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Shatters the Illusion

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Published September 3, 2023

Morning Report — Not Your Typical Medical Newsletter

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Did you know that several years back the CDC published a comprehensive power ranking of the most nutrient-dense foods? They designed a 0-to-100–point scoring system with points awarded to food with the greatest value of potassium, fiber, protein, calcium, iron, thiamin, riboflavin, niacin, folate, zinc, and vitamins A, B6, B12, C, D, E, and K. Atop the rankings was a surprise produce: watercress—the only food to garner a perfect score. This cruciferous Mary Lou Retton is a dynamo of vitamin A and potassium, and its vitamin C volume puts oranges on notice. It elevates any salad, stir fry, or broth. But good luck finding this delicacy. You’ll need to shop a specialty grocery store or raid William and Kate’s royal fridge.

Nonstimulant Scores Big Against ADHD

NEURO NEWS

Researchers in pursuit of “a more acceptable alternative to psychostimulant treatments for ADHD” may be a step closer to unseating this side-effect-laden gold standard. A new ADHD study pitting newcomer viloxazine extended release (VER) against fellow nonstimulant atomoxetine shows that it may be possible to come for the safety and stay for the efficacy.

In a single-arm, blinded, retrospective, real-world study, researchers looked no further than their own patient panel for a sample of 50 children and adults with ADHD. After a trial of the generic atomoxetine (as dictated by insurers), participants underwent a washout period and then a trial of the branded VER. Participants reported their experience with each of the two selective norepinephrine inhibitors using a symptom rating scale. Like a Simone Biles vs the field matchup, it wasn’t particularly close:

VER scored significant improvements in inattention AND hyperactivity/impulsivity
96% of patients favored VER over atomoxetine
85% of patients tapered off psychostimulants after VER stabilization
89% of children reported a positive response with VER; 14% with atomoxetine
87% of adults reported a positive response with VER; 13% with atomoxetine
Only 4% of patients ceased VER because of side effects vs 36% with atomoxetine

Key takeaway

The authors concede that the study was small in scope and insurance mandates hamstrung the mechanics, but nonetheless, the differences were not trivial. The results indicate that VER—recently reformulated and minted with FDA approval for ADHD—may vault ahead of atomoxetine as the go-to nonstimulant for ADHD. And it may supersede psychostimulants. The authors recommend VER as a first-line monotherapy or as an adjunct to stimulants. “It is timely to have a rapidly acting and highly effective non-stimulant option across the full spectrum of ADHD symptoms, for both children and adults, in light of recent stimulant shortages and the new FDA boxed warnings regarding increased mortality associated with overuse of stimulants.”

Sports Supplements Underperform in Label Accuracy

DIETARY DIGEST

“What you see when you actually take a close look at the products is that it’s really a hot mess.” That’s Dr. Pieter Cohen’s description of the nearly 60 botanical performance-enhancing supplements claiming to have stimulant or anabolic effects that his team studied in a small case series. Their research revealed that the products matched their labels about as well as most singles match their online dating profiles.

Sports supplements are like a box of chocolates

The researchers purchased one sample from each sports supplement purportedly containing at least one of the following botanicals: R vomitoria, methylliberine, turkesterone, halostachine, or octopamine. A chemical analysis then identified the true ingredients and quantities of each product. After comparing the real ingredients with those listed on the label, researchers concluded that you never know what you’re gonna get with these supplements:

40% of the products showed no trace of the labeled botanical ingredient
In the other 60%, the botanical quantity was 0.02% to 334% of the labeled amount
12% of the products contained at least one FDA-prohibited ingredient

Misrepresentation matters

Consuming some of the surprise stimulants in tandem with exercising could trigger serious cardiovascular, neurological, and psychological conditions. And if your patient is an Olympic hopeful, having these banned substances in their bloodstream could dash their dreams.

Key takeaway

A mere 11% of the supplements analyzed contained “the right ingredients at the right dose.” You may want to counsel patients that a simple “performance boost” may be a game of supplement roulette. This study adds to the evidence that Big Supplement has run amok, and further splits open the fault lines of the FDA’s regulatory process for supplements. In the current framework, the FDA essentially allows supplement manufacturers to grade their own homework.

Guideline Alert …

American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults

Preexposure prophylaxis to prevent acquisition of HIV: US Preventive Services Task Force Recommendation Statement

Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2023–24 Influenza Season

Cochrane Shatters the Illusion of Blue Blocker Glasses

OPHTHALMIC OVERVIEW

In rolling with the theme of dismantling product claims, a new Cochrane Review takes aim at the alleged benefits of blue-light–filtering lenses on visual performance, macular protection, and sleep quality. Despite Warby Parker’s assertions and your colleagues’ anecdotal evidence, these lenses seemingly do little to mitigate the effects linked to prolonged computer use.

Researchers amassed data from 17 RCTs involving >600 screen gazers who used or did not use blue-light–filtering lenses. The follow-up period ranged from <1 to 5 weeks. The results showed indeterminate effects of blue blockers at best and ineffectiveness at worst.

The filters likely don’t reduce short-term visual fatigue associated with computer use
Benefits to vision or sleep quality are unclear
Long-term benefits to retinal health are also unclear
Included studies did not assess contrast sensitivity, color discrimination, discomfort glare, macular health, serum melatonin levels, or overall satisfaction

Key takeaway

Lens companies routinely upsell consumers on the $50 blue-light filter like it’s a scoop of guac at Chipotle. But the filters—unlike the guac—may not be worth the extra cost. Senior author Laura Downie framed the findings as follows: “Our review doesn’t support using a blue-light filtering lens if you’re a healthy adult for the purpose of reducing eyestrain with computer use.” Why? For two reasons: (1) blue-light–filtering lenses block only 10% to 25% of blue light from screens, and (2) the real culprit behind eye strain with computer use isn’t blue light; it’s failure to blink, says the American Academy of Ophthalmology. And to ease patients’ minds, a link between blue light and retina damage doesn’t exist. If it did, patients would surely want to avoid the sun, which emits a thousand times more blue light than a computer screen.

FDA Approves …

Tixel noninvasive skin resurfacing technology to treat periorbital wrinkles

**Turtles Spreading Salmonella to 11 States**

INFECTIOUS FINDINGS

The CDC reports a Salmonella outbreak affecting at least 26 people (9 hospitalizations, 0 deaths) across 11 states and counting. The key to halting the spread: resisting the urge to kiss turtles. The agency made the connection when 80% of those afflicted disclosed their recent direct contact with pet turtles, in particular the smaller variety.

Judge a turtle by its cover

Pet turtles—big and small—can harbor Salmonella germs in their feces, but turtles with a <4-inch shell are typically the worst offenders of disease spread. The Fed bans the sale of these tiny turtles (and most retailers oblige) but can’t easily regulate exchanges with the back-alley “turtle guy.”

**CDC shells out guidance to avoid Salmonella spread**

Don’t kiss or snuggle (or otherwise canoodle) turtles of any size
Wash hands thoroughly (especially if poor adherence to bullet #1)
Pet turtles are not recommended for those <5 years, >65 years, or immunocompromised
Don’t release unwanted pet turtles into the wild; instead call the local reptile rescue

Key takeaway

While turtle ownership delivers unlimited entertainment, the risk of spreading Salmonella and other illnesses exists. Experts note, “You can get sick from touching a turtle or anything in its environment and then touching your mouth or food with unwashed hands and swallowing Salmonella germs.” Signs and symptoms of Salmonella include gastrointestinal effects, fever >102° Fahrenheit, and dehydration. Consider asking patients about the reptile headcount in their home and advising against owning smaller turtles. And although a poor substitute, air kisses may help patients and their beloved turtles stay healthy and “happy together.”

Interested in more healthcare news? Here are some other articles we don’t want you to miss:

Morning Report is written by:

Alissa Scott, Lead Author
Emily Ruge, Author, Editor
Aylin Madore, MD, MEd, Editor
Ariel Reinish, MD, MEd, Editor

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