADCS-ADL) Inventory; secondary outcomes were measures of cognition and behavior.
During a mean follow-up of 2.27 years, the vitamin E group had a statistically significant 19% annual slowing of functional decline (3.15 units on the ADCS-ADL Inventory) compared with the placebo group. Memantine had no significant benefit on any of the preselected outcome measures. No treatment group had significant benefits on any secondary outcome measures. The vitamin E group had no greater mortality or adverse-event rate than the other groups.
Comment: The safety outcomes with high-dose vitamin E (2000 IU daily) in this particular patient population (white male veterans with mild-to-moderate Alzheimer disease) are encouraging. Unfortunately, the clinical relevance of the reported slowing of functional decline with vitamin E is difficult to interpret, given the absence of effect in patients treated with both vitamin E and memantine and the lack of supporting findings in the numerous cognitive, behavioral, and functional secondary outcomes. I will continue to advise my patients with mild-to-moderate AD to take no more than 400 IU of vitamin E daily and to refrain from initiating memantine until later disease stages.
Citation(s): Dysken MW et al. Effect of vitamin E and memantine on functional decline in Alzheimer disease: The TEAM-AD VA cooperative randomized trial. JAMA 2014 Jan 1; 311:33. (http://dx.doi.org/10.1001/jama.2013.282834)
http://www.ncbi.nlm.nih.gov/pubmed/24381967?access_num=24381967&link_
type=MED&dopt=Abstract
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MM: Just a little more information on this study.
Vitamin E Supplementation Linked to Better Functional Outcomes in Alzheimer's Patients
By Kelly Young
Vitamin E supplementation is associated with slower functional decline among patients with mild-to-moderate Alzheimer disease, according to a JAMA study.
Over 600 Veterans Affairs patients with mild-to-moderate Alzheimer's who were taking an acetylcholinesterase inhibitor were randomized to receive synthetic vitamin E (2000 IU/day) plus placebo, memantine plus placebo, vitamin E plus memantine, or double placebo.
After a mean follow-up of roughly 2 years, patients assigned to vitamin E alone had better scores on their ability to perform activities of daily living, translating to a 6-month delay in disease progression, compared with patients given placebo. Patients taking memantine — either alone or with vitamin E — did not see a similar benefit. Neither treatment was associated with increased risk for adverse events, including all-cause mortality.
Editorialists stress the importance of not extrapolating the current findings to the "use of vitamin E at different dosages, among people with different [Alzheimer's] severity levels, or in combination with different agents."
http://jama.jamanetwork.com/article.aspx?articleid=1810379
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MM: Let us not throw the baby out with the bath water. Although I use extra virgin olive oil (EVOO) in the majority of my cooking, salad dressings and other food preparations, I do not believe that other methods of improving general health should be ignored. I also encourage exercise at comfortable levels, stress management through meditation and/or prayer for the "whole person and package."
Mediterranean Diet Protects Against Diabetes, Regardless of Weight Loss.
By Larry Husten
Even if it doesn't lead to weight loss, a Mediterranean diet could help prevent type 2 diabetes, according to a subanalysis of the PREDIMED study published in the Annals of Internal Medicine.
Some 3500 adults without diabetes but at high cardiovascular risk were randomized to a Mediterranean diet supplemented by either extra-virgin olive oil or nuts or to a low-fat diet (control). Calorie restriction or increased physical activity was not advised.
After 4 years, diabetes had developed in 6.9% of the olive oil group, 7.4% of the nuts group, and 8.8% of controls. After multivariable adjustment, there was a significant, 40% reduction in diabetes risk in the olive oil group, but no such reduction in the nuts group. The differences in outcome appeared unrelated to weight loss.
The authors conclude that PREDIMED "provides strong evidence that long-term adherence to a Mediterranean diet supplemented with [olive oil] without energy restrictions ... results in a substantial reduction in the risk for type 2 diabetes among older persons with high cardiovascular risk."
Editor's note: Adapted with permission from CardioExchange.
http://annals.org/article.aspx?articleid=1811025
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MM: Irrespective of a preference to have or not have a vaccination, I agree with the state of Oregon that consumers need to be educated on the pros and cons. An informed consumer is the best consumer and when it comes to healthcare, the best patient.
Some States Making it Harder for Parents to Opt Out of Vaccination
By Amy Orciari Herman
Parents in Colorado may soon need to undergo counseling on the benefits and risks of vaccination before they decide to skip immunizing their children for nonmedical reasons, the Wall Street Journal reports. Over 4% of Colorado children were exempt from vaccinations last school year — at the same time, the state saw a spike in pertussis cases.
Other states are taking similar measures. For example, Oregon, beginning in March, will require parents seeking exemptions to listen to a scientific presentation about vaccine's pros and cons, with a focus on immunization as a "community prevention tool."
Officials blame the recent rise in measles cases to "pockets of low vaccination rates," the WSJ notes.
http://online.wsj.com/news/articles/SB10001424052702303640604579300951685638992
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MM: Here is another stab at using magnetic theory as a treatment. Magnetic treatments have shown wonderful results for a variety of maladies but have limited acceptance in the general medical community. As we search for more non-invasive approaches to chronic conditions we can only hope for some reproducible and consistent positive results. Perhaps this will be one. Until then, I'm afraid that the jury is still out.
Magnetizing Depression
In early research, application of a rapidly oscillating low-voltage electromagnetic field seems to have positive effects in depressed patients.
Low-field magnetic stimulation (LFMS), a rapidly oscillating, low-voltage (1 kHz, <1 V/m) electromagnetic field, is thought to have a swift antidepressant effect (NEJM JW Psychiatry Jan 29 2004). Designers of a portable electromagnetic LFMS device applied to the head performed a double-blind, sham-treatment–controlled study of its effects in 41 patients with bipolar depression and 22 with unipolar depression (mean ages, 43 and 49, respectively). Some of the authors hold proprietary interests in the device, which is not yet FDA-approved.
Most patients in both diagnostic groups were taking antidepressants. Also, most bipolar patients were taking antipsychotic drugs, anticonvulsants, and/or benzodiazepines, but still had mild-to-moderate levels of depression of unstated duration or recurrence. Compared with sham LFMS, 20 minutes of active treatment was associated with greater reductions on depression-rating and visual-analog depression scales, but results were statistically significant only in the secondary analysis of the entire group (i.e., not in analyses of individual diagnostic groups). Researchers did not attempt to assess the duration of improvement.
Comment: LFMS has a lower voltage but much higher frequency of pulsed fields than electroconvulsive therapy, deep brain stimulation, and repetitive transcranial magnetic stimulation. Thus, LFMS might act differently on the brain than those treatments. The authors theorize that fluctuating magnetic fields at this strength may entrain fluctuations of dendritic electrical activity in cortical regions that project to subcortical areas involved in the regulation of mood. Further research is needed to determine whether such repeatedly applied, fluctuating magnetic fields can be clinically useful and to understand more about neuronal activity in depression and its treatment.
Citation(s): Rohan ML et al. Rapid mood-elevating effects of low field magnetic stimulation in depression. Biol Psychiatry 2013 Nov 14; [e-pub ahead of print].
(http://dx.doi.org/10.1016/j.biopsych.2013.10.024)
- See more at:
http://www.jwatch.org/na32919/2014/01/02/magnetizing-depression?query=topic_depression#sthash.NHCpVFXH.dpuf
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Gene Therapy For Parkinson's Improves Motor Symptoms in Early Study
By Joe Elia
A preliminary study of gene therapy for Parkinson disease showed improved motor symptoms, according to a Lancet report.
Under the direction of the manufacturer, researchers injected various doses of a viral vector (ProSavin) bilaterally into the putamen of 15 patients with Parkinson's. The vector carried three genes enabling the continuous production of dopamine.
During a 12-month follow-up, improvement in motor function occurred in all patients, without detectable antibody response against any of the vector products. The most common treatment-related effects were increased on-medication dyskinesias (addressed by reduction of oral dopaminergic drugs) and "on-off" phenomena. But the authors caution that the magnitude of efficacy falls within the range observed in placebo treatments during other trials.
Asked to comment, NEJM Journal Watch neurologist Michael Okun wrote: "It will be intriguing to observe how (in the planned follow-up and larger study) this approach will compare to deep brain stimulation, and also whether patients will [experience] any delayed adverse events as the result of the gene therapy."
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)61939-X/abstract
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MM: Longitudinal use of probiotics will have an effect on gut health and with that, on inlammation. Whether it is inflammation of the gut, the respiratory system or the joints, the stabilization of the gut and the immune system will have a positive effect on the body as a whole.
BMJ 2013 Dec 4; 347:f6471
Can Probiotics Prevent Asthma?
In this meta-analysis, probiotic use during pregnancy or infancy did not affect risk for development of asthma or wheezing.
Preventive probiotic supplementation during pregnancy and infancy has shown some promise in reducing atopic dermatitis, and factors that disrupt gut flora, such as antibiotics and lack of breast-feeding, are associated with increased risk for asthma. Can probiotics prevent asthma? Researchers examined this question in a thorough systematic review and meta-analysis of 20 randomized controlled trials (primarily from developed countries) involving 4866 infants who were followed for a median of 24 months.
Probiotics were given to infants in 10 trials, pregnant women only in 1 trial, and both women and infants in 9 trials. Duration (range, 1–25 months), species/strain, and dose of probiotic supplementation varied greatly. About 10% of children in 9 trials developed physician-diagnosed asthma, with no significant difference between groups (risk ratio, 0.99). One third of children in 9 trials had a wheezing episode, again with no significant difference between groups (risk ratio, 0.97). These results were not affected by baseline asthma risk, timing or duration of probiotic administration, or recipient (mother, child, or both). Only 3 trials with conflicting results and statistical heterogeneity reported recurrent wheezing as an outcome. About 14% of children in 6 trials had lower respiratory tract infection (LRTI); probiotics were associated with an elevated risk ratio of 1.26 for LRTI (95% confidence interval, 0.99–1.45). However, 4 of these trials reported lower RTI only as an adverse event and not as a targeted outcome. Overall adverse events leading to supplement discontinuation were similar with probiotics and placebo.
Comment: Despite the inclusion of trials with industry sponsorship and participants with high risk for asthma, probiotics did not seem to prevent asthma in this well-conducted meta-analysis. The authors wonder whether prolonged probiotic use might decrease asthma risk through persistent gut-based immune modulation. The bottom line is that probiotics are not a panacea: specific probiotic regimens can be helpful in certain conditions, but not when used during pregnancy and early infancy to prevent childhood asthma.
Citation(s): Azad MB et al. Probiotic supplementation during pregnancy or infancy for the prevention of asthma and wheeze: Systematic review and meta-analysis. BMJ 2013 Dec 4; 347:f6471.
(http://dx.doi.org/10.1136/bmj.f6471)
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Obstet Gynecol 2014 Jan; 123:21
Antiepileptic Drugs, Weight Loss, and Pregnancy
Maternal use of topiramate or zonisamide during pregnancy was associated with lower fetal birth weight and shorter fetal length.
In addition to its approved use for management of seizures and migraine headaches, topiramate is used off-label for weight loss. In an analysis of data from 2026 enrollees in the North American Antiepileptic Drug Pregnancy Registry and 457 pregnant women without epilepsy, investigators assessed the effects on fetal growth of in utero exposure to topiramate or zonisamide (another antiepileptic drug that causes weight loss). Outcomes in neonates of women using these two drugs were compared to outcomes in neonates of women using lamotrigine (a weight-neutral antiepileptic drug) and of nonexposed women.
Mean birth weight was 3458 gm in the unexposed group, 3402 gm in the lamotrigine group, 3200 in the zonisamide group, and 3181 gm in the topiramate group. Infants prenatally exposed to zonisamide or topiramate had mean shorter birth length of 1 cm (P<0.01 for both comparisons). Prevalence of small-for-gestational-age (SGA) infants was 6.8% in the lamotrigine group, 12.2% in the zonisamide group, and 17.9% in the topiramate group.
Comment: Small-for-gestational-age babies who have been subjected to intrauterine growth restriction are prone to medical issues; thus, in utero exposure to either topiramate or zonisamide can have significant consequences for neonates. Although smoking (also linked to fetal growth restriction) was more common among topiramate users, nonsmokers in the topiramate group had excess risk for SGA as well. Larger studies are needed to assess the effects of drug dosage and duration. In the meantime, prescription of topiramate (whether for antiepileptic therapy or for controlled weight loss) should be approached carefully in women of childbearing age — moreover, effective contraception should always be readily available to such women.
Citation(s): Hernández-Díaz S et al. Association between topiramate and zonisamide use during pregnancy and low birth weight. Obstet Gynecol 2014 Jan; 123:21.
(http://dx.doi.org/10.1097/AOG.0000000000000018)
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JAMA Pediatr 2013 Nov 18
Is Teenage Milk Consumption Good for the Hips?
Greater consumption was associated with later hip fracture in men but did not affect risk in women.
Bone mineral content increases most during adolescence, and adequate milk consumption is recommended for teenagers. But, does greater milk intake during adolescence prevent later osteoporotic fractures? To find out, investigators examined teenage milk consumption as reported at enrollment by 61,600 women (age range, 30–55) in the Nurses' Health Study and 35,350 men (age range, 40–75) in the Health Professionals Follow-up Study. Women were prospectively followed for up to 22 years after reaching menopause, and men after age 50, for self-reported hip fractures not due to major trauma or malignancy.
In analyses adjusted for adult and teenage diet measures, supplement use, physical activity, and body-mass index, and adult medication use, milk intake, and age, the risk for hip fracture in men increased significantly by 9% for each additional 8-ounce glass of milk per day consumed between ages 13 and 18 years (relative risk, 1.09). Teenage milk intake did not affect risk for hip fractures in women. Both men and women who drank more milk as teenagers were taller than those who drank less. Adjustment for height (an independent risk factor for hip fracture) attenuated the fracture risk associated with teenage milk intake in men (RR, 1.06).
Comment: In this white American population, following the recommendation that adolescents consume three cups of milk or equivalent dairy foods daily did not prevent adult hip fractures. Milk consumption made no difference in women, and the slightly increased risk in men was mediated by an increase in height. As the authors and an editorialist note, milk intake may be especially important for bone mineral increase in girls during the preteen years (not captured in this study). The editorialist also notes that achieving good overall nutrition without dairy intake can be difficult. I will continue to recommend that boys and girls drink milk.
Citation(s): Feskanich D et al. Milk consumption during teenage years and risk of hip fractures in older adults. JAMA Pediatr2013 Nov 18; [e-pub ahead of print].
(http://dx.doi.org/10.1001/jamapediatrics.2013.3821).
Weaver CM.Milk consumption and bone health. JAMA Pediatr 2013 Nov 18; [e-pub ahead of print].
(http://dx.doi.org/10.1001/jamapediatrics.2013.4239)
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MM: People will typically consider the possible adverse effects of what they put in their mouths but when it comes to other methods of delivering drugs those concerns may be ignored.
FDA Warns of Risks from Overdose of OTC Sodium Phosphate for Constipation
By Kelly Young
The FDA is warning that the over-the-counter constipation drug sodium phosphate (marketed as Fleet, and generics) has been tied to heart and kidney damage and even death when patients exceed the recommended dose.
The agency has identified over 50 serious adverse events related to dehydration and electrolyte disturbances (sodium, calcium, and phosphate) with both the oral and rectal formulations. Most cases occurred in older adults and children younger than 5 years.
The FDA warns:
- Rectal sodium phosphate should never be used in children under age 2 years.
- In children 5 years and younger, caution should be used in recommending the oral version.
- Patients should stay below the maximum recommended dose; they should not take another dose within 24 hours.
- Patients at higher risk include those older than 55; those with decreased intravascular volume, baseline kidney disease, decreased bowel transit time, or active colitis; and those taking diuretics, ACE inhibitors, angiotensin receptor blockers, or NSAIDs.
- Patients should be advised to stay well hydrated during use. Electrolytes and renal function should be assessed in high-risk patients.
http://www.fda.gov/Safety/MedWatch/SafetyInformation/
SafetyAlertsforHumanMedicalProducts/ucm380833.htm
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MM: I always like to see new technology and where it is headed. CPAP units may be cumbersome and disruptive to relationships when used for sleep apnea. This is a novel approach to treatment and may offer a valid alternative treatment. It will be interesting to see what the costs of this treatment end up being.
Implantable Device Reduces Episodes of Obstructive Sleep Apnea
By Joe Elia
Patients with obstructive sleep apnea unresponsive to continuous positive airway pressure may benefit from an implantable device that stimulates a nerve involved with airway patency.
Researchers, writing in the New England Journal of Medicine, conducted a two-part trial sponsored by the device manufacturer.
They first recruited 126 patients with moderate-to-severe sleep apnea and BMIs under 32, and implanted a hypoglossal nerve-stimulating device in their upper chest. After 1 year, the average number of episodes of apnea or hypopnea per hour fell from about 29 to 9. There was a similar drop in episodes of oxygen desaturation.
Next, the stimulators were randomly shut off for a week in a subgroup of patients who'd responded successfully to nerve stimulation. Their episodes of apnea and hypopnea increased by 18 per hour, compared with only 2 per hour among those whose stimulators were left on.
An editorialist concludes that the results provide a rationale for conducting definitive studies.
http://www.nejm.org/doi/full/10.1056/NEJMoa1308659
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MM: Although I am typically pleased when compounding opportunities come along because it opens the public eye to some of the potential benefits of my profession and passion, it disturbs me when a sham process or treatment is promoted and in my opinion, that is what the use of Tamiflu is, a sham. As a healthcare professional, I cannot recommend its use. The benefits are marginal at best and unless used at the very beginning of a flu episode, resistance of the virus is increased and no clinical benefit is typically observed.
Tamiflu Oral Suspension in Short Supply
The FDA is reporting a temporary shortage of the antiviral Tamiflu's oral suspension because of increased demand during influenza season. The shortage is only expected to last until mid-January.
In the meantime, Tamiflu (oseltamivir) capsules, which are not affected by the shortage, can be opened and mixed with a thick, sweet liquid for patients who can't swallow pills.
http://www.fda.gov/Drugs/DrugSafety/DrugShortages/ucm314742.htm#oseltamivir
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Only 1 in 6 Patients Have Talked with Their Providers About Drinking
By Amy Orciari Herman
Only 16% of U.S. adults have ever discussed alcohol use with their healthcare providers, according to a CDC report in MMWR.
As part of the 2011 Behavioral Risk Factor Surveillance System survey, nearly 170,000 adults reported whether a clinician had ever talked with them about alcohol use. Among the other findings: 25% of binge drinkers had ever had such conversations, and just 13% within the previous year. Women were less likely than men to report talking about alcohol with their providers.
The CDC reminds clinicians that since 2004, the U.S. Preventive Services Task Force has recommended that primary care clinicians screen adults for alcohol misuse and provide behavioral counseling if appropriate.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6301a4.htm?s_cid=mm6301a4_w
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Mixed Long-Term Results with Smoking Cessation Drugs
By Joe Elia
Two studies in a JAMA issue devoted to smoking offer insight into the efficacy of smoking-cessation drugs — and how difficult it is to quit.
In one study, 500 adult smokers were randomized to receive daily varenicline plus either bupropion or placebo for 12 weeks. During a 52-week follow-up, combination therapy produced higher biochemically confirmed, prolonged abstinence rates at 12 and 26 weeks, but not at 52 weeks. The 7-day point prevalence abstinence rate (no smoking in the previous 7 days) did not differ between the groups at any follow-up point.
The other study examined the effect of prolonged varenicline maintenance therapy among roughly 90 patients with schizophrenia or bipolar disorder who'd successfully quit smoking after a 12-week course of varenicline. The patients were randomized to either an additional 40 weeks of varenicline or placebo. All received cognitive behavioral therapy. By 72 weeks, varenicline had outperformed placebo at every time point, resulting in roughly a 30% quit rate for extended-course varenicline versus 10% for placebo.
http://jama.jamanetwork.com/article.aspx?articleid=1812963
http://jama.jamanetwork.com/article.aspx?articleid=1812959
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U.S. Cancer Death Rates Drop by 20% over Two Decades
By Kelly Young
Cancer death rates declined by 20% between 1991 and 2010, according to a new compendium of statistics from the American Cancer Society. The 2010 rate stood at 172 per 100,000 population, down from a peak of 215 per 100,000 in 1991 — translating to about 1.3 million cancer deaths averted in the past two decades.
The article, published in CA: A Cancer Journal for Clinicians, notes that for black men in their 40s, the drop in cancer mortality has been even steeper, with a 55% decline, which the CEO of the American Cancer Society called "extraordinary." However, he said, "it is immediately tempered by the knowledge that death rates are still higher among black men than white men for nearly every major cancer and for all cancers combined."
http://onlinelibrary.wiley.com/doi/10.3322/caac.21208/full
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Neurology 2013 Dec 27
Assessing and Managing Depression in Multiple Sclerosis
Emotional disorders are common and should be assessed in MS clinical practice.
Sponsoring Organization: Guideline Development Subcommittee of the American Academy of Neurology
Target Population: Neurologists, psychiatrists, primary care providers
Background and Objective: An expert panel reviewed 115 relevant articles on emotional disorders in MS to derive these evidence-based guidelines.
Key Points or Recommendations: SCREENING Undiagnosed and untreated psychiatric illness in MS may lead to reduced quality of life, decreased disease-modifying therapy adherence, worse disease outcomes, and suicide. Patients with MS are at increased risk for major depression and anxiety, adjustment, psychotic, and bipolar disorders. The Beck Depression Inventory (BDI) may be considered to identify major depressive disorder in patients with MS (Level C Recommendation). Scores over 17 may indicate depression and scores of 10 to 17 may indicate dysphoria. Depression can also be screened by inquiring about (1) a depressed mood and (2) diminished interest or pleasure in prior activities (Level C Recommendation). The Center for Neurologic Study Emotional Lability Scale may be used to screen for pseudobulbar affect (Level C Recommendation).
TREATMENT: Insufficient evidence exists regarding use of individual in-person cognitive behavioral therapy and pharmacologic antidepressants in MS. One trial suggested that a 16-week telephone-administered cognitive behavioral therapy program could be beneficial. For distressing pseudobulbar affect symptoms in MS, dextromethorphan/quinidine may be beneficial (Level C Recommendation).
Comment: Psychiatric disorders in MS are common, perhaps resulting from structural brain lesions, and contribute to increased morbidity and mortality but are potentially treatable if detected and appropriately managed. This subcommittee found few studies to guide detection and treatment of emotional disorders in MS. Current practice is based on evidence from outside the MS population. Such practice may be acceptable for now, but future research should help clarify the role and effectiveness of various pharmacologic and nonpharmacologic treatments.
Citation(s): Minden S et al. Evidence-based guideline: Assessment and management of psychiatric disorders in individuals with MS. Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 2013 Dec 27; [e-pub ahead of print].
(http://dx.doi.org/10.1212/WNL.0000000000000013)
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