• Dementia Outpaces Cancer in Financial Burden to United States
• Pediatric GERD Guidelines Urge Conservative Approach in Children with Reflux
• Foreign-Born American Children Have Fewer Childhood Allergies
• Postmenopausal Estrogen Therapy: Advantages of Transdermal Delivery
• Estrogen and Menopausal Joint Pain
• Financial Incentives Motivate People to Lose Weight
• Zolpidem-Related Emergency Department Visits Triple over 5 Years
• For Infants, Optimal Dose of Vitamin D Supplement Not So Clear
• Pediatrics Academy Issues Statement on Planned Home Birth
• Trachea Grown from Stem Cells Implanted in Child
• Sharp Rise in Suicide Among Middle-Aged Adults
MM: Why do we have such a high rate of dementia in our elderly? One theory is that it is due to systemic inflammation. If this is truly a major cause then things that we can do to lower this inflammation include fish or krill oil containing omega 3 fatty acids, probiotics and vitamin D3. All of these can decrease systemic inflammation and possibly deter the rate of dementia.
N Engl J Med 2013 Apr 4; 368:1326
Dementia Outpaces Cancer in Financial Burden to United States
A model that includes costs of informal care estimates that more than US$150 billion was spent in 2010.
The greatest risk factor for dementia is advancing age. Therefore, with the aging of the population, the prevalence of dementia is increasing. The U.S. government has deemed it critical to determine the cost of dementia care and generate strategies for managing this growing problem without bankrupting the nation. To this end, researchers surveyed a nationally representative sample of more than 10,000 people aged 51 or older in 1992, or their caregivers, on cognitive and physical functioning. The investigators calculated annual costs from self-reported out-of-pocket expenditures and nursing home care, Medicare claims data, and informal caregiving costs.
Using more than 30,000 person-years' worth of data captured by these surveys, researchers estimated that in 2010, the prevalence of dementia in people older than 70 was 14.7%. The estimated annual cost per patient, adjusted for comorbid conditions and demographics, ranged from US$41,689 to $56,290, depending on the method used to calculate the costs of informal care. The estimated total dementia cost in the U.S. in 2010 was US$159 to $215 billion.
Comment: As the authors acknowledge, this model estimates a lower prevalence and associated cost of dementia than those previously published by the Alzheimer's Association. Nonetheless, both models underscore the gravity of the situation and importance of addressing this issue urgently. The cost estimates generated by this model are likely conservative, given the adjustments for comorbid conditions. Likewise, the modeling of informal care costs based on lost wages was adjusted for age of the caregiver and does not account for delays in retirement in the current financial environment, a trend that is likely to continue. Remarkably, Medicare paid less than 10% of the predicted cost of dementia care. The cost of caring for dementia might well stress Medicare, Medicaid, and private insurers to a breaking point in the near future if mitigating strategies are not implemented immediately.
— Brandy R. Matthews, MD Published in Journal Watch Neurology April 30, 2013
Citation(s): Hurd MD et al. Monetary costs of dementia in the United States. N Engl J Med 2013 Apr 4; 368:1326.
http://www.ncbi.nlm.nih.gov/pubmed/23550670?dopt=Abstract
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MM: Note that the first recommendation is that of Lifestyle Changes. This is a great idea and our HeartBurn Away is just such a Lifestyle Change. It contains natural probiotics and digestive enzymes. These are found in foods and stabilize the digestive tract.For infants we have these same ingredients available in our Pro-Digest product. It is a capsule that can be opened and the contents placed inside an infant's mouth. The next question should be why don't the gastroenterologists follow this same recommendation. It is safe, effective and reasonably priced.
Pediatric GERD Guidelines Urge Conservative Approach in Children with Reflux
By Kelly Young
The American Academy of Pediatrics has endorsed a set of guidelines on diagnosing and treating gastroesophageal reflux (GER) and gastroesophageal reflux disease (GERD) in infants and children.
The guidance for pediatricians, published in Pediatrics, recommends lifestyle changes as first-line treatment for both GER and GERD; only patients with GERD should receive pharmacotherapy if lifestyle changes are insufficient. The article provides pediatric doses of GERD medications and algorithms for different patients. The authors caution that "overuse or misuse of PPIs in infants with reflux is a matter for great concern." Surgery is recommended only for children with treatment-resistant GERD or those at risk for life-threatening complications.
The authors conclude: "It cannot be overemphasized that pediatric best practice involves both identifying children at risk for complications of GERD and reassuring parents of patients with physiologic GER who are not at risk for complications to avoid unnecessary diagnostic procedures or pharmacologic therapy."
http://pediatrics.aappublications.org/content/early/2013/04/24/peds.2013-0421.full.pdf
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MM: I really like this article and the "hygiene hypothesis" attached to it. Similar studies comparing children in Estonia and Sweden have shown similar results.
Foreign-Born American Children Have Fewer Childhood Allergies
By Joe Elia
Atopic disease is more common among children who are born in the U.S. than among those who move here, according to a JAMA Pediatrics study.
Researchers reviewed data from some 80,000 participants in a national survey of child health. The information collected included the children's and parents' birthplaces, and whether the child had ever been diagnosed with asthma, eczema, hay fever, or food allergy.
Birth outside the U.S. was associated with a roughly 50% decreased risk for having an atopic disorder. A foreign-born child with foreign-born parents was at even lower risk, but not for eczema or food allergies. Living in the U.S. for more than 10 years blunted the effect, however.
The authors say their results support the "hygiene hypothesis" that early childhood microbial exposures protect against atopic disorders.
http://archpedi.jamanetwork.com/article.aspx?articleid=1681064
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MM: Compounding pharmacists have known this data for decades and we have communicated it to a variety of physicians. Many have listened and understood the message and as a result their patients have benefitted. Unfortunately, it has taken close to 20 years for ACOG to figure this out. If this is the organization that is supposed to guide OB & GYN physicians, they might try using a GPS or at least an updated road map instead of a globe and sextant from a previous era.
Obstet Gynecol 2013 Apr; 121:887
Postmenopausal Estrogen Therapy: Advantages of Transdermal Delivery
ACOG suggests clinicians should consider transdermal forms of estrogen for their possible thrombosis-sparing effects.
Administration of either combined estrogen-progestin or estrogen-only therapy to postmenopausal women is associated with as much as fivefold excess risk for venous thromboembolism (VTE). Moreover, this risk increases with age and certain common preexisting conditions (e.g., obesity, immobility, fracture, underlying cardiovascular disease). Now, the American College of Obstetricians and Gynecologists has released a Committee Opinion on route of estrogen administration and VTE risk.
Most studies of postmenopausal estrogen therapy and risk for VTE have involved oral hormone administration. First-pass metabolism of oral estrogen in the liver is thought to cause prothrombotic and proinflammatory effects through the hepatic induction of substances such as coagulation factors and C-reactive protein. By contrast, transdermally administered estrogens show little or no effect on prothrombotic factors and a reduction in proinflammatory markers. In addition, the estradiol-acetate–containing vaginal ring does not seem to raise risk for VTE. The Committee Opinion includes cautions about the use of transbuccal lozenges and troches, noting that, although these compounded preparations are intended to eliminate first-pass effects and are widely used in the U.S., few safety data are available. Taken together, these observations led the Committee on Gynecologic Practice to recommend that clinicians — together with informed patients — carefully assess the risks and benefits of various estrogen preparations to determine the best form of therapy. In healthy women with negative risk histories, the "probability of [VTE] is generally low."
Comment: When these observations are considered along with pharmacologic findings that transdermally administered estrogen more closely approximates physiologic levels of circulating estrogen, the transdermal route seems safer than oral preparations in most postmenopausal women who would benefit from estrogen therapy. However, taking individual patient preferences and risk factors into account is more important than insisting on transdermal estrogen for everyone.
— Robert W. Rebar, MD Published in Journal Watch Women's Health May 2, 2013
Citation(s): Committee on Gynecological Practice. Postmenopausal estrogen therapy: Route of administration and risk of venous thromboembolism. Obstet Gynecol 2013 Apr; 121:887.
(http://dx.doi.org/10.1097/01.AOG.0000428645.90795.d9)
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Menopause 2013 Mar 18
Estrogen and Menopausal Joint Pain
Encouraging news arising from WHI data.
Data from the Women's Health Initiative (WHI) continue to provide insight into the effects of estrogen therapy on menopausal symptoms. In a post hoc analysis of the placebo-controlled, estrogen-only component of the WHI trial, researchers evaluated the relation between estrogen use and joint symptoms. Participants completed questionnaires at baseline and 1, 3, and 6 years later in which they reported any experience of mild, moderate, or severe joint pain or swelling.
Joint pain was reported by 77% of participants at baseline. At 1 year, pain was reported less commonly in the estrogen group than the placebo group (76.3% vs. 79.2%, P=0.0001) and mean joint pain scores (range, 0–3) were modestly lower (1.16 vs. 1.22, P=0.0001). At 3 years, 72.5% of adherent women in the estrogen group reported joint pain whereas 81.7% of those in the placebo group reported pain (P=0.006).
Comment: Proposed mechanisms of estrogen's action include attenuation of inflammation and cartilage turnover. The authors note that adherence-adjusted analysis strengthened the association between exogenous estrogen and reduced joint pain; nonetheless, this improvement was still generally modest. For those recently menopausal women whose bothersome symptoms are relieved by estrogen therapy — and who also note improvement in joint pain — the benefits and risks of longer-term estrogen might be considered.
— Anne A. Moore, DNP, APRN, FAANP Dr. Andrew M. Kaunitz, Editor-in-Chief of Journal Watch Women's Health, wrote the editorial accompanying the Menopause article but had no role in writing this summary and Comment.
Published in Journal Watch Women's Health May 2, 2013
Citation(s): Chlebowski RT et al. Estrogen alone and joint symptoms in the Women's Health Initiative randomized trial. Menopause 2013 Mar 18; [e-pub ahead of print].
(http://dx.doi.org/10.1097/gme.0b013e31828392c4)
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MM: People in general tend to respond better to immediate gratification and paying for pounds may be a good incentive to initially losing weight. Unfortunately it seems that most of those who lose weight rapidly tend to find it rapidly. I firmly believe that this is due to most people who do rapid weight loss losing a predominant amount of the weight at muscle wasting. This lowers the net Basal Metabolic Rate (BMR) that results in regaining the pounds lost. The HCG Metabolic Syndrome and Weight Loss Protocol has been repeatedly demonstrated to lose a predominance of fat, not muscle resulting in long term weight loss and even more important, long term health benefits of lower fasting blood sugars, blood pressure and an improved lipid/cholesterol profile.
Ann Intern Med 2013 Apr 2; 158:505
Financial Incentives Motivate People to Lose Weight
Adding competition to a weight-loss financial intervention made it effective.
Paying people to lose weight has proven to be effective in the short term. In this study, researchers evaluated two different financial incentives (vs. a control intervention) to promote weight loss among 105 employees (body-mass index, 30–40 kg/m2) of a Philadelphia hospital:
Control participants were provided with a link to the Weight-control Information Networkhttp://win.niddk.nih.gov.
Individual-incentive participants received the same information as control participants and were told they would receive US$100/month if they achieved their weight-loss targets.
Group-incentive participants were placed anonymously in groups of five. Group participants received the same information as control participants and were told that members who achieved their weight-loss targets would split the $500/month allocated to the group.
Financial incentives ended at 24 weeks. Participants were followed for an additional 12 weeks. At 24 weeks, mean weight loss was greatest among group-incentive participants (4.8 kg) relative to individual-incentive (1.7 kg) or control participants (0.5 kg). At 36 weeks, the group-incentive participants exhibited more weight loss than individual-incentive or control participants (mean, 3.4 vs. 0.8 and 0.4 kg).
Comment: Paying people to lose weight was effective, when the financial incentive was offered in the context of competition, group dynamics, and an opportunity to increase one's reward above a baseline amount. However, even when weight-loss interventions work, the biggest hurdle is weight-loss maintenance.
— Jamaluddin Moloo, MD, MPH Published in Journal Watch General Medicine May 2, 2013
Citation(s): Kullgren JT et al. Individual- versus group-based financial incentives for weight loss: A randomized, controlled trial. Ann Intern Med 2013 Apr 2; 158:505.
(http://annals.org/article.aspx?articleid=1671710")
http://www.ncbi.nlm.nih.gov/pubmed/23546562?dopt=Abstract
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MM:There are other options that may help people sleep. Although each person has different needs and the cause of insomnia will vary, many people respond to herbal and glandular supplements that help to modulate cortisol production and adrenal function. Many of these adaptogens are available at Mark Drugs. Please call our staff to see which of these Adrenal support products may be right for you.
Zolpidem-Related Emergency Department Visits Triple over 5 Years
By Amy Orciari Herman
The number of emergency department visits related to the insomnia drug zolpidem (e.g., Ambien) more than tripled in the U.S. from 2005 to 2010, according to a report from the Substance Abuse and Mental Health Services Administration.
Overall, the number rose from 6111 to 19,487. Females were especially at risk, accounting for over two thirds of visits in 2010. (In January 2013, the FDA halved the recommended dose of zolpidem in women, noting that women process the drug more slowly than men.) One third of visits involved adults aged 65 and older.
The report concludes: "Physicians and pharmacists can emphasize the importance of using zolpidem safely and only for short-term problems with insomnia. This may be especially crucial for older adults, for whom insomnia is a common complaint and who often take other prescription medications that may interact with zolpidem."
http://www.samhsa.gov/data/2k13/DAWN079/sr079-Zolpidem.htm
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MM: At what point should we be concerned with Vitamin D levels? Most people can agree that adolescents and adults should be concerned as well as pregnant women. Infants also need supplementation but I think that we have to look at these developing humans and determine what is the best source. I believe that it is a combination of moderate sunlight exposure and moderate supplementation similar to the study that was performed on French women in the Mediterranean area of France several years ago. This study demonstrated that women who had a combination of moderate sun exposure and supplements fared the best of all when it came to quality of life, morbidity and mortality. It makes a lot of sense that this approach would be best for all ages including infants.
For Infants, Optimal Dose of Vitamin D Supplement Not So Clear
By Kelly Young
Only a high dose of vitamin D supplementation is associated with achieving a plasma 25-hydroxyvitamin D target of 75 nmol/L(30ng/ml) in infants, but this dose is also linked to hypercalcemia, according to a JAMA study.
Roughly 130 1-month-old breast-fed infants were randomized to receive 400, 800, 1200, or 1600 IU of oral vitamin D daily. The primary outcome — 97.5% of the group achieving 75 nmol/L (30ng/ml) of 25(OH)D at 3 months of age — was achieved only in the 1600 IU group. However, treatment for this arm was stopped prematurely because of 25(OH)D levels thought to be associated with hypercalcemia. The higher doses weren't associated with improved bone density.
Roughly 97% of all infants studied achieved a lower target of 50 nmol/L (20ng/ml) at 3 months.
An editorialist offers reassurance that "a daily vitamin D intake of 400 IU/d in infants, as currently recommended," is adequate for bone health.
http://jama.jamanetwork.com/article.aspx?articleid=1682941
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Pediatrics Academy Issues Statement on Planned Home Birth
By Amy Orciari Herman
"Pediatricians must be prepared to provide supportive, informed counsel to women considering home birth while retaining their role as child advocates in assessing whether the situation is appropriate to support a planned home birth," according to a new policy statement from the American Academy of Pediatrics.
The statement, published in Pediatrics, notes that hospitals and birthing centers are the safest places for U.S. women to deliver, and expectant mothers should be informed of the increase in neonatal mortality and complications that come with home births. However, the AAP says, clinicians must respect "the right of women to make a medically informed decision about delivery."
Home delivery should be reserved for healthy women with full-term, singleton pregnancies, the AAP notes. Other criteria include cephalic presentation and appropriate fetal size for gestational age.
The AAP's statement concurs with a 2011 statement from the American College of Obstetricians and Gynecologists.
http://pediatrics.aappublications.org/content/early/2013/04/24/peds.2013-0575.full.pdf+html
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MM: Simply amazing! What else can be said?
Trachea Grown from Stem Cells Implanted in Child
By Joe Elia
A 2-year-old girl born without a trachea has received one fashioned from a plastic matrix that had been immersed in a solution containing her own stem cells, according to a New York Times account.
The trachea was then incubated for a time and implanted. The surgeons "think that the stem cells signal the body to send other cells to the windpipe, which then sort out so the appropriate tissues grow on the inside and outside of the tube," according to the Times.
The girl is the youngest to have received such an implant. An Eritrean man has survived for over 2 years after similar surgery.
http://www.nytimes.com/2013/04/30/science/groundbreaking-surgery-for-girl-born-without-windpipe.html?_r=0
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Sharp Rise in Suicide Among Middle-Aged Adults
By Cara Adler
Suicide among people aged 35 to 64 increased 28% from 1999 to 2010, according to a CDC analysis of national mortality data published in MMWR.
The annual age-adjusted suicide rate in this group increased from 13.7 to 17.6 per 100,000 people. Among adults in their 50s, the rate rose nearly 50%. Suicide by suffocation (mostly hanging) increased more than 80%.
Noting that suicide prevention typically focuses on youth and older adults, MMWR's editors say the findings highlight the need for prevention efforts aimed at the stresses faced by middle-aged adults, such as job loss, caregiver responsibilities, and declining health.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6217a1.htm?s_cid=mm6217a1_w
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