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Content 7

 

The Doctor and the Pharmacist

Radio Show Articles:
August 17, 2013

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What Prompts Pneumonia Readmissions?
Probiotics Fail to Reduce Antibiotic Associated Diarrhea
Lack of Hormone Replacement Therapy Estimated to be Deadly for Nearly 50,000
Finasteride Lowers Risk for Prostate Cancer But Offers No Mortality Advantage
Androgen Replacement Therapy Growing
More than Half Psoriasis Patients Surveyed are Dissatisfied
Psoriasis Often Goes Untreated or Undertreated
No Effect of Medical Marijuana Laws on Adolescent Marijuana Use
Breast-Feeding Is Less Costly in the Short and Long Run
Mediterranean Diet Reduces Stroke Risk Even in Those with High Genetic Risk
For Some, Another Costly Delay in Implementing Part of the Affordable Care Act
Does Low-Dose Aspirin Lower Cancer Risk in Women?
Induced or Augmented Labor Linked to Higher Autism Risk
Long Term Use of Calcium Channel Blockers Linked to Increased Breast Cancer Risk
Elevated Glucose Levels Associated with Dementia
Glucose Levels Predict Risk for Dementia
Fluoroquinolones Linked to Dysglycemia in Patients with Diabetes
Fluoroquinolone Labels Updated to Reflect heightened Risk for Peripheral Neuropathy
Nurse Practitioners' Efforts to Operate Independently Seen in Five States

MM: The current practice of penalizing hospitals for readmission of patients with conditions such as pneumonia is reprehensible. This article emphasizes that certain populations are prone to chronic re-infection and that the "failure to cure" penalties are unfair and without substance. This is another example of an idea and program initiated by big government that has not been vetted by scientific support and fact.
  
Clin Infect Dis 2013 Aug 1; 57:362
What Prompts Pneumonia Readmissions?
Rehospitalization after pneumonia correlated with non-modifiable patient characteristics, not poor care.
Hospitals recently have become subject to fines for “excess readmissions” of patients following discharge after pneumonia, among other diseases, which has inspired new interest in understanding why readmissions occur. Researchers retrospectively reviewed the records of all adults with culture-confirmed bacterial pneumonia admitted to a single U.S. tertiary care hospital during 2010. Of 977 patients, 771 survived to discharge; of these, 149 (19%) were rehospitalized within 30 days. The most common diagnoses at readmission were chronic obstructive pulmonary disease (COPD) in 25% and congestive heart failure in 23%; infectious complications prompted only 17% of readmissions, including pneumonia in 7%.
Demographic variables and pneumonia severity, including admission to intensive care and intubation, did not predict readmission. No deficiencies in antibiotic coverage were found. Some comorbidities were more common in the readmission group, including diabetes, COPD, malignancies, and immunosuppression, and patients who were readmitted were significantly more likely to meet diagnostic criteria for healthcare-associated pneumonia rather than community-acquired pneumonia. Multivariate analysis identified four predictors of readmission: admission from a nursing home or long-term care facility, immunosuppression, prior antibiotic therapy, and hospitalization during the past 90 days.
Comment: These authors, like others, find that most readmissions indicate sicker, weaker patients, rather than deficient care. An editorialist wishes for more information on post-discharge care in this cohort, which might have influenced the study's results, but concurs that readmissions apparently are so seldom due to modifiable factors in acute care that the recently enacted set of penalties should be reconsidered.
Citation(s): Shorr AF et al. Readmission following hospitalization for pneumonia: The impact of pneumonia type and its implication for hospitals. Clin Infect Dis 2013 Aug 1; 57:362. (http://dx.doi.org/10.1093/cid/cit254) Abstract/FREE Full Text Sexton DJ. “Excess readmissions” for pneumonia: A dilemma with a penalty. Clin Infect Dis 2013 Aug 1; 57:368.
(http://dx.doi.org/10.1093/cid/cit260)
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MM: This is not a surprise. With all the patients, clinicians, food manufacturers and pharmaceutical companies jumping on the Probiotic bandwagon, it is no wonder that they are being inappropriately used. The appropriate Probiotic for antibiotic associated diarrhea is the non-commensal fungal based probiotic Saccharomyces Boulardii, not a bacterial based probiotic. This has been known for almost a century.
  
Probiotics Fail to Reduce Antibiotic Associated Diarrhea
By Kelly Young
High-dose probiotics do not prevent diarrhea in older hospitalized patients, according to a large study in the Lancet.
Nearly 3000 inpatients aged 65 and older who were on antibiotic therapy were randomized to 21 days of a placebo capsule or a capsule containing lactobacilli and bifidobacteria, taken once daily. After 8 weeks, the incidence of antibiotic-associated diarrhea or Clostridium difficile diarrhea did not differ significantly between the groups.
The authors conclude: "Our findings do not provide statistical evidence to support recommendations for the routine use of microbial preparations for the prevention" of diarrhea.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2813%2961218-0/abstract
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MM: Fear can be a strong motivator or it can cripple an individual or an entire group of individuals. Fear has been one of the effects of the Women's Health Initiative (WHI) on patients and practitioners alike and this is why over the past decade women have either self-denied or been denied by their well meaning physicians, appropriate hormone therapy. Ignorance and fear tend to work hand in hand and the combination of these two factors has done women a disservice. Bio-identical Hormone Replacement Therapy (BHRT) has been lumped into the misinformation or limited information sources that have been made available and this has also contributed to the disservice of care that has been perpetrated against the female public.
  
Lack of Hormone Replacement Therapy Estimated to be Deadly for Nearly 50,000
Hormone replacement therapy (HRT) has drastically dropped among U.S. women since the Women's Health Initiative cut short its Estrogen Plus Progestin Trial in 2002, when study results revealed that women who took the two-hormone therapy suffered adverse effects and higher mortality. However, the widespread rejection of HRT has been misguided, according to a team of researchers from the Yale School of Medicine as reported in the American Journal of Public Health. The authors calculated that rejecting estrogen-only hormone therapy resulted in the early deaths of nearly 50,000 women between 2002 and 2011.
http://www.latimes.com/news/science/sciencenow/la-sci-sn-estrogen-alone-hormone-therapy-deaths-20130718,0,7828032.story
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MM: Prostate cancer is typically a very slowly progressing disease and the majority of older men die from some other factor although they may have an ongoing diagnosis of prostate cancer. In fact, many times men are completely unaware that the condition even exists. For these reasons it is questionable whether prostate cancer need always be treated or not.
  
Finasteride Lowers Risk for Prostate Cancer But Offers No Mortality Advantage
By Joe Elia
Finasteride reduces the risk for developing prostate cancer, but it may be linked to more high-grade cancers and offers no mortality benefit, according to an updated New England Journal of Medicine study.
Researchers did an additional 10 years of case finding and mortality ascertainment among nearly 19,000 participants in the Prostate Cancer Prevention Trial, first reported in 2003. Participants had been randomized to either 7 years' prophylaxis with finasteride or placebo. The finasteride group showed a roughly 30% reduction in risk relative to placebo recipients. They also had a 17% increased risk for high-grade cancers, but this result was of borderline significance. Survival rates were similar between the groups, both overall and among those diagnosed with prostate cancer.
An editorialist concludes that some men may decide to take the drug to reduce screening's known harms, but, he says, "another way to reduce the harm of screening is to choose not to be screened."
http://www.nejm.org/doi/full/10.1056/NEJMoa1215932
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MM: More and more men are interested in Quality of Life (QOL) as well as simply living a long time. As Americans are getting older as a population more men will consider Testosterone replacement therapy. It is important to realize that when men start receiving testosterone from an outside source their own production frequently diminishes thereby necessitating testosterone REPLACEMENT and not testosterone SUPPLEMENTATION.
  
Androgen Replacement Therapy Growing
Forty-years and older American men have tripled their use of androgen replacement therapy between 2001 and 2011; this includes a greater than 5-fold surge in use of the hormone testosterone as a topical gel. The findings, published in a research letter in the August 12/26 issue of JAMA Internal Medicine, studied prescription drug claims data; some 10.74 million men aged 40 years or older were included in the study population. Androgen use rose from 0.81% in 2001 to 2.91% in 2011.
http://www.medscape.com/viewarticle/809321
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MM: Psoriasis is frequently considered an auto-immune condition so merely treating the symptoms will do nothing more than ameliorate the condition. Going to the potential or probable source of the problem - the immune system - tends to make a lot more sense. That is why I recommend at least a 3 month trial course of Low Dose Naltrexone (LDN) for patients who present with various forms of psoriasis. This inexpensive, low risk treatment may diminish symptoms and severity. The cost is only pennies a day compared to the very high cost of many of the newer drugs on the market and the benefits may be substantial.
  
More than Half Psoriasis Patients Surveyed are Dissatisfied
Psoriasis affects millions of Americans, but a new study suggests it remains woefully undertreated. In 2011, between 30% and nearly 50% of patients said they had no treatment for their psoriasis. Nontreatment and undertreatment of psoriasis patients is a significant problem in the U.S. The undertreated patients might be using only a topical cream to ease their psoriasis, when the addition of a systemic drug might help even more. Discontinuation of therapy is widespread (the most common reason given was unwanted side effects) followed by the inability to obtain adequate insurance coverage.
http://consumer.healthday.com/diseases-and-conditions-information-37/psoriasis-news-621/many-psoriasis-patients-going-without-treatment-study-finds-679240.html
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Psoriasis Often Goes Untreated or Undertreated
By Kelly Young
Patients with psoriasis are frequently untreated or undertreated, and those who are treated are often dissatisfied with the results, according to a study in JAMA Dermatology.
Some 5600 patients with psoriasis or psoriatic arthritis completed surveys about their treatments between 2003 and 2011. In 2011, 24% of patients with moderate psoriasis and 9% of patients with severe psoriasis (>10% of body surface area) were not being treated. One in three patients with moderate disease and 22% with severe disease received only topical drugs. One of the main reasons was that the providers did not prescribe an alternative.
UV-B was the most commonly used phototherapeutic treatment, and methotrexate was used more often than acitretin or cyclosporine.
Dissatisfaction with treatment was high, with just over half of patients with psoriasis and 46% with psoriatic arthritis reporting they were dissatisfied. Primary reasons for discontinuation of a biologic agent were adverse events and the patient's perception that the drug was not effective
http://archderm.jamanetwork.com/article.aspx?articleid=1729130
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Am J Public Health 2013 Aug; 103:1500
No Effect of Medical Marijuana Laws on Adolescent Marijuana Use
Both before-and-after and between-state comparisons did not demonstrate increases in adolescents' use.
Passage of state medical marijuana laws (MMLs) might decrease adolescents' perceptions of the risk associated with marijuana use as well as make it less expensive and easier to obtain. Investigators studied use rates in four states (Montana, Rhode Island, Delaware, and Michigan) that passed MMLs between 2004 and 2011 and provided data from the Youth Risk Behavior Survey on adolescent marijuana use. Outcomes examined were lifetime and past 30-day use of marijuana, and among users, past week and daily use.
In a series of 40 analyses examining use within states before and after enactment of MMLs and between states based on the year MMLs were passed, only two significant effects were found after controlling for demographic factors: From 2003 to 2009, lifetime prevalence of marijuana use and frequency of daily use decreased in Montana compared with a smaller decrease in lifetime prevalence and a slight increase in daily use in Delaware.
Comment : Given that 40 comparisons were made and significance levels were set at P=0.05, chance alone could account for the significant findings. Furthermore, the increase in daily use by adolescents in Delaware cannot be attributed to medical marijuana laws because Delaware enacted its MML in 2011. Other studies have also failed to find negative effects of MMLs on adolescents' marijuana use. Although these results are encouraging, nonmedical marijuana use by adolescents has increased since 2008 (http://viajwat.ch/19fAn21), concurrent with more states enacting and implementing MMLs. Hence, additional studies, particularly ones that analyze longer-term use patterns in more states and among the most vulnerable youth (those <16 years) are still needed before we can be completely reassured.
Citation(s): Lynne-Landsman SD et al. Effects of state medical marijuana laws on adolescent marijuana use. Am J Public Health 2013 Aug; 103:1500.
(http://dx.doi.org/10.2105/AJPH.2012.301117
 
http://www.ncbi.nlm.nih.gov/pubmed/23763418?access_num=
23763418&link_type=MED&dopt=Abstract

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MM: You have to love when mother nature trumps big manufacturers in a positive fashion. Not only does nursing your child create a stronger bond between mother and child and provide short term immune support to the child but now it appears that it protects against chronic life threatening disease for the mother too!
  
Obstet Gynecol 2013 Jul; 122:111
Breast-Feeding Is Less Costly in the Short and Long Run
Optimizing breast-feeding in the U.S. could decrease long-term maternal morbidity and healthcare costs.
Only 23% of U.S. mothers breast-feed throughout the first year of their infant's life, although the practice is associated with a host of short- and long-term health benefits. Investigators used modeling techniques to estimate the cost savings that could be expected if yearlong breast-feeding were more prevalent. The analysis focused on five disease risks lowered by lactation (invasive breast cancer, ovarian cancer, type 2 diabetes, hypertension, and myocardial infarction [MI]).
Assuming causal relations between breast-feeding and lifetime disease risk, the model projected that optimal (≥1 year) breast-feeding by 90% of mothers would result in significant reductions in incidence of breast cancer (4.3%), hypertension (5.5%), and MI (8.5%). The model estimated savings of US$734 million in direct costs and $17.9 billion when indirect costs, as well as costs of premature mortality, were included.
Comment: The true costs of not breast-feeding include those related not only to formula and bottles, but also to maternal health for years to come. Although one could quibble with some of the quantitative assumptions about disease prevalence, costs, and discount rates in this study — and one should be mindful of the stresses associated with being unable to breast-feed (NEJM JW Womens Health May 2 2013) — the authors make a convincing argument for the high cost of suboptimal breast-feeding rates. Stakeholders for this issue include employers and taxpayers, who shoulder a sizeable proportion of the nation's ever-rising healthcare cost burden. Findings such as these should reinforce calls for practices and policies (including those in the workplace) that support breast-feeding, particularly in low-income and minority communities, in which rates of maternal disease are high but prevalence of optimal breast-feeding remains woefully low.
Citation(s): Bartick MC et al. Cost analysis of maternal disease associated with suboptimal breast-feeding. Obstet Gynecol 2013 Jul; 122:111.
(http://dx.doi.org/10.1097/AOG.0b013e318297a047)
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MM: Even a genetic predisposition towards stroke may be positively influenced by diet. This is very good news for those who already know that they are pre-disposed to stroke or cardiovascular (CV) disease.
  
Mediterranean Diet Reduces Stroke Risk Even in Those with High Genetic Risk
By Joe Elia
High risks for type 2 diabetes and cardiovascular complications conferred by variants in the TCF7L2 gene can be partially offset by strict adherence to a Mediterranean-style diet, according to a Diabetes Care study.
PREDIMED investigators followed some 7000 participants at very high risk for cardiovascular disease. Their genetic risks were determined by ascertaining the variant of the TCF7L2 gene they carried, with "TT" variants known to confer higher risk than "CT" or "CC" variants.
The subjects were randomized to Mediterranean or low-fat diets and followed for roughly 5 years. TT carriers who did not generally observe Mediterranean-style diets at baseline showed higher risks for cardiovascular events, although not significantly so. Furthermore, TT carriers randomized to and adhering to a Mediterranean diet had stroke rates similar to CT and CC carriers.
The authors conclude that their findings support the benefits of a Mediterranean diet, "especially for genetically susceptible individuals."
http://care.diabetesjournals.org/content/early/2013/08/06/dc13-0955.abstract
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MM: This is another example of why government needs to back out of healthcare. The Affordable care Act (ACA) is a poorly designed and difficult to implement program. It will be rife with fraud, both intentional and unintentional and will likely further bankrupt our nation. The intent is honorable but the activation is incompetent.
  
For Some, Another Costly Delay in Implementing Part of the Affordable Care Act
By Joe Elia
The Obama administration has deferred for a year putting into place a provision of the Affordable Care Act that limits an individual's annual out-of-pocket expenditures to $6350.
Some patients will have to pay up to $6350 for physician and hospital services, plus another $6350 for prescription drugs — and possibly more, according to the New York Times.
Why the delay? The Times explains that separate computer billing systems for drugs and services within some organizations cannot communicate. One unnamed administration source told the newspaper: "We had to balance the interests of consumers with the concerns of health plan sponsors and carriers, which told us that their computer systems were not set up to aggregate all of a person's out-of-pocket costs. They asked for more time to comply."
In addition, last month the administration announced a delay in the requirement that large employers offer health insurance to full-time employees.
http://www.nytimes.com/2013/08/13/us/a-limit-on-consumer-costs-is-delayed-in-health-care-law.html?_r=0
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MM: I have nothing intrinsically against using aspirin when the benefits definitively outweigh the risks associated with it. Therefore, if a woman is at risk of colorectal cancer from either a familial or personal perspective, then she should consider Low Dose Aspirin on an Every Other Day schedule.
  
Ann Intern Med 2013 Jul 16; 159:7
Does Low-Dose Aspirin Lower Cancer Risk in Women?
Taking 100 mg of aspirin every other day for 10 years was associated with lower colorectal cancer risk.
Recent data from multiple trials suggest that long-term daily use of aspirin lowers risk for colorectal cancer (NEJM JW Gen Med Apr 24 2012). The randomized Women's Health Study (WHS) showed cancer incidence (total or colorectal) was the same after 10 years of alternate-day, low-dose aspirin (100 mg) as after placebo (NEJM JW Gen Med Aug 2 2005). At the end of that trial in 2004, participants were asked to continue in an observational study; 34,000 agreed, and the researchers now report longer-term outcomes.
During a median follow-up of 18 years, incidence of total cancer, breast cancer, and lung cancer did not differ between the women initially randomized to aspirin and those randomized to placebo, whereas colorectal cancer incidence was significantly lower in the aspirin group during the post-trial observation period (0.3% vs. 0.6%) and during overall follow-up (1.0% vs. 1.2%). In further analyses, women originally randomized to aspirin who continued to use aspirin during the observation period had the lowest incidence of colorectal cancer. Endoscopy rates did not differ between aspirin and placebo groups.
 Comment: In this observational extension of the Women's Health Study, alternate-day, low-dose aspirin use for 10 years was associated with lower colorectal cancer incidence as long as 8 years later. The authors note that 53 fewer cancer cases occurred in the aspirin group during the 18-year study, as did 193 more gastrointestinal bleeds and 214 more peptic ulcers. These findings alone should not alter the U.S. Preventive Services Task Force guideline (NEJM JW Gen Med Apr 14 2009), which indicates that aspirin should be offered for primary prevention only when potential cardiovascular benefit outweighs potential harm of gastrointestinal bleeding. However, future guideline writers will need to consider whether the data on colorectal cancer prevention expands the universe of people for whom aspirin's benefits outweigh its harms.
Citation(s): Cook NR et al. Alternate-day, low-dose aspirin and cancer risk: Long-term observational follow-up of a randomized trial. Ann Intern Med 2013 Jul 16; 159:77. (http://annals.org/article.aspx?articleid=1709803)
 
http://www.ncbi.nlm.nih.gov/pubmed/23856681?access_
num=23856681&link_type=MED&dopt=Abstract

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Induced or Augmented Labor Linked to Higher Autism Risk
By Joe Elia           
Children whose mothers had induced or augmented labor show increased risk for autism spectrum disorders, according to a JAMA Pediatrics study.
Researchers matched birth and public education records for some 625,000 North Carolina children, including 5500 with documented autism. Compared with children delivered without labor induction or augmentation, children of induced or augmented deliveries faced between a 10% and 25% increased risk for an autism diagnosis. The effect was stronger in boys.
The authors speculate that the effect may be due to exposure to exogenous oxytocin. They remind readers of the benefits of labor induction, especially with regard to preventing meconium aspiration syndrome. They also assert that their findings should not change care standards until more data become available.
http://archpedi.jamanetwork.com/article.aspx?articleid=1725449
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Long Term Use of Calcium Channel Blockers Linked to Increased
Breast Cancer Risk

By Amy Orciari Herman
Current, long-term use of calcium-channel blockers is associated with more than a doubling of risk for breast cancer among postmenopausal women, according to a case-control study in JAMA Internal Medicine.
Researchers interviewed some 900 postmenopausal women diagnosed with invasive ductal breast cancer, 1100 with invasive lobular cancer, and 900 controls without cancer. In adjusted analyses, current use of calcium-channel blockers for 10 years or longer was associated with a roughly 2.5-fold increase in risk for either type of breast cancer, relative to nonuse. Shorter durations of use and past use did not appear to increase risk, nor did other types of antihypertensives (e.g., beta-blockers, diuretics).
A commentator says that while these findings should not change clinical practice, they "make a convincing case" that a potential link between calcium-channel blockers and breast cancer "is worthy of being pursued."
http://archinte.jamanetwork.com/article.aspx?articleid=1723871
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MM: With obesity and diabetes on the rise throughout the world, it is disconcerting that making more empty calories available to a variety of populations may allow fewer people to go hungry but may create a state of dementia. We need to take a closer look at what is being provided in the form of food donations to impoverished areas and individuals and we need to provide more and better information to all people starting at the grade school level in our own country.
  
Elevated Glucose Levels Associated with Dementia
By Kelly Young
Higher glucose levels are associated with increased dementia risk, according to a prospective cohort study in the New England Journal of Medicine.
Researchers followed roughly 2100 people aged 65 and older who were free of dementia at baseline. Over a median follow-up of 6.8 years, patients had at least five measurements of glucose or glycated hemoglobin taken. About a quarter of patients developed dementia.
For all participants, the risk for dementia increased with increasing glucose readings. For patients without diabetes, an average glucose level of 115 mg/dL was associated with an 18% higher risk for dementia, compared with a level of 100 mg/dL. For those with diabetes, 190 mg/dL was associated with a 40% increased risk, relative to 160 mg/dL.
The authors speculate that microvascular disease of the central nervous system could contribute to the association.
http://www.nejm.org/doi/full/10.1056/NEJMoa1215740
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N Engl J Med 2013 Aug 8; 369:540
Glucose Levels Predict Risk for Dementia
Higher glucose levels within the nondiabetic range predicted higher risk for dementia.
Observational studies have established an association between diabetes and dementia. In this prospective study from Seattle's Group Health Cooperative, researchers sought to determine whether average glucose levels in people without diabetes predict development of dementia. The study involved 2067 older adults (mean age 74; 11% with diabetes) who had no evidence of dementia at baseline and who were screened every 2 years using the Cognitive Abilities Screening Instrument. Average glucose levels were estimated using models that incorporated both serial glycosylated hemoglobin and blood glucose values.
During a median follow-up of 7 years, 25% of participants were diagnosed with dementia. Among participants who did not have diabetes, risk for developing dementia increased with increasing average glucose levels, after adjustment for potentially confounding variables. For example, in those whose average glucose level was 115 mg/dL, relative risk for dementia was 18% higher than in those whose average glucose level was 100 mg/dL. Among participants who had diabetes, relative risk for dementia was 40% higher in those whose average glucose level was 190 mg/dL compared with 160 mg/dL.
Comment: The prospective nature of this study, in which patients screened negative for dementia at baseline, is a strength. However, unmeasured confounders might have influenced the association between glycemia and dementia, and reverse causality is remotely possible (e.g., lifestyle changes in patients with early subclinical dementia might promote higher glucose levels). If higher blood glucose levels within the nondiabetic range do contribute to development of dementia, the mechanism is unclear.
Citation(s): Crane PK et al. Glucose levels and risk of dementia. N Engl J Med 2013 Aug 8; 369:540.
(http://dx.doi.org/10.1056/NEJMoa1215740) CrossRef
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Fluoroquinolones Linked to Dysglycemia in Patients with Diabetes
By Kelly Young
Fluoroquinolones are associated with increased risk for both hyperglycemia and hypoglycemia among patients with diabetes, compared with other antibiotics, according to a study in CliAunical Infectious Diseases.
Researchers in Taiwan used national insurance claims data to identify roughly 78,000 outpatients with diabetes who received a new prescription for an oral antibiotic.
Within 30 days of starting the antibiotic, patients taking moxifloxacin, levofloxacin, or ciprofloxacin had 1.75 to 2.48 times the risk for hyperglycemia-related emergency department visits or hospitalizations, relative to patients taking macrolides. Risks were similarly elevated for episodes of hypoglycemia. Moxifloxacin was associated with the highest risk for dysglycemia.
The authors conclude: "Clinicians should consider these risks when treating patients with diabetes and prescribe fluoroquinolones cautiously."
http://cid.oxfordjournals.org/content/early/2013/07/23/cid.cit439.abstract
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Fluoroquinolone Labels Updated to Reflect heightened Risk for Peripheral Neuropathy
By Kelly Young
The FDA is requiring that the labels of fluoroquinolone antibiotics warn of the drugs' increased risk for peripheral neuropathy.
The risk has been observed with oral and injectable fluoroquinolones, but not topical agents. Patients could experience peripheral neuropathy any time during their treatment, and it could persist for months or years or be permanent.
Patients should contact their healthcare providers if they develop symptoms consistent with peripheral neuropathy in the arms and legs, including pain, burning, numbness, or weakness; change in sensation to touch, pain, or temperature; or change in the sense of body position.
Patients who develop these symptoms should stop taking the antibiotic and receive alternative therapies unless the benefit of the fluoroquinolone outweighs the risk.
http://www.fda.gov/Safety/MedWatch/SafetyInformation/
SafetyAlertsforHumanMedicalProducts/ucm365302.htm

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Nurse Practitioners' Efforts to Operate Independently Seen in Five States
By Joe Elia
Colleagues may be talking about a Wall Street Journal story on the effort by nurse practitioners in five states to operate with more independence.
A bill allowing NPs to practice autonomously of physician control passed the California State Senate but was hobbled in the Assembly after lobbying by the state's medical association. The WSJ writer predicts "more bitter fights in coming weeks."
Other states with pending legislation that proposes full practice autonomy include Massachusetts, Michigan, New Jersey, and Pennsylvania.

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