• Beginning to Understand the Effect of the Human Microbiome on Health
• Picosecond Laser Tattoo Treatment
• Hunting for "the" MS Autoantibody
• Dalfampridine (4-aminopyridine) Poses Seizure Risk for Multiple Sclerosis Patients
• CDC: Trained Pharmacists Must Be Involved in Dividing Single-use Vials
• Obesity's Effects on Duration of Labor
• Effect on Resting Energy Expenditure of Three Maintenance Diets
• New Position Statement for Managing Type 2 Diabetes
• Natural History of Subclinical Hypothyroidism in Older Adults
• Moderate Alcohol Consumption Is Associated with Lower Risk for Rheumatoid Arthritis
• Assisted Reproductive Technology: Cumulative Live-Birth Rates Offer Hope to
Infertile Couples
• Silymarin Is Ineffective for Chronic Hepatitis C Virus Infection
• Long-Term Cure Rates from Fecal Transplantation for C. Difficile Infection
• Does Dog or Cat Exposure Protect Against Respiratory Tract Infections During the
First Year of Life?
• Guillain-Barré Syndrome After Influenza Vaccination
• Dark Chocolate Affirmed as Brain-Booster
MM: We have been touting the benefits of probiotics for well over a decade. It seems that probiotic research has finally become completely mainstream. This article states, rather well, how important probiotics are to our daily life as well as to the numerous disease states that we as humans are potentiallty subject to. Unfortunately there will be many who will try to take advantage of the public by providing limited or incorrect information to consumers about probiotics. This is an area that has tremendous opportunity for abuse. My staff, colleagues and I have, and will, strive to inform, educate and protect our patients and the public in general from misinformation and disinformation regarding probiotics.
Nature 2012 Jun 14; 486:207
Beginning to Understand the Effect of the Human Microbiome on Health
Each of us harbors 10 times more microbial cells than human cells in our bodies — Can we live in peace?
From shortly after we are born, each of us lives with 10 times as many microbial cells as human cells in our bodies. The metabolism of human cells influences that of microbial cells and vice versa. For that reason, the collection of microbial genes (the microbiome) has been called "the second human genome."
The microbiome has been implicated as a cofactor in diseases as diverse as obesity (JW Gen Med Jan 2 2007), inflammatory bowel disease (JW Gen Med Jun 19 2008), cancer (JW Gen Med Nov 3 2011), psoriasis, nonalcoholic fatty liver disease, insulin resistance and type 2 diabetes, asthma, and even autism.
The advent of rapid and relatively inexpensive genome sequencing (JW Gen Med Oct 4 2005) fueled international efforts to study the microbiome. The Human Microbiome Project collected repeated samples from 18 body sites of 242 healthy adults in the U.S. and reported its findings in 17 newly published reports, 2 of which are summarized here.
Along with roughly 20,000 human genes, 5 to 8 million bacterial genes exist in the microbiome. The greatest number and variety of microbes are found in the mouth and gut, and the smallest variety is found in the vagina. Different species dominate in each body niche. Microbial species are influenced by body weight, ethnic and racial background, and geographical location (e.g., developed vs. developing world).
Comment: These studies are just building a foundation for a huge new field in biology and medicine. Researchers haven't proved yet how the human microbiome affects normal human physiology or leads to disease, and some skeptics doubt they ever will. But if they do, these papers will be regarded as landmarks in the history of human biology.
— Anthony L. Komaroff, MD Published in Journal Watch General Medicine July 24, 2012
Citation(s): The Human Microbiome Project Consortium. Structure, function and diversity of the healthy human microbiome. Nature 2012 Jun 14; 486:207.
(http://dx.doi.org/10.1038/nature11234)
http://www.ncbi.nlm.nih.gov/pubmed/22699609?dopt=Abstract
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MM: This is very exciting stuff. Over the past 25 years I have had dozens of people come into the pharmacy in agony from the painful removal of tattoos that they obtained earlier in their lives. Previous processes have led to discomfort, scarring and many repeatitive treatments. This new process appears much less painful and much more effective. More advancement will be needed to take care of a greater variety of tattoo removal but this certainly changes the game for now.
Arch Dermatol 2012 Jul; 148:820
Picosecond Laser Tattoo Treatment
A new laser effectively fades blue and green ink.
Tattoos are in great demand, but the desire to get rid of them is also great. The Q-switched lasers in current use have pulse durations in the 10–100 nanosecond range; for tattoo removal, many treatments are required for successful fading. The authors of this case series report their experience with a new 750–900-picosecond pulse duration, 755-nm alexandrite laser. The new laser was used to treat 12 multicolored tattoos, 10 previously untreated and 2 recalcitrant after at least 10 prior Q-switched laser treatments. Eleven patients underwent one treatment, and one patient underwent two treatments, under topical or local anesthesia with energy fluences of 2.0–2.8 J/cm2.
At the 1 month follow-up, 11 tattoos had greater than 75% clearance of blue and green pigment after only one treatment; more than two thirds had almost 100% fading of these colors. A 12th, all-green tattoo had greater than 75% fading after a second treatment. Better than 75% fading of purple pigment was also noted, but other colors faded 25% or less. On a scale of 1 to 10, patients gave the treatment an average pain score of 1.08. No prolonged pigmentary changes or scarring were observed.
Comment: Using shorter pulse durations in the picosecond range seems to dramatically accelerate tattoo pigment fading. How colors respond depends on laser wavelength; 755 nm is especially effective for blue, green, and purple ink — some of the most resistant colors with current technology. With the significantly lower energy fluences needed for the shorter pulse durations, the pain of treatment also seems to be far less. This is the first new technological development in tattoo treatment in 2 decades, but to be truly useful, additional wavelengths will be needed to deal with the multitude of colors that make up many tattoos.
— George J. Hruza, MD Published in Journal Watch Dermatology July 27, 2012
Citation(s): Brauer JA et al. Successful and rapid treatment of blue and green tattoo pigment with a novel picosecond laser. Arch Dermatol 2012 Jul; 148:820
http://www.ncbi.nlm.nih.gov/pubmed/22801616?dopt=Abstract
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N Engl J Med 2012 Jul 12; 367:115.
Hunting for "the" MS Autoantibody
An antibody to a glial potassium channel was present in almost half of a cohort of patients with MS and resulted in inflammation when injected into mice.
Multiple sclerosis (MS) is thought to be an autoimmune disease, but the pathogenetic autoantibody has not been identified. In search of such an autoantibody, researchers isolated immunoglobulin G (IgG) antibodies from the serum of 12 individuals with MS. The antibodies were enriched for antigenicity against central nervous system membranes, separated by isoelectric focusing, and analyzed by gel electrophoresis and mass spectrometry.
One electrophoresis spot contained KIR4.1, a potassium channel on astroglia thought to affect myelin development and axonal signal transduction. Among 397 people with MS who were tested, 186 (46.9%) had antibodies to KIR4.1, compared with 3 of 329 (0.9%) with other neurological diseases and none of 59 healthy controls. Anti-KIR4.1 was also found in the cerebrospinal fluid of 19 of 30 patients with MS, with evidence of intrathecal antibody synthesis in 2 of the 19. No correlation was found between anti-KIR4.1 positivity and disease subtype or clinical characteristics. When the researchers injected human IgG KIR4.1 antibodies into mice, the mice demonstrated altered glial fibrillary acidic protein expression, loss of KIR4.1 expression, and complement deposition.
Comment: The cause of MS remains unknown. MS is thought to be caused by complex and heterogenous interactions of environment and genes. Here, investigators identified and validated an autoantibody that appears to be present in almost half of patients with MS. The antibody results in altered glial expression and complement deposition when injected into mice. Whether anti-KIR4.1 antibody production is one of the inciting events toward MS development is unclear, but its discovery provides a clue to disease pathogenesis and is a potential target for therapeutic manipulation. Although there may not be a "the" autoantibody in MS, the KIR4.1 protein may be an important part of the puzzle and will help incite new lines of research into MS pathogenesis, disease initiation, and propagation.
— Robert T. Naismith, MD Published in Journal Watch Neurology July 24, 2012
Citation(s): Srivastava R et al. Potassium channel KIR4.1 as an immune target in multiple sclerosis. N Engl J Med 2012 Jul 12; 367:115.
http://www.ncbi.nlm.nih.gov/pubmed/22784115?dopt=Abstract
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Dalfampridine (4-aminopyridine) Poses Seizure Risk for
Multiple Sclerosis Patients
Ampyra was approved to improve walking in patients with MS. Seizures are a known side effect of Ampyra, and seizure risk increases with higher blood levels of the drug. The majority of seizures happened within days to weeks after starting the recommended dose and occurred in patients having no history of seizures. The FDA is updating the Ampyra drug label to clarify recommendations. Ampyra should be discontinued permanently if a seizure occurs.
http://www.fda.gov/Safety/MedWatch/SafetyInformation/../ucm313055.htm
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MM: Mark Drugs has been a leader in the aseptic preparation of products for sterile and surgical use throughout Chicagoland for more than 20 years. Many hospitals, clinics and physicians have turned to Mark Drugs and continue to use our services to help provide drugs that are in short supply to their patients. Whether this means making sterile products from the raw ingredients or re-packaging existing inventory, it is imperative to patient safety that “splitting vials” of single dose vials into multiple smaller unit doses be done in a proper environment with properly trained technicians or pharmacists. Mark Drugs has the expertise, training and skill to perform these tasks in our labs. Please contact us for more information so that we may help meet your institution’s needs.
CDC: Trained Pharmacists Must Be Involved in Dividing Single-use Vials
Following two outbreaks of Staphylococcus aureus infection in 10 patients being treated for pain in outpatient clinics, the CDC is strongly urging providers faced with drug shortages to avoid using single-dose vials (SDVs) or single-use medications for more than one patient unless the formulation is prepared by a “high-quality” pharmacy. In both cases, the clinics reported that they were unable to obtain smaller vial sizes needed by patients either because of drug shortages or because the smaller size wasn’t being manufactured.
The outbreaks are a reminder of the serious consequences that can result when SDVs are used for more than one patient. If SDVs must be used for more than one patient, full adherence to United States Pharmacopeia standards is critical to minimize the risks that be associated with of “multipatient use.”
http://www.uspharmacist.com/weekly_news_update/story/35642/
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Obstet Gynecol 2012 Jul; 120:130
Obesity's Effects on Duration of Labor
Obese women took longer to progress from 4-cm to 6-cm cervical dilation.
Maternal obesity is a risk factor for cesarean delivery, complications of which affect obese women disproportionately. In a retrospective cohort study designed to estimate the effects of obesity on labor progression, investigators compared duration of labor as a function of body-mass index (BMI) among women with full-term, singleton pregnancies who completed the first stage of labor.
Among 5204 women, 53.6% were obese (BMI 
30 kg/m2) and 10.8% had BMIs >40. Obese women were older, had higher gravidity and parity, were more often black, and had more medical comorbidities than normal-weight women. After adjusting for parity, labor induction, race, and birth weight >4000 g, median time to progress from 4 cm to complete dilation was longer for obese than for nonobese women (4.7 hours versus 4.1 hours). When assessed in 2-cm intervals, the greatest difference between groups was during the latent phase (i.e., progression from 4 cm to 6 cm; 2.2 hours vs. 1.9 hours). No difference was found after 6-cm dilation.
Comment: The relation between obesity and first-stage labor progression seems to be strongest during the latent phase. The authors comment that existing criteria for normal labor progression might need to be changed to accommodate obese women. Their findings suggest that standard definitions of labor arrest may be especially inappropriate for obese women, possibly leading to unnecessary cesarean deliveries. Interestingly, others have suggested that, in general, the definition of active labor should be adjusted to reflect current patterns of progression (JW Womens Health Dec 16 2010).
— Diane J. Angelini, EdD, CNM, FACNM, FAAN, NEA-BC Published in Journal Watch Women's Health July 26, 2012
Citation(s): Norman SM et al. The effects of obesity on the first stage of labor. Obstet Gynecol 2012 Jul; 120:130.
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JAMA 2012 Jun 27; 307:2627
Effect on Resting Energy Expenditure of Three Maintenance Diets
A low-carbohydrate diet, even if higher in fat, produced the best results.
Patients who diet often regain all or part of lost weight, possibly because calorie restriction induces a decline in resting energy expenditure (REE). Whether the composition of the maintenance diet affects this decrease in REE was assessed in 21 overweight and obese adults (mean age, 30; mean body-mass index, 34 kg/m2).
After a run-in period of 12 weeks on a high-protein diet that resulted in a mean weight loss of 14.3 kg (13.6% of baseline body weight), participants were assigned to a random sequence of three different diets for 4 weeks each. The three test diets were low-fat (60% carbohydrate), moderate-carbohydrate (40% carbohydrate), and very low-carbohydrate (10% carbohydrate, 30% protein, 60% fat). REE was measured for each diet and compared with pre–weight-loss measures. The decline in REE was greatest for the low-fat diet (205 kcal/day), least for the very low-carbohydrate diet (138 kcal/day), and intermediate for the moderate-carbohydrate diet. Changes in several metabolic parameters (leptin, HDL cholesterol, triglycerides, and insulin sensitivity) also were more favorable for the very low-carbohydrate diet.
Comment: In the short term, a low-carbohydrate diet might be more effective for both weight loss and for improving several metabolic parameters, even if high in fat content. However, the best maintenance diet that leads to favorable clinical outcomes in the long term is unclear.
— Thomas L. Schwenk, MD Published in Journal Watch General Medicine July 10, 2012
Citation(s): Ebbeling CB et al. Effects of dietary composition on energy expenditure during weight-loss maintenance. JAMA 2012 Jun 27; 307:2627.
(http://dx.doi.org/10.1001/jama.2012.6607)
http://www.ncbi.nlm.nih.gov/pubmed/22735432?dopt=Abstract
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Diabetes Care 2012 Jun; 35:1364
New Position Statement for Managing Type 2 Diabetes
A one-size-fits-all approach is rejected.
The American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) have published a new position statement entitled, "Management of Hyperglycemia in Type 2 Diabetes: A Patient-Centered Approach." The document outlines basic elements of lifestyle modification, oral agents, noninsulin injectable agents, and insulin, and provides management tips that even experienced clinicians might find helpful. Two aspects of the report are particularly noteworthy:
- Acknowledging "mounting concerns about . . . potential adverse effects [of drug therapies] and new uncertainties regarding the benefits of intensive glycemic control on macrovascular complications," the authors emphasize a patient-centered approach with individualized targets for glycemic control. For example, they recommend more-stringent control (e.g., glycosylated hemoglobin [HbA1c] target, <7%) for motivated patients with new-onset diabetes and long life expectancies, and less-stringent control (e.g., HbA1c goal, 8% or even higher) for less-motivated patients with longstanding diabetes, limited life expectancies, and high risk for adverse outcomes from hypoglycemia.
- Because the authors reject a one-size-fits-all approach, they make this important statement: "Utilizing the percentage of diabetic patients who are achieving an HbA1c <7% as a quality indicator, as promulgated by various health care organizations, is inconsistent with the emphasis on individualization of treatment goals."
Comment: Many clinicians talk about getting their patients with type 2 diabetes "to goal," as if a single, evidence-based target was applicable to every patient. Others talk about being "dinged" by real or imagined organizations if their patients' HbA1c levels are not in a certain range. In contrast, this position statement supports a more-reasoned approach that involves shared decision making and flexible goals. In a worthwhile accompanying editorial, the author describes the process that resulted in this position statement. One note: Nine of the 10 authors of the statement each have financial ties to numerous pharmaceutical companies.
— Allan S. Brett, MD Published in Journal Watch General Medicine July 24, 2012
Citation(s): Inzucchi SE et al. Management of hyperglycemia in type 2 diabetes: A patient-centered approach. Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care 2012 Jun; 35:1364.
(http://dx.doi.org/10.2337/dc12-0413)
http://www.ncbi.nlm.nih.gov/pubmed/22619286?dopt=Abstract
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MM: It is not unusual for patients of all ages who are exhibiting symptoms of subclinical hypothyroidism to show reversals of these symptoms when presented with supplements such as iodine, selenium, zinc, vanadium and the B vitamins. The Licensed Dietitian or Pharmacists at Mark Drugs can provide you with more information and guidance to assess if any of these nutritional products may be appropriate for you or a loved one.
J Clin Endocrinol Metab 2012 Jun; 97:1962
Natural History of Subclinical Hypothyroidism in Older Adults
Some people revert back to euthyroid status.
Because thyroid testing is performed widely in older adults, clinicians often encounter cases of subclinical hypothyroidism (i.e., elevated serum thyroid-stimulating hormone [TSH] and normal serum free thyroxine [T4] levels). According to the authors, this U.S. study is the largest longitudinal cohort study of the natural history of subclinical hypothyroidism in older community-dwelling adults. About 3600 people (age, 
65; mean age, 75) were tested at baseline; those with subclinical hypothyroidism (TSH level 
4.5 mIU/L) were retested at 2 and 4 years.
At baseline, 13 of every 100 people exhibited subclinical hypothyroidism. The figure shows outcomes for 13 hypothetical participants with subclinical hypothyroidism at 2 and 4 years. Participants moved back and forth between the euthyroid and subclinical hypothyroid categories. Higher baseline TSH levels (e.g., 7–10 vs. 4.5–6.9 mIU/L) and baseline presence of antithyroid peroxidase antibodies predicted a lower likelihood of reverting to euthyroidism. Relatively few people progressed to overt hypothyroidism.
Comment: These data provide estimates that clinicians might find useful in following older patients with subclinical hypothyroidism; in a nontrivial proportion of such patients, subsequent TSH levels revert to the euthyroid range. However, the study doesn't address the controversial issue of whether early thyroid supplementation benefits older patients with persistent subclinical hypothyroidism.
— Allan S. Brett, MD Published in Journal Watch General Medicine July 24, 2012
Citation(s): Somwaru LL et al. The natural history of subclinical hypothyroidism in the elderly: The Cardiovascular Health Study. J Clin Endocrinol Metab 2012 Jun; 97:1962.
(http://dx.doi.org/10.1210/jc.2011-3047)
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BMJ 2012 Jul 10; 345:e4230
Moderate Alcohol Consumption Is Associated with Lower Risk for Rheumatoid Arthritis
In a prospective study, risk was 40% to 50% lower in older women who weren't teetotalers.
Alcohol consumption lowers production of proinflammatory molecules, and an inverse relation between alcohol consumption and risk for rheumatoid arthritis (RA) has been observed previously in case-control studies. To test this association prospectively, researchers conducted a population-based cohort study of more than 34,000 Swedish women (age, 
39 in 1987). Participants provided data on alcohol consumption in 1987 and 1997.
During follow-up from 2003 until 2009, 197 new cases of RA were identified. The multivariable adjusted relative risk for RA during follow-up was 37% lower in women who drank >4 glasses of alcohol (1 glass = 15 g of ethanol) weekly in 1997 than in women who drank <1 glass of alcohol weekly. Similarly, adjusted risk for RA was 52% lower in women who drank >3 glasses of alcohol weekly in both 1987 and 1997 than in never drinkers.
Comment: This prospective study affirms that moderate alcohol consumption is associated with lower risk for rheumatoid arthritis in women. The investigators note that their results are consistent with the known inverse relation between alcohol consumption and coronary heart disease risk (JW Gen Med Mar 15 2011) and "add to the evidence that moderate alcohol consumption is not harmful and can be protective against" chronic disease.
— Paul S. Mueller, MD, MPH, FACP Published in Journal Watch General Medicine July 26, 2012
Citation(s): Di Giuseppe D et al. Long term alcohol intake and risk of rheumatoid arthritis in women: A population based cohort study. BMJ 2012 Jul 10; 345:e4230.
(http://dx.doi.org/10.1136/bmj.e4230)
http://www.ncbi.nlm.nih.gov/pubmed/22782847?dopt=Abstract
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N Engl J Med 2012 Jun 28; 366:2483
Assisted Reproductive Technology: Cumulative Live-Birth Rates Offer Hope to Infertile Couples
Cumulative live-birth rates can approach those arising from spontaneous conception.
Assisted reproductive technology has helped infertile couples build families for more than 20 years, yielding almost 4 million births worldwide. Just how successful is this approach, and under what conditions is it most apt to result in babies? Registries worldwide commonly refer to "per cycle" pregnancy rates, but what matters to the individual patient is her own likelihood of having a baby. U.S. investigators used the nationwide database of the Society for Assisted Reproductive Technology from 2004 through 2009 to link cycles to individual women, thereby estimating cumulative live-birth rates per cycle. Conservative rates were calculated on the assumption that women who did not return for subsequent treatment would not experience live birth; optimal rates assumed that women who did not return for treatment would experience live-birth rates similar to those who continued treatment.
Data were derived from 246,740 women who underwent 471,208 cycles resulting in 140,859 live births. Live births occurred in 30% of cycles and 57% of women; rates were highest in women younger than 31 and fell with advancing maternal age. After three cycles, conservative and optimal live-birth rates with autologous oocytes in women younger than 31 were 63.3% and 74.6%, respectively. These rates were only 18.6% and 27.8%, respectively, in women aged 41 or 42 and were 6.6% and 11.3% in those 43 or older. When donor oocytes were used, conservative and optimal rates were >60% and >80%, respectively, regardless of recipients' maternal age.
Comment: If only it were this simple! Although live-birth rates with assisted reproductive technology have improved impressively, procedures remain stressful and costly, and discontinuation rates are high (in this study, 25% of women discontinued treatment after unsuccessful first cycles and 33% after subsequent cycles). Still, this study confirms just how much these procedures have advanced; furthermore, the findings make a strong case for encouraging use of donor oocytes in infertile women who are 43 or older.
— Robert W. Rebar, MD Published in Journal Watch Women's Health June 27, 2012
Citation(s): Luke B et al. Cumulative birth rates with linked assisted reproductive technology cycles. N Engl J Med 2012 Jun 28; 366:2483.
http://www.ncbi.nlm.nih.gov/pubmed/22738098?dopt=Abstract
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MM: It’s important to constantly review data irrespective of whether it coincides with the conventional paradigm or if it is in opposition. This is the only way that we can learn and grow. This study is large and appears well structured yet its results fly in the face of other studies that have shown conflicting results. I wouldn’t give up on the use of milk thistle as it may have a synergistic effect on the use of other conventional products. After all, conventional medicine has little to offer at this time for HCV so I’m keeping my eyes and mind open.
JAMA 2012 Jul 18; 308:274
Silymarin Is Ineffective for Chronic Hepatitis C Virus Infection
In the most rigorous trial to date, oral silymarin was not superior to placebo in decreasing disease activity.
Silymarin is a botanical extract of milk thistle commonly used by patients with liver disease. In vitro studies have demonstrated antiviral, anti-inflammatory properties of silymarin in hepatitis C virus (HCV) replicon systems. However, the few efficacy studies conducted in patients with chronic HCV infection have produced mixed results.
In a new multicenter, double-blind, placebo-controlled efficacy trial, investigators randomized 154 patients (median age, 54; 71% men) with chronic HCV infection who previously failed interferon-based therapy to receive 420 mg of silymarin, 700 mg of silymarin, or placebo three times daily for 24 weeks. The two oral doses of pure silymarin were determined by earlier dose finding studies and were three to five times higher than concentrations used in previous studies. The primary endpoint was a serum alanine aminotransferase (ALT) level of 
45 U/L or a 50% reduction from baseline ALT to a level <65 U/L. Secondary endpoints included HCV RNA levels and quality-of-life indicators.
After 24 weeks of treatment, only two patients in each group achieved the primary endpoint. The mean decline in ALT levels at the end of treatment, the mean change in HCV RNA levels, and the quality-of-life indicators did not differ among the three groups.
Comment: This trial definitively demonstrates that silymarin, even at three to five times the typical dose, is ineffective in treating patients with chronic HCV infection. Unlike previous trials, this study used a pure, quantifiable formulation of silymarin and well-defined outcomes, its cohort was large and representative of the patient population, the treatment period was sufficiently long, and both medication and visit adherence rates were high. Clinicians should quote this study when addressing patients' questions regarding the use of milk thistle for treating HCV infection.
— Atif Zaman, MD, MPH Published in Journal Watch Gastroenterology July 27, 2012
Citation(s): Fried MW et al. Effect of silymarin (milk thistle) on liver disease in patients with chronic hepatitis C unsuccessfully treated with interferon therapy: A randomized controlled trial. JAMA 2012 Jul 18; 308:274
http://www.ncbi.nlm.nih.gov/pubmed/22797645?dopt=Abstract
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MM: We’ve visited this topic several times in the past in these article lists. Historically, it has been considered by conventional, allopathic medicine as unique and has been typically rejected as “too alternative” or irresponsible. It appears that once again, what was extremely new and revolutionary a short while ago may find a place in conventional allopathic medicine. As we become more wary across society of the flagrant use and subsequent failure of antibiotics we will continue to look for other economic options that will not coome back and bite us further down the road. This may not be the complete answer. Time will tell, but like probiotics, I will not be surprised if we see more and more of this treatment finding its way into hospitals and GI clinics across the country.
Am J Gastroenterol 2012 Jul; 107:1079
Long-Term Cure Rates from Fecal Transplantation for C. Difficile Infection
Symptoms were resolved for at least 90 days in 91% of patients.
Recent studies have described the benefits of fecal transplantation in patients with recurrent Clostridium difficile infections (JW Gastroenterol Mar 30 2012 and JW Gastroenterol Jun 4 2010).
To study the long-term effects of fecal transplantation, investigators conducted a multicenter follow-up study of 77 adults (mean age, 65; 73% women) who underwent the procedure for refractory C. difficile colitis. On average, patients had experienced diarrhea symptoms for 11 months and had failed to respond to five antimicrobial regimens prior to fecal transplantation.
Results were as follows:
- Diarrhea symptoms resolved in 74% of patients in
3 days. - Diarrhea symptoms resolved in 82% of patients and improved in 17% within an average of 5 days (range, 1–60 days).
- The primary cure rate (resolution of symptoms without recurrence within 90 days) was 91%.
- Of seven patients who did not respond to treatment or experienced recurrence of symptoms within 90 days, four were treated successfully with vancomycin with or without probiotics, two failed to respond to vancomycin but did respond to repeat transplant, and one died in hospice care of unknown cause without undergoing treatment for recurrence.
- The secondary cure rate (resolution of symptoms after an additional course of vancomycin with or without repeat transplant) was 98%.
- Of all patients, 53% stated they would use fecal transplant as their preferred first-line therapy for another recurrence.
- No definite complications occurred, but four patients developed new medical conditions, including peripheral neuropathy, Sjögren syndrome, idiopathic thrombocytopenic purpura, and rheumatoid arthritis.
Comment: These data provide additional support for the use of fecal transplantation in patients with refractory C. difficile infections.
— Douglas K. Rex, MD Published in Journal Watch Gastroenterology July 27, 2012
Citation(s): Brandt LJ et al. Long-term follow-up of colonoscopic fecal microbiota transplant for recurrent Clostridium difficile infection. Am J Gastroenterol 2012 Jul; 107:1079.
http://www.ncbi.nlm.nih.gov/pubmed/22450732?dopt=Abstract
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MM: We have had dogs since I was a small child. My kids have been raised with a dog always nearby and my brother swears by his cats. Whatever the pet is, we, as humans will benefit. Our kids have been blessed with few infections and very few prescriptions for antibiotics. Have the pets helped with this? Perhaps. In any case, I wouldn’t give up the added benefits that my children have had to train, take care of and receive the love and affection that they have received from these four legged housemates.
Pediatrics 2012 Jul 9
Does Dog or Cat Exposure Protect Against Respiratory Tract Infections During the First Year of Life?
In this prospective study, dog contact was more protective than cat contact, but the results leave the question unresolved.
Upper respiratory tract infections are common during the first year of life, and numerous studies have identified factors that either increase (e.g., day care attendance) or decrease (e.g., breast-feeding) risk. The role of animal exposure in early respiratory tract infections is less certain. In this study, researchers examined the effect of dog and cat contact on respiratory symptoms in a prospective birth cohort of 397 children in Finland.
The children were followed for 1 year, and parents completed weekly diary questionnaires about symptoms, antibiotic use, and amount of contact with dogs or cats at home. In univariate analysis of 17,124 diary weeks, children who were exposed to dogs or cats at home had significantly fewer weeks with cough, rhinitis, and otitis symptoms and fewer courses of antibiotics than children who had no contact. In adjusted multivariate analysis, children who had contact with a dog had significantly more healthy weeks (adjusted odds ratio, 1.31; 95% confidence interval, 1.13–1.52; P<0.001) and used fewer antibiotics (aOR, 0.71; 95% CI, 0.52–0.96; P=0.03) than children without dogs at home. Cats did not have a significant protective effect in multivariate analysis.
Comment: As an animal lover, I would like to believe that dogs and cats in the home protect against respiratory illness during the first year of life. However, this prospective study showed only a modest benefit and did not account for day care attendance. It's probably safe to conclude that as far as respiratory infections are concerned, having a dog or cat at home at least does no harm.
— Peggy Sue Weintrub, MD Published in Journal Watch Pediatrics and Adolescent Medicine July 25, 2012
Citation(s): Bergroth E et al. Respiratory tract illnesses during the first year of life: Effect of dog and cat contacts. Pediatrics 2012 Jul 9; [e-pub ahead of print].
(http://dx.doi.org/10.1542/peds.2011-2825)
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JAMA 2012 Jul 11; 308:175.
Guillain-Barré Syndrome After Influenza Vaccination
The potential risk for GBS warrants vigilance but should not discourage vaccination.
Guillain-Barré Syndrome (GBS) is an acute immune-mediated inflammatory polyradiculoneuropathy that may follow triggering events such as infections and vaccination. The relative risk for GBS ("extensive" paresis or paralysis) after administration of the 1976–1977 inactivated swine influenza A (H1N1) vaccine was significantly increased, ranging from 4.0 to 7.8 for the 6-week period following vaccination. Studies of influenza vaccination in subsequent years, however, have found either no increase in risk (for the years 1978–1988; N Engl J Med 1981; 304:1557 and Am J Epidemiol 1991; 133:952) or an increase of about one case of GBS per million vaccinations (for 1992–1994; N Engl J Med 1998; 339:1797). To assess the potential association between vaccination against the 2009 pandemic influenza A (H1N1) virus and GBS, researchers conducted a population-based cohort study, following vaccination against this strain in 57% of the 7.8 million residents in Quebec.
Active surveillance identified 25 cases of GBS within 8 weeks after vaccination; most cases (19 of 25) occurred within 4 weeks after vaccination. Another 58 cases occurred in individuals considered unexposed. All cases were confirmed by medical record review. Compared with the unexposed group, the vaccine-exposed group had a significantly higher relative risk for GBS at both 4 and 8 weeks (2.75 and 1.80, respectively). The number of GBS cases attributed to vaccination was approximately two cases per 1 million vaccine doses, with the excess risk confined to people older than 50.
Comment: Concerns about the potential association between influenza vaccination and GBS have persisted for almost 30 years, despite repeated studies showing either no increased risk or a marginal increase. The observations made in Quebec following the 2009 influenza A (H1N1) vaccination campaign are of interest for a few reasons. An increased risk for GBS was observed, and the increased risk was evident only in the 4-week period following vaccination and only in those older than 50. By contrast, in the 1992–1994 period, the excess risk was confined to those younger than 65.
The combined epidemiological data suggest that the risk for GBS following influenza vaccination varies from year to year (probably as a function of the different immunogenic composition of the vaccine each year), that the age group at risk cannot easily be predicted, and that we should remain vigilant. These data, however, do not suggest that the potential increased risk for GBS should discourage people from seeking influenza vaccination.
— Michael Benatar, MD, MS, PhD Published in Journal Watch Neurology July 24, 2012
Citation(s): De Wals P et al. Risk of Guillain-Barré syndrome following H1N1 influenza vaccination in Quebec. JAMA 2012 Jul 11; 308:175.
http://www.ncbi.nlm.nih.gov/pubmed/22782419?dopt=Abstract
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Dark Chocolate Affirmed as Brain-Booster
Official French evidence review concludes that dark, antioxidant-rich chocolate or cocoa can protect or improve brain function and mood
by Craig Weatherby
Headlines touting the health benefits of raw cocoa – and extra-dark chocolate bars made from it – aren’t just hype. While limited, the clinical evidence for dark chocolate’s artery-health and blood-flow benefits is almost entirely positive … and its plausibility is supported by bountiful lab evidence.
Earlier this month, the famously hard-nosed European Food Safety Authority approved this health claim for extra-dark (80% cocoa) chocolate: “cocoa flavanols help maintain endothelium-dependent vasodilation which contributes to normal blood flow.” The EFSA’s approval was based on evidence that daily intake of 200mg of cocoa flavanols – which include epicatechins and procyanidins – promotes optimal blood circulation. This amount of cocoa flavanols can be gotten from 2.5 grams (about one-tenth ounce) of “raw,” non-Dutched cocoa powder or 10 grams (about one-third ounce) of 80% extra-dark chocolate.
(Most cocoa brands treat their cocoa with alkali – the process known as “Dutching” – which destroys some 90 percent of its healthful flavanols.)
Some chocolate is made with Dutched, low-flavanol cocoa, while some brands – including Vital Choice – use non-Dutched, high-flavanol cocoa. More recently, clinical research has linked cocoa’s flavanols to enhanced brain health.
For example, see “Extra-Dark Chocolate Eased Memory Tasks”, “Cocoa May Boost Eyes and Brain”, and related articles in the Cocoa, Tea & Coffee section of our news archive. And those indications have just been affirmed in an evidence review from the French Medical Research Institute (INSERM) … which is that nation’s counterpart to the U.S. National Institutes of Health.
French evidence review sees evidence of chocolate’s brain benefits
The evidence review was authored by functional neurochemist Astrid Nehlig, Ph.D., of INSERM. She analyzed the many studies submitted to the European Food Safety Authority and found the evidence in them sufficient to support the idea that cocoa flavanols boost basic thinking functions. As Dr. Nehlig wrote, “Cocoa powder and chocolate contain a large percentage of flavonoids that display several beneficial actions on the brain.” (Nehlig A 2012) She noted evidence that cocoa flavanols keep brain cells alive by enhancing the supply of blood to capillaries in the brain, and help create new blood vessels. Specifically, Dr. Nehlig concluded that epicatechin – the main flavanol in cocoa, which also occurs in green and white tea – was the major reason for these benefits.
She hypothesized that regular consumption of flavanol-rich chocolate or cocoa might reduce stroke risk and help prevent or delay age-related cognitive decline and dementia. As Dr. Nehlig put it, “… [cocoa] flavonoids preserve cognitive abilities during aging in rats, [and] lower the risk for developing Alzheimer's disease and … stroke in humans.” (Nehlig A 2012) Finally, she observed that “Chocolate also induces positive effects on mood ... in part because eating it stimulates the release of endorphins.” (Nehlig A 2012)
Choose your cocoa and chocolate carefully
The epicatechin content of chocolate rests largely on two factors: use of non-Dutched cocoa and moderate roasting temperatures. The cocoa butter (cocoa fat) used to make chocolate is high in saturated fat, but it’s of a type (stearic acid) that does not harm heart health. And extra-dark chocolate is relatively low in sugar compared with milkier, low-cocoa bars. Dr. Nehlig concluded that the evidence is clear on one key point: “On the basis of the present knowledge, it appears that the benefits from moderate cocoa or chocolate consumption likely outweigh the possible risks.”
Source: Nehlig A. The neuroprotective effects of cocoa flavanol and its influence on cognitive performance. Br J Clin Pharmacol. 2012 Jul 10. doi: 10.1111/j.1365-2125.2012.04378.x. [Epub ahead of print]
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