Market Wakes Up to Fact That Fed Pivot Could Signal Recession

 The steady drumbeat of warnings that the American economy is careening toward a recession finally struck a nerve on Wall Street.

Investors who had tuned out warnings for the past two months — from the most inverted Treasury yield curve in four decades to a wipeout for 2022’s heady oil price gains — began trading as if the biggest threat to risk assets was now a looming downturn in growth.

Cyclical stocks led the S&P 500 to a 3.4% drop in the week after the equity benchmark failed to hold above its average price for the past 200 days. While optimism that the Fed would slow the pace of rate increases had stoked a 14% rally since mid-October, investor moods have now darkened with worries that such a move, when it does come, will be the mark of an economy laid low.

Already signs are emerging that the growth is buckling under the Fed’s aggressive tightening. The US services sector contracted last month. Although the labor market remains sturdy, some weakness has appeared, most recently in another rise in continuing claims for jobless benefits. At the same time, inflation may have peaked but it’s still elevated enough to keep the Fed vigilant, raising the risk it will overtighten.

“We will shift from seeing ‘bad data’ as being ‘good’ to bad data being bad because it is a signal the economy is weakening faster and worse than most expected,” said Peter Tchir, head of macro strategy at Academy Securities.

Markets have started trading the stream of gloomy economic news as bad, rather than a reason to rally on the prospect for easier Fed policy. At the same time, inflation remains elevated — evidenced by an unexpectedly rapid rise in producer prices last month — and the central bank will render its final policy verdict of the year Wednesday. Taken together, it was enough to squash the fall rally.

https://finance.yahoo.com/news/market-wakes-fact-fed-pivot-211824388.html

Big Pharma Holds 4 Of 5 Top Buys By The Best Mutual Funds

 Including Merck and Eli Lilly, drug and biotech stocks account for four of the top five investments by leading mutual funds. Amgen (AMGN) and AbbVie (ABBV) also earn that distinction.

Such institutional demand has lifted LLY and MRK above and beyond their most recent buy zones. AMGN is also extended. The biotech has posted several weeks of tight trading, which could be like a coil about to spring a new move.

With its relative strength line already at a new high, AbbVie continues to work on a chart pattern showing a 176.01 buy point.

Specialty chemicals firm Linde (LIN) round out the biggest new investments by the best mutual funds. The United Kingdom-based producer of industrial gases trades just above its recent buy zone from a double-bottom breakout.

https://www.investors.com/etfs-and-funds/mutual-funds/best-mutual-funds-bet-on-medical-stocks-lly-mrk-abbv-amgn-add-retailers-to-holiday-shopping-bag/

Lilly Decision Could Light Up The Red-Hot Obesity Landscape — Again

 A key decision from Eli Lilly (LLY) — possibly next week — could light up the obesity treatment landscape again, an analyst said Friday as LLY stock lingers near a record high.

All eyes have been on Lilly's tirzepatide in obesity, but the company is also developing a next-generation approach to weight loss called retatrutide. While tirzepatide hits on two elements that can impact body weight, retatrutide loops in a third.

"We see a reasonable likelihood that Lilly will provide an update on retatrutide, its triple (obesity treatment regimen), on the 2023 guidance call," UBS analyst Colin Bristow said in a note to clients. Lilly has scheduled that call for Tuesday morning.

Representatives of Eli Lilly didn't immediately return a request for comment.

https://www.investors.com/news/technology/lly-stock-why-the-obesity-treatment-landscape-could-heat-up-again-next-week/

The Most Damaging Exercise Myth

 About a quarter of American adults are physically inactive, getting no exercise whatsoever. And that unfortunate statistic progressively worsens as adults grow older: 25.4% for adults aged 50 to 64, 26.9% for those aged 65 to 74, and 35.3% for people aged 75 years and older.

Feeding this pernicious trend is a common exercise myth: namely, that it is for the young, and it’s typical — essentially inevitable — to move much less as you get older. But as Daniel Lieberman, a professor in the Department of Human Evolutionary Biology at Harvard University, recently stated in an interview with Big Think, this may be the most damaging exercise myth.

“I think the most pernicious, the most serious, the most problematic, the most concerning way in which we think about exercise in the Western world is that as people get older, it’s kind of normal to be less physically active,” he said.

Lieberman came to this conclusion looking through the lens of evolutionary biology. Historically, hunter-gatherers remained fit into old age because their lifestyle required that they move. Repeated walking, bending, lifting, and carrying didn’t degrade their muscles, as is often erroneously believed. To the contrary, the exercise maintained them. Elderly hunter-gatherers in the modern day tend to avoid the frailty that plagues adults in Western societies.

It’s a frailty that regularly spirals out of control, Lieberman said. “As people get older in the West, they tend to lose a lot of strength and power, and that makes basic tasks difficult. And when that happens, people become less active. When they become less active, they become less fit. And it kind of sets in motion a really disastrous, vicious cycle.”

Think about someone who falls from a lack of muscle coordination. This single trauma could derail an otherwise self-sufficient life, leading to a loss of autonomy, which can devolve into depression and listlessness.

Modern medicine, safer environments, and far better nutrition do keep people alive much longer, Lieberman adds. But these advances don’t necessarily make them physically healthier.

“Before modern medicine, what determined how long you lived was actually how long you were healthy, your ‘healthspan’,” he explained. “And what physical activity does is it increases your healthspan, and your healthspan therefore increases your lifespan.”

Thus, Lieberman recommends that people not cut back on exercise as they age, especially strength training, which is key to maintaining motor function and bone mass. Ideally, adults over age 60 should be lifting weights two to four times per week. Studies suggest that those starting a program in old age for the first time can actually experience proportional increases in muscle mass on par with younger adults.

Exercise can seem like a chore, but it pays off in saved time and money. According to the CDC, four of the five most costly chronic conditions among adults aged 50 or older — arthritis, stroke, heart disease, and diabetes — can be prevented or managed through physical activity. Working out is vastly preferable to a doctor’s visit, and far cheaper.

“The evidence is incontrovertible… Physical activity, as you get older, is more important, not less important, for preserving your health,” Lieberman concluded.

https://www.realclearscience.com/blog/2022/12/05/the_most_damaging_exercise_myth_868231.html

Behavioral Treatment Tied to Lower Medical, Pharmacy Costs

 Outpatient behavioral health treatment (OPBHT) for patients newly diagnosed with depression, substance use disorder, or other behavioral health condition (BHC) is cost-effective.

Results of a large retrospective study showed that patients newly diagnosed with a BHC who receive OPBHT following diagnosis incur lower medical and pharmacy costs over roughly the next 1 to 2 years compared with peers who don’t receive OPBHT.

"Our findings suggest that promoting OPBHT as part of a population health strategy is associated with improved overall medical spending, particularly among adults," the investigators write.

The study was published online December 6 in JAMA Network Open.

Common, Undertreated

Nearly a quarter of adults in the US have a BHC, and they incur greater medical costs than those without a BHC. However, diagnosis of a BHC is often delayed, and most affected individuals receive little to no treatment.

In their cost analysis, Johanna Bellon, PhD, and colleagues with Evernorth Health, Inc, St. Louis, Missouri, analyzed commercial insurance claims data for 203,401 US individuals newly diagnosed with one or more BHCs between 2017 and 2018.

About half of participants had depression and/or anxiety, 11% had substance use or alcohol use disorder, and 6% had a higher-acuity diagnosis, such as bipolar disorder, severe depression, eating disorder, psychotic disorder, or autism spectrum disorder.

About 1 in 5 (22%) had at least one chronic medical condition along with their BHC.

The researchers found that having at least one OPBHT visit was associated with lower medical and pharmacy costs during 15- and 27-month follow-up periods.

Over 15 months, the adjusted mean per member per month (PMPM) medical/pharmacy cost was $686 with no OPBHT visit compared with $571 with one or more OPBHT visits.

Over 27 months, the adjusted mean PMPM was $464 with no OPBHT, vs $391 with one or more OPBHT visits.

Dose-Response Effect

In addition, there was a "dose-response" relationship between OPBHT and medical/pharmacy costs, such that estimated cost savings were significantly lower in the treated vs the untreated groups at almost every level of treatment.

"Our findings were also largely age independent, especially over 15 months, suggesting that OPBHT has favorable effects among children, young adults, and adults," the researchers report.

"This is promising given that disease etiology and progression, treatment paradigms, presence of comorbid medical conditions, and overall medical and pharmacy costs differ among the three groups," they say.

Notably, the dataset largely encompassed in-person OPBHT, because the study period preceded the transition into virtual care that occurred in 2020.

However, overall use of OPBHT was low ― older adults, adults with lower income, individuals with comorbid medical conditions, and persons of racial and ethnic minorities were less likely to receive OPBHT, they found.

"These findings support the cost-effectiveness of practitioner- and insurance-based interventions to increase OPBHT utilization, which is a critical resource as new BHC diagnoses continue to increase," the researchers say.

"Future research should validate these findings in other populations, including government-insured individuals, and explore data by chronic disease category, over longer time horizons, by type and quality of OPBHT, by type of medical spending, within subpopulations with BHCs, and including virtual and digital behavioral health services," they suggest.

The study had no specific funding. The authors have disclosed no relevant financial relationships.

JAMA Netw Open. Published online December 6, 2022. Full text

https://www.medscape.com/viewarticle/985321

Is Using Antibiotics Before STI Exposure Risky?

 The use of antibiotics to prevent — not just treat — sexually transmitted infections was a fringe idea just a decade ago. Now, it has the backing of several studies and a green light from a California public health department.

Jeffrey Klausner, MD, an infectious disease doctor and professor of public health at the University of Southern California, published the first randomized, controlled trial on whether doxycycline — an antibiotic commonly used to treat infections, including syphilis, chlamydia, and others — could prevent STIs back in 2015. At first, he says the National Institutes of Health didn't want to fund the work, expressing concerns about the potential for antimicrobial resistance.

In a worst-case scenario, microbes change over time and no longer respond to medicine, and treatments stop working.

But a growing STI crisis has health care professionals searching for new options to help. 

"There were more than 170,000 cases of syphilis [in the U.S.] last year, and yearly cases have doubled over the past five years," says Klausner. 

Repeated studies, with slightly different designs, also found lower rates of STIs among people who took doxycycline either daily or after sex. The method, known as pre-exposure doxycycline prophylaxis, now has its own name: doxyPEP.

And in October, the San Francisco Department of Public Health recommended doxyPEP for cisgender men and transgender women who have had a bacterial STI in the past year as well as condomless oral or anal sex with one or more cis men or trans women in the past year.

For those who meet the second criteria but haven't been diagnosed with an STI in the last year, the department is advising a "shared decision-making approach," where doctors discuss the benefits and risks of doxyPEP and prescribe it for patients who feel they will benefit, explains Stephanie Cohen, MD, the department's acting director of disease prevention and control in the Population Health Division. 

The department also recommends doxyPEP for anyone diagnosed with syphilis, regardless of their gender or sexual partners.

Cohen says the U.S. has among the highest rates of STIs in the world and that "San Francisco, in particular, has some of the highest rates of sexually transmitted infections in the country."

Latest Results

The most recent study of doxyPEP followed 501 men and trans women in Seattle and San Francisco. About two-thirds were taking HIV pre-exposure prophylaxis (HIV PrEP) and the rest were living with HIV. The results of that study, shared at the International AIDS Society (IAS) Conference earlier this year, found STIs were lower in the group told to take a single dose of doxycycline within 72 hours of unprotected sex. The rate of STI reduction was 66% in the HIV PrEP group and 62% in the HIV-positive group. 

"It can be a bit of a paradigm shift when you talk about using antibiotics before someone has an infection," says Annie Luetkemeyer, MD, an infectious disease doctor and STI researcher at the University of California San Francisco, who co-led the study.

She recalls that when HIV PreP came out, there was pushback that it would lead to riskier sex or increased HIV drug resistance. In reality, "we've learned that for some segments of the population, having access to HIV PrEP has absolutely been essential to reduce the risk in HIV."

Now, the pushback to doxyPEP is that it could lead to more antimicrobial resistance. But Luetkemeyer points out that the highest-risk populations, for whom the intervention is meant, are already exposed to high rates of antibiotic use, largely to treat STIs. 

In the study's control group, the rate of STIs was 32% in a 3-month period, compared to 11% in the doxyPEP group. But the doxyPEP use wasn't perfect, and people in the study reported they took it after 87% of unprotected sexual encounters, on average.

"This isn't a question of taking doxycycline versus taking no antibiotics," Luetkemeyer says. In fact, the control group had a 50% higher exposure to ceftriaxone, a broad-spectrum antibiotic that has a higher potential, compared to doxycycline, of spurring drug-resistant gonorrhea.

Still, Luetkemeyer and Klausner say it's important to monitor both drug-resistant STIs, as well as other infections, like doxycycline-resistant Staphylococcus aureus, to ensure that doxyPEP isn't increasing them. 

Making Things Worse?

Luetkemeyer and her colleagues are now studying to see whether doxyPEP increases drug-resistant bacteria in those who take it. There are no red flags yet, but the research is ongoing.

While San Francisco's public health department has given the first official endorsement of doxyPEP, doctors who work with high-risk populations have been prescribing it off-label for years. Klausner says that when he was treating patients living with HIV or at risk of HIV, he would prescribe prophylactic doxycycline either daily or after sex without a condom, depending on the patient's frequency of sexual activity. For as-needed use, he would typically start with 15 doses at 200 milligrams, with refills.

He also notes that there isn't one, fixed group of people who need doxyPEP, pointing out that people may benefit for a period in between monogamous or relatively monogamous relationships, for example. 

"People's risk profile is dynamic…doxyPEP isn't a strategy we're encouraging people to adopt forever," he says. 

And while doxyPEP could increase the risk of drug-resistant infections, it could also theoretically reduce it, by lowering the burden of STIs in the population, and the need for antibiotic treatments, Klausner says.

"It's been known since the 1970s that sexually transmitted infections — like chlamydia, gonorrhea, syphilis — are perpetuated by a core group," he says, typically men who have sex with many male partners over a month. "If you can control that spread of infection in the core group, the rest of the population is more protected."

Cohen at the San Francisco Department of Public Health said that while "it's definitely a priority as we roll it out to do surveillance to see if there's any concerning signs of antimicrobial resistance," for now, "the desire from the community to have new tools to protect themselves from STIs outweigh the potential and unknown risks of antimicrobial resistance."

What is certain is that decades of experience shows that the only other prevention tool, condoms, aren't going to be widely adopted by everyone, due to partner or personal preferences. 

"For some populations, with really soaring rates of sexually transmitted infections, what we currently have to offer isn't working, so we really need new tools," says Luetkemeyer.

Sources:

Jeffrey Klausner, MD, professor of public health, University of Southern California. 

Stephanie Cohen, MD, acting director, disease prevention and control, Population Health Division, San Francisco Department of Public Health. 

Annie Luetkemeyer, MD, infectious disease doctor and STI researcher, University of California San Francisco. 

https://www.medscape.com/viewarticle/985347

New AHA Statement on Complementary Medicine in Heart Failure

 There are some benefits and potentially serious risks associated with complementary and alternative medicines (CAM) patients with heart failure (HF) may use to manage symptoms, the American Heart Association (AHA) says in a new scientific statement on the topic.

For example, yoga and tai chi can be helpful for people HF, and omega-3 polyunsaturated fatty acids may also have benefits. However, there are safety concerns with other commonly used over-the-counter (OTC) CAM therapies, including vitamin D, blue cohosh, and Lily of the Valley, the writing group says.

It's estimated that roughly 1 in 3 patients with HF use CAM. But often patients don't report their CAM use to their clinician and clinicians may not routinely ask about CAM use or have the resources to evaluate CAM therapies, writing group chair Sheryl L. Chow, PharmD, told theheart.org | Medscape Cardiology.

Dr Sheryl L. Chow

"This represents a major public health problem given that consumers are frequently purchasing these potentially dangerous and minimally regulated products without the knowledge or advice from a healthcare professional," said Chow, with Western University of Health Sciences, Pomona, California, and University of California Irvine.

The 27-page statement was published online December 8 in Circulation.

CAM Use Common in HF

The statement defines CAM as medical practices, supplements, and approaches that do not conform to the standards of conventional, evidence-based practice guidelines. CAM products are available without prescriptions or medical guidance at pharmacies, health food stores, and online retailers.

"These agents are largely unregulated by the FDA and manufacturers do not need to demonstrate efficacy or safety. It is important that both healthcare professionals and consumers improve communication with respect to OTC therapies and are educated about potential efficacy and risk of harm so that shared and informed decision-making can occur," Chow said.

The writing group reviewed research published before November 2021 on CAM among people with HF.

Omega-3 polyunsaturated fatty acids (PUFAs), such as fish oil, have the strongest evidence among CAM agents for clinical benefit in HF and may be used safely by patients in moderation and in consultation with their healthcare team, the writing group says.

Research has shown that omega-3 PUFAs are associated with a lower risk of developing HF as well as improvements left ventricular systolic function in those with existing HF, they point out.

However, two clinical trials found a higher incidence of atrial fibrillation with high-dose omega-3 PUFA administration. "This risk appears to be dose-related and increased when exceeding 2 g/d of fish oil," the writing group says.

Research suggests that yoga and tai chi, when added to standard HF treatment, may help improve exercise tolerance and quality of life and decrease blood pressure.

Inconclusive or Potentially Harmful CAM Therapies

Other CAM therapies for HF have been shown as ineffective based on current data, have mixed findings, or appear to be harmful. The writing highlights the following examples:

• Overall evidence regarding the value of vitamin D supplementation in patients with HF remains "inconclusive" and may be harmful when taken with HF medications such as digoxin, calcium channel blockers, and diuretics.

• Routine thiamine supplementation in patients with HF and without clinically significant thiamine deficiency may not be efficacious and should be avoided.

• Research on alcohol varies, with some data showing that drinking low-to-moderate amounts (one to two drinks per day) may help prevent HF, while habitual drinking or consuming higher amounts is known to contribute to HF.

• The literature is mixed on vitamin E. It may have some benefit in reducing the risk of HF with preserved ejection fraction but has also been associated with an increased risk of HF hospitalization.

• Coenzyme Q10 (Co-Q10), commonly taken as a dietary supplement, may help improve HF class, symptoms, and quality of life, but it also may interact with antihypertensive and anticoagulant medication. Co-Q10 remains of "uncertain" value in HF at this time. Large-scale randomized controlled trials are needed before any definitive conclusion can be reached.

• Hawthorn, a flowering shrub, has been shown in some studies to increase exercise tolerance and improve HF symptoms such as fatigue. Yet it also has the potential to worsen HF, and there is conflicting research about whether it interacts with digoxin.

• The herbal supplement blue cohosh, from the root of a flowering plant found in hardwood forests, could cause tachycardia, high blood pressure, chest pain, and increased blood glucose. It may also decrease the effect of medications taken to treat high blood pressure and type 2 diabetes, they note.

• Lily of the Valley, the root, stems, and flower of which are used in supplements, has long been used in mild HF because it contains active chemicals similar to digoxin. But when taken with digoxin, it could lead to hypokalemia.

In an AHA news release, Chow says, "Overall, more quality research and well-powered randomized controlled trials are needed to better understand the risks and benefits" of CAM therapies for HF.

"This scientific statement provides critical information to healthcare professionals who treat people with heart failure and may be used as a resource for consumers about the potential benefit and harm associated with complementary and alternative medicine products," Chow adds.

The writing group encourages healthcare professionals to routinely ask their HF patients about their use of CAM therapies. They also say pharmacists should be included in the multidisciplinary healthcare team to provide consultations about the use of CAM therapies for HF patients.

The scientific statement does not include cannabis or traditional Chinese medicine, which have also been used in HF.

In 2020, the AHA published a separate scientific statement on the use of medical marijuana and recreational cannabis on cardiovascular health, as reported previously by theheart.org | Medscape Cardiology.

The scientific statement on CAM for HF was prepared by the volunteer writing group on behalf of the AHA Clinical Pharmacology Committee and Heart Failure and Transplantation Committee of the Council on Clinical Cardiology; the Council on Epidemiology and Prevention; and the Council on Cardiovascular and Stroke Nursing.

Circulation. Published online December 8, 2022. Abstract

https://www.medscape.com/viewarticle/985343