Lower verbal intelligence is associated with diabetic complications and slower walking speed in people with Type 2 diabetes: the Maastricht Study

This study was designed to see if there was a correlation between verbal intelligence, Type 2 diabetes, and walking speed.  They had each participant take the Groningen Intelligence Test which tested their vocabulary and then were assigned a score.  This score was then compared to indicators if Type 2 diabetes like A1C and glucose levels.  This vocabulary score was also compared to other diabetic health complications like chronic kidney disease, cardiovascular disease, and neuropathic pain.  Lastly, they assessed this vocabulary score with the speed at which the individual walked.  They tried to minimize confounding variables like age or gender.

In total, only 228 patients were fully assessed on all three tests.  When the verbal score was compared to the indicators of Type 2 diabetes (A1C, LDL, glucose, etc.) there was no association between the two.  The verbal score was also not associated with kidney disease.  Lower verbal scores did show an association with increased cardiovascular disease and neuropathic pain and decreased walking speed.

They noted that the lower verbal intelligence might be correlated with some diabetic functions because they aren’t as educated and have a lesser understanding of their disease state.  But I’d like to pose the question that if they don’t understand their disease state, then why isn’t there a correlation between low intelligence and out-of-range A1C, LDL, etc.  I also wonder why low intelligence was associated with slower walking.  It would be very interesting to see why exactly they chose to compare these three very different assessments and compared them to each other.  The walking speed especially seems unrelated.

 

Tang JYM, Wong GHY, Ng CKM, et al. Lower verbal intelligence is associated with diabetic complications and slower walking speed in people with Type 2 diabetes: the Maastricht Study. J Am Geriatr Soc. 10.1111/jgs.13938 (1 March 2016).

Uncomplicated Pregnancies and Ultrasounds for Fetal Growth Restriction: A Pilot Randomized Clinical Trial

This study was a randomized control trial to see if we should continue to give women ultrasonographic exams in their third trimester if their pregnancies are deemed uncomplicated.  These ultrasounds can be expensive, and this study was designed to see if they are beneficial at that point in the pregnancy.  Specifically, they wanted to see if having a third trimester ultrasound in an uncomplicated pregnancy would have any effect on detection of “small for gestational age” (SGA) when the birth weight of the baby less than 10% for the baby’s gestational age.

From a study done in 2012, approximately 10% of babies were born with SGA, and these pregnancies did not improve with the routine prenatal care  (bed rest, nutritional care, supplements).  These pregnancies did improve when abnormal growth is discovered before birth so that it may be evaluated and techniques to improve growth could be implemented.  The thinking is that these ultrasonographic exams can provide this information as to prevent the prevalence of SGA.

Of the women who were approached and gave consent, the detection of SGA was much higher (67%) when women had an ultrasonographic exam than the control (9%).  The evidence is overwhelming that receiving an ultrasound–even in the third trimester of an uncomplicated pregnancy–can still be beneficial and worth the time and money.  It was noted in the study that this may not be reflective of the entire population, as it had a small sample size.  The women they studied were very easy to find and only came from three sites.

 

Hammad IA, Chauhan SP, Mlynarczyk M, et al. Uncomplicated pregnancies and ultrasounds for fetal growth restriction: a pilot randomized clinical trial. AJP Rep. 2016; 6(1):83-90.

Efforts in Epilepsy Prevention in the Last 40 Years

This was a study conducted to see if new-onset epilepsy prevention strategies have been identified and successfully implemented.  This was done in Finland from 1973 to 2013 and analyzed first-time inpatients with an epilepsy diagnosis.  “Epilepsy” in this study was defined as two or more “unprovoked” seizures.

Previously, antiepileptic drugs have been proven to subdue epilepsy, but have failed to prevent new-onset epilepsy in individuals at risk for developing it.  They studied three different age groups longitudinally to see if there was an increase, decrease, or lack of change in the rates at which first-time patients were admitted with new-onset epilepsy.

In the last 40 years, the rate at which those 65 and younger were admitted to the hospital and newly diagnosed with epilepsy was constant.  However, the rate at which those 65 and older were diagnosed increase 5-fold over the last four decades.

They concluded that no advances had been made in the prevention of epilepsy.  However, I’d like to pose a question…is there really a way to definitively tell if someone will develop epilepsy in the future?  Often our healthcare is reactive not proactive–meaning we only treat things when there’s a problem.  If there aren’t any health complications, we don’t usually go seeking potential ones.  This can relate back to the study.  Yes, we have not been able to make strides with epilepsy prevention, but is that attainable at this time?

Sillanpaa M, Gissler M, Schmidt D. Efforts in Epilepsy Prevention in the Last 40 Years. JAMA Neurol. doi:10.1001/jamaneurol.2015.4515 (15 February 2016).

New Societal Approaches to Empowering Antibiotic Stewardship

All over the world, antibiotic resistance is a constant issue.  The CDC has issued statements about antibiotic stewardship, and now event the US Government wants to implement programs in hospitals to cut down on overuse of antibiotics.  Antibiotic “stewardship” is the description of these programs that will optimize the antibiotic selection process.

The first step is making sure hospitals are transparent and public about the frequency of health-care related infections along with making them commit to establishing these programs.  A lot of medical professionals need to be reminded that they are the only pharmacological entity that loses efficacy over extended use, so the the criteria for prescribing them should also be put under scrutiny.  If a well-defined system is put in place, with regulations on things like time frames of use or prior authorization for specific antibiotics before use, maybe they can crack down on the complication that is antibiotic resistance.

The article uses the example of fluroquinolones, the only antibiotic that is used to treat gram-negative bacilli.  Oftentimes, prescribers just resort to the antibiotic, where there are other treatment options readily available.  The more we prescribe antibiotics over other treatments, the more susceptible we make the patient and society in general to infections.  Here’s a situation where a guideline could be put in place.  Maybe if a diagnosis is reached, there could be a chart with potential action plans that prioritize antibiotics as a last option.

 

Spellberg B, Srinivasn A, Chambers H. New societal approaches to empowering antibiotic stewardship. JAMA. doi:10.1001/jama.2016.1346 (published 25 February 2016).

Cannabis Use and Risk of Psychiatric Disorders Prospective Evidence From a US National Longitudinal Study

With many states beginning to legalize cannabis, whether medicinal or recreational, there has been an increase in interest as to what kind of consequences it might have.  This particular study wanted to test the psychiatry of those smoking cannabis–particularly if it would affect their tendencies to abuse other drugs afterwards.  They also attempted to evaluate whether smoking marijuana would cause mood disorders, like bipolar disorder or anxiety, as some studies have previously.

The study was conducted in two “waves.” One was held 2001-2002 and the second was held from 2004-2005 with the same participants to make it a longitudinal study.  The participants were screened for psychiatric disorders like depression, anxiety, substance abuse, etc. and assessed according to the DSM-IV.  This was done at the onset of the trial and again at the end.  34,653 participants were interviewed, and of those 1,279 used cannabis.

Those who were smoking cannabis at the time of Wave 1 were much more likely to struggle with mental health issues or substance abuse by the time of Wave 2.  However, after adjusting their data, the only firm conclusion they made was that smoking cannabis indeed increased the risk of abusing other substances like alcohol, nicotine, or other drugs.  They did not conclude that marijuana induced or worsened mental disorders.  They reasoned that maybe the mental health issues came first and the cannabis use was a result, making this relationship correlational but NOT causal.

 

Blanco C, Hasin DS, Wall MM, et al. Cannabis Use and Risk of Psychiatric Disorders-Prospective Evidence From a US National Longitudinal Study. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2015.3229 (published 17 February 2016).

Treatment with Tacrolimus and Sirolimus Reveals No Additional Adverse Effects on Human Islets In Vitro Compared to Each Drug Alone but They Are Reduced by Adding Glucocorticoids

Human islet transplantation is an experimental method for treating Type 1 Diabetes.  The islet cells are isolated from the donor’s pancreas, and once transplanted will hopefully begin to produce insulin in the recipient.  This study wanted to test some common immunosupressants–tacrolimus and sirolimus–and their effects on islet cells, which at this point are relatively undefined.  They also want to see what these immunosupressants would do when combined with each other and with a glucocorticoid, methylprednisilone.  All trials were done in vitro with human cells.

When tacrolimus alone was added to the islet cells, they did not decrease their ability to produce a basal rate of insulin, but did decrease their ability to respond acutely to a high concentration of glucose.  Sarolimus had no deleterious effects on the islet cells’ insulin production at all.  When the two immunosupressants were combined and added to the cells, they were no more harmful than the tacrolimus alone.  When the methylprednisilone was added, there was no decrease in the basal insulin rate, however, the stimulated secretion decreased after an hour in the glucose-dense solution.  Methylprednisolone did have another effect: it reduced the pro inflammatory abilities of the immunosupressants.  This trial will help pave the way for medication regimens for those receiving islet transplants in the future.

 

Kloster-Jensen K, Sahraoui A, Vethe NT, et al. Treatment with Tacrolimus and Sirolimus Reveals No Additional Adverse Effects on Human Islets In Vitro Compared to Each Drug Alone but They Are Reduced by Adding Glucocorticoids. J Diabetes Res. 2016;2016:1-9.

 

Safety of artemisinins in first trimester of prospectively followed pregnancies: an observational study

This study was designed to yield the safety and efficacy of the most rapid-acting antiparasitic drug class, artemisinin derivatives, during the first trimester of human pregnancies.  Previously, it administered as a preventative intervention only during the second and third trimesters successfully. However, when these same drugs were tested on animals during their first trimester, their pregnancies either ended in a miscarriage or serious congenital malformations.   It is to be noted that the drug quinine, an antiparasitic, had been given to women in their first three months of pregnancy up to this point. This research would hopefully find out if artemisinins can safely and effectively be given to mother in the first trimester.  It is also of interest to see if it is more successful in preventing the spread of Malaria from mother to child–and ultimately miscarriages–than quinine.

This study was conducted near the border of Thailand and Myanmar between January 1994 and December 2013. They documented 55,636 pregnancies, but only 25,485 were further analyzed for Malaria and miscarriages. After ruling out many of the pregnancy cases, 183 were given the artemisinin treatment. They noticed no significant decrease or increase in the miscarriage rate as compared to treatment with quinine. They also could not draw firm conclusions on artemisinin’s effect on malformations, as the number of actual participants in the treatment ended up being too small.

Overall, they were able to determine that artemisinin derivatives are not as harmful to humans as they were in the animal trials. First-line artemisinin treatment is not deemed more effective after this research, but the miscarriage rate when receiving first-line artemisinin is lower than receiving quinine first and artemisinins secondarily. Artemisinin safety in the first trimester is still to be determined, but this sheds light to the severity of Malaria during pregnancies and how hard it can be to treat it successfully.

 

Moore KA, Simpson JA, Paw MK, et al. Safety of artemisinins in first trimester of prospectively followed pregnancies: an observational study. Lancet Infect Dis. 2016.

Preventing infant mortality: Pharmacists’ call to action

The United States has a higher infant mortality rate than many other developed countries.  6.1 of every 1000 babies born in the U.S. dies within their first 12 months of life, not including miscarriages or stillbirths.  The leading causes of death in this country are preterm births (when the baby is born before the 37th week of the pregnancy), sudden infant death syndrome (SIDS), or low birth weight.  These deaths aren’t caused by a single factor, but a multitude of them.  Pharmacists can impact society more than they know by informing the population of the factors that contribute to infant mortality and hopefully reduce their frequency.

For example, tobacco use during pregnancy increases the likelihood of all of the leading causes of infant death in the U.S. in addition to birth defects.  Both smoking and smokeless tobacco have affects on the baby  even after it is born and can lead to complications.  Pharmacists can intervene by providing information and advice on smoking cessation as well as recommend products to help mothers quit.  Alcohol, illicit drugs, and marijuana all can have deleterious affects as well, and pharmacists can spread knowledge about these too.

Vaccines are also highly recommended to pregnant women to prevent infants from susceptibility to those diseases and infections.  The inactive forms are preferred and can range from flu to tetanus.  Pharmacists can educate their pregnant patients as well as administer these immunizations to prevent death from preventable causes.

Pharmacists can also inform the public on the advantages of breastfeeding, for instance babies who are breast fed have a lower risk of death due to SIDS.  Critical vitamins during pregnancy are another counseling point for pharmacists.

Overall, including pharmacists in the education of mothers during and after pregnancy can and should have a profound effect.  Together with their inter-professional health team, they can reduce infant mortality rates by informing the public on preventable actions that cause infant death.

DiPietro Mager N. Preventing infant mortality: Pharmacists’ call to action. JAPhA. 2016;56(1):82-87