Wednesday, October 31, 2007

Another VEGF Inhibitor Shows Activity Against Kidney Cancer

PARIS, Oct. 30 -- Treatment with axitinib resulted in at least a partial response in nearly half of patients with cytokine-refractory metastatic kidney cancer, investigators in a multinational trial have found.
The investigational vascular endothelial growth factor (VEGF) inhibitor resulted in two complete responses and 21 partial responses in 52 patients, Olivier Rixe, M.D., of the University of Paris, and colleagues, reported in the November issue of The Lancet Oncology.
Additionally, they said, in 22 patients the disease stabilized for at least eight weeks, and in 13 patients, for 24 weeks or longer.
"The objective response and time to progression in our study suggest that axitinib might be a promising drug in the treatment of patients with metastatic renal-cell cancer; although a randomized controlled trial is needed to confirm this finding," the authors concluded.

Biological therapy with interferon alfa or interleukin-2 has only modest activity in good-risk patients with renal-cell carcinoma. Antiangiogenic therapies have improved survival in the disease, and two agents, sunitinib and sorafenib (also VEGF inhibitors) have been approved for treatment of metastatic renal-cell carcinoma.
Axitinib is an oral selective inhibitor of VEGF receptors 1, 2, and 3. Preclinical studies suggested that the agent had antitumor activity related to antiangiogenic effects, and phase 1 clinical investigation provided additional evidence of activity in patients with various advanced solid tumors.
Dr. Rixe and investigators in Europe and the United States continued the evaluation of the drug in a phase II trial involving patients with metastatic renal-cell carcinoma unresponsive to cytokine therapy. Treatment began at a dose of 5 mg twice daily. The dose could be titrated upward by 20% after eight weeks if a patient had no tumor response and no grade 2+ toxicity.
The primary endpoint was objective response. Secondary endpoints were response duration, time to progression, overall survival, safety, pharmacokinetics, and patient-reported health-related quality of life.
In an intention-to-treat analysis, axitinib resulted in an overall response rate of 44.2%. The median response duration was 23 months. However, 12 of 23 initial responders progressed with a response that lasted between 4.2 and 26.5 months. An additional 42.3% of patients had prolonged disease stabilization.
Four patients had early disease progression, and three had incomplete data. The median time to progression was 15.7 months, and the median overall survival was 29.9 months.
The most common treatment-related adverse events were diarrhea, hypertension, fatigue, nausea, and hoarseness. Thirty patients had treatment-related hypertension that resolved with antihypertensive therapy in 22 cases. Seven of the remaining eight patients had a history of hypertension.
Dr. Rixe disclosed that he has been a consultant to Pfizer and received honoraria for participation in Pfizer-supported activities. The study was supported by Pfizer. Primary source: The Lancet OncologySource reference: Rixe O, et al "Axitinib treatment in patients with cytokine-refractory metastatic renal-cell cancer: a phase II study." Lancet Oncol 2007; 8: 975-984.
Pacing the Brain Quiets Dyskinesia but Triggers Snap Decisions

TUCSON, Oct. 30 -- Deep-brain stimulation can help patients with Parkinson's disease control their limbs, but it may also cause them to lose impulse control, investigators here reported. In a study of decision-making skills, patients with implanted deep-brain stimulation devices tended to make hasty judgments when faced with conflicts, noted Michael J. Frank, Ph.D.,of the University of Arizona, and colleagues. "While on deep-brain stimulation, patients actually sped up under high-conflict conditions. This form of impulsivity was not affected by dopaminergic medication status. Instead, medication impaired patients' ability to learn from negative decision outcomes," the investigators wrote in an early online publication in Sciencexpress.
The finding suggests how deep-brain stimulation of the subthalamic nucleus can simultaneously quiet motor neuron signals and interfere with the timing of decision-making processes, the authors wrote.
One hypothesis holds that "when faced with multiple seemingly good options, the subthalamic nucleus enables one to adaptively 'hold your horses,' buying more time to settle on the best one."
Evidence to support this theory comes from animal studies in which rats with subthalamic nucleus dysfunction made premature choices in a task that would reward them with food, the authors noted.
To see whether a similar effect occurs in humans, they recruited 17 patients with Parkinson's controlled by deep-brain stimulation, 15 controlled on dopaminergic agents, and age-matched controls.
The Parkinson's patients were tested on and off treatment to test whether the forms of therapies had selective effects on conflict-based decisions, and to replicate previous findings that dopaminergic drugs impair the ability of patients to learn from negative outcomes of their decisions, as evidenced by the tendency of some patients on the drugs to become pathological gamblers.
All three groups of participants were tested with a probabilistic selection task, in which patients are presented with three different pairs of symbols presented in random order, and asked to choose one of the symbols.
The patients received feedback about whether the choices were "correct or incorrect," but the feedback itself is probabilistic -- that is, one pair will lead to positive feedback in 80% of trials if one element of a pair is chosen and negative feedback in 80% of trials if the other symbol is chosen.
The testing indicates whether participants learn from positive feedback by choosing the most reliably correct option, or from negative feedback by avoiding the incorrect option.
"We predicted that, compared with controls, Parkinson's disease patients (regardless of treatment) would show reinforcement learning deficits," the investigators wrote. "We further predicted that dopaminergic medication would impair negative feedback learning, whereas deep-brain stimulation would cause impulsive responding in the face of conflict."
They found that patients were generally slower than controls to learn the reinforcements, and that, as other researchers had shown, patients on dopaminergic agents had selective impairments in their ability to learn from the outcomes of the negative decisions.
In the overall sample, the participants slowed down significantly when making high-conflict decisions compared with low-conflict decisions (P<0.001). But patients on deep-brain stimulation did not slow down as decision conflict increased, and, in fact, responded slightly faster under the high-conflict conditions (P=0.06).
Dopaminergic agents had no effect on whether patients slowed down in high conflict situations, and there were no other between-group or conflict differences.
"Notably, the tendency for deep brain stimulation patients to show speeded high-conflict responses was especially pronounced when choosing the less optimal stimulus," the investigators wrote.
"Further," they said, "High-conflict premature responding led to suboptimal choices under deep-brain stimulation."
The investigators said that their findings point to the presence of two distinct roles for basal ganglia in computation during decision making.
"In brief, two main neuronal populations in the striatum have opposing effects on action selection via output projections through globus pallidus, thalamus, and back to cortex," they wrote. "Activity in 'Go' neurons facilitates the execution of a cortical response, whereas 'No Go' activity suppresses competing responses. Dopamine bursts and dips that occur during positive and negative outcomes drive Go learning (via D1 receptors) to seek rewarding actions, and No Go learning (via D2 receptors) to avoid those that are nonrewarding."
The subthalamic nucleus normally acts a temporary brake, the authors suggested, sending out a global "No Go" response that gives the thinker time to think when confronted with conflicting information.
"Maybe the same circuits are involved in gamblers who don't have Parkinson's," Dr. Frank said.
Funding sources and author conflicts of interest were not listed.Primary source: SciencexpressSource reference: Frank MJ, et al "Hold Your Horses: Impulsivity, Deep Brain Stimulation, and Medication in Parkinsonism" Sciencexpress doi: 10.1126/science.1146157.
Cancer Benefit of Vitamin D May Be Limited to Colon Cancer

BETHESDA, Md., Oct. 30 -- Vitamin D levels do not appear to protect against cancer, with the possible exception of colorectal disease, according to data from a nationwide study.
The analysis failed to show an association between baseline vitamin D status and overall cancer risk in men, women, or in various racial, ethnic or age groups, Michal Freedman, Ph.D., of the National Cancer Institute, and colleagues, reported in the Nov. 7 issue of the Journal of the National Cancer Institute.
However, individuals with baseline serum levels of 25-hydroxyvitamin D of 80 nmol/L or higher did have a 72% (95% confidence interval = 32% to 89%) lower risk of colorectal cancer compared with people who had lower serum levels of vitamin D (lower than 50 nmol/L; P=0.02 for the trend).
The investigators left the door open, though, for continued investigation of associations between the vitamin and cancer risk.
"Additional studies with large numbers of samples of measured 25(OH)D serum levels, preferably at multiple time points, are needed to confirm the total cancer mortality findings of this paper and to obtain more accurate risk estimates for mortality from specific cancers," they concluded.
A variety of preclinical and epidemiologic evidence has suggested that increased intake or endogenous production of vitamin D is associated with reduced cancer risk. In vitro studies have shown that vitamin D reduces cell proliferation, and stimulates apoptosis and cell differentiation, the authors noted.
Ecologic and observational studies have demonstrated an inverse association between residential exposure to ultraviolet radiation (the principal source of naturally occurring vitamin D) and cancer mortality. However, the association between vitamin D and cancer risk and mortality had not been evaluated prospectively.
So Dr. Freedman and colleagues reviewed data from the Third National Health and Nutrition Examination Survey. They focused on 16,818 adult participants who completed the NHANES physical examination from 1988 through 1994 with measurement of serum 25(OH)D. Follow-up from data collection continued until Dec. 31, 2000.
Baseline data showed that men, whites, and better-educated individuals had significantly higher serum levels of 25(OH)D.
Increasing body mass index was associated with decreasing levels of 25(OH)D, but increasing physical activity was associated with higher levels.
Dietary vitamin D and calcium and serum retinol were higher in participants who had higher 25(OH)D levels.
The investigators identified 536 cancer deaths in 146,578 person-years. Analysis of season/latitude subpopulations revealed no association between cancer mortality and winter/lower latitude or summer/higher latitude groups. Extensive subgroup analysis failed to reveal any significant associations between 25(OH)D levels and overall cancer mortality.
Analysis of the relationship between serum 25(OH)D and site-specific cancer mortality revealed no association with lung cancer, non-colorectal digestive cancers, breast cancer, prostate cancer, lymphoma or leukemia, or the category of "other" cancers.
In an editorial that accompanied the article, Johanna T. Dwyer, D.Sc., and Cindy D. Davis, Ph.D., of the National Institutes of Health, emphasized the complicated nature of the relationship between nutritional factors and cancer.
"These findings must be put into the context of total diet and lifestyle," they wrote. "While vitamin D may well have multiple benefits beyond [strengthening] bone, health professionals and the public should not in a rush to judgment assume that vitamin D is a magic bullet and consume high amounts of vitamin D," they continued. "More definitive data on both benefits and potential adverse effects of high doses are urgently needed."
The editorialists noted some limitations with the use of the NHANES III cohort. "NHANES III was a cross-sectional study that identified associations but not causation," they said.
They also pointed out that residual confounding is a particular problem because peculiarities in NHANES sampling may have affected both measures of vitamin D exposure and outcomes. For instance, season and latitude, both related to 25(OH)D levels, were linked in the dataset.
Furthermore, they noted, the fact that 25(OH)D levels were measured only at one point in time means they would not represent long-term levels. "Nor would they reflect the nadir of 25(OH)D reached during the year. There also might be fewer lower 25(OH)D levels in the summer/higher latitude sample than would be the case if all subjects had been examined in the winter. This is a cause of concern because in Norway the maximal level of 25(OH)D is reached between the months of July and September and it is 20% - 120% higher than the corresponding winter value, suggesting that season of diagnosis is a predictor of colon cancer survival."
The authors of the study and editorial had no disclosures. The study was supported by the National Cancer Institute. Primary source: Journal of the National Cancer InstituteSource reference: Freedman DM, et al "Prospective study of serum vitamin D and cancer mortality in the United States" J Natl Cancer Inst 2007; 99: 1594-1602. Additional source: Journal of the National Cancer InstituteSource reference: Davis CD, Dwyer JT, "The 'sunshine vitamin': benefits beyond bone?" J Natl Cancer Inst 2007; 99: 1563-1565.
Rosiglitazone (Avandia) Deleted from VA Formulary for Diabetes

WASHINGTON, Oct. 30 -- The U.S. Department of Veterans Affairs has deleted rosiglitazone (Avandia), the diabetes drug that has been linked to increased risk of myocardial infarction and heart failure, from its formulary.
The action followed an internal review of medical records of diabetes patients treated in the VA system. Moreover, the VA representative to the FDA's 15-member Drug Safety Oversight Board (DSOB) rallied other members in an attempt to have rosiglitazone pulled from the market.
According to Senator Chuck Grassley (R-Iowa), the move to ban rosiglitazone fell only one vote short. Grassley said the DSOB met on Oct. 2 and seven members of the DSOB voted to pull the drug.
In a letter to FDA Commissioner Andrew C. von Eschenbach, M.D., Grassley demanded that the FDA make public both the DSOB vote and "information from the FDA regarding the internal policies and procedures governing the DSOB and the terms and conditions governing release of information from the DSOB to the public."
In July members of two FDA advisory boards, meeting jointly, voted 22 to one to keep the drug on the market. But those same advisers also overwhelmingly agreed that the drug should carry a black box warning about ischemic heart disease. The drug already has a black box warning for heart failure. (See: FDA Advisers Vote to Keep Rosiglitazone (Avandia) But Cite Risks)
The FDA is expected to announce rosiglitazone label changes within the next few weeks and although the agency is not required to follow the advice of its advisers, it is widely expected that the agency will order a black box warning about ischemic heart disease.
In his letter, dated Oct. 26, Grassley said he has been investigating the FDA's handling of rosiglitazone since May when the New England Journal of Medicine published a meta-analysis that reported a 43% increase in the relative risk of MI and a 64% increase in relative risk of cardiovascular deaths. (See: Meta-Analysis Links Rosiglitazone (Avandia) to Risk of Myocardial Infarction)
Rosiglitazone is marketed by GlaxoSmithKline.
Study Supports Cost-Effectiveness of Genetic Screening to Prevent Ovarian Cancer

Jacquelyn K. Beals, PhD

October 29, 2007 (San Diego) — Population testing of Ashkenazi Jewish (AJ) women for BRCA1/2 has the potential to prevent ovarian cancer (OC), prolong survival, and save nondiscounted costs of screening, according to an analysis presented here at the American Society of Human Genetics 57th Annual Meeting. Although current guidelines recommend BRCA1/2 testing if there is a positive family history, they do not recommend screening of all AJ women.
The poster cited studies showing that family history fails to identify half the women who carry the mutations and broke down the health and cost benefits of extending BRCA1/2 testing to the entire population of AJ women. Three founder mutations are responsible for 10% of breast cancers and 30% to 50% of OCs in this population.
Wendy S. Rubinstein, MD, PhD, FACMG, medical director, Center for Medical Genetics, Evanston Northwestern Healthcare Research Institute, Illinois, and lead author of the study, talked with Medscape Pathology about the decision analysis and its significance:
"If you start with an unselected group of women, you don't know what their family history is, but [if] they have ovarian cancer and they're Jewish, and then you test for the founder mutations, you'll find about 30% to 50% have that cancer due to an inherited tendency," said Dr. Rubinstein. "It's a very high proportion, it's not seen at that rate in very many other populations."
Values used for the decision analysis were drawn from research literature and included screening program participation rate, 0.9; mutation carrier rate in the population, 0.025; probability that a 40-year old carrier will follow up with a bilateral prophylactic salpingo-oophorectomy (BPSO), 0.50; probability that a mutation carrier will not get OC after PBSO, 0.96; probability that a mutation carrier will not get OC without PBSO, 0.84; probability that a noncarrier will develop OC, 0.016.
Additional parameters included in the analysis were the probability that women would get screening in the absence of a screening program and the proportion of carriers among women screened independently.
Dr. Rubinstein noted: "People that can find their way to clinics that do primary BRCA1/2 testing are knowledgeable. They usually have a high socioeconomic status, they usually have insurance, access to the types of screening that would be entailed to preventive measures. That means that there's a whole group of people who don't know, who aren't referred, and can't avail themselves of this.
"Education about your family history, that's where most people focus their efforts, and that's very appropriate," she continued. "The point is, that approach may miss a very significant number of individuals.... I don't know that it's a matter of access so much: Access implies that you know you have a problem but you can't get care for it. This is more an issue of awareness."
The analysis predicted that population-based BRCA1/2 screening in the AJ population would increase average survival by approximately 384 days for a 40-year old AJ woman BRCA1/2 carrier who had PBSO and would save about $100 in nondiscounted costs for each woman screened. The latter figure was based on the commercial cost of testing for the 3 founder mutations, $460; the cost of PBSO, $4622; the cost of OC treatments, $55,323; and the cost of follow-up care and last-year-of-life care.
Dr. Rubinstein commented on the challenges of dealing with health issues in a particular ethnic group: "The issue that I'm starting with is: Would it be cost effective to do this approach...would it save lives? It's very different than saying it should be done, because there are many other societal issues that have to be dealt with. When you're dealing with an ethnic group of any kind, you want them to have a stake in this rather than just saying "oh, yes, it's obvious this should be done."
Sharon Plon, MD, PhD, associate professor of pediatrics, director of Baylor Cancer Genetics Clinics and Neurofibromatosis Clinic, Texas Children's Hospital, Baylor College of Medicine, Houston, also talked with Medscape Pathology about population-based screening.
"It's a subject that I've studied for many years, and I think it's very important to really consider the ramifications of doing population-based screening...," Dr. Plon said. "Looking [at] the cost-effectiveness and some of the ongoing studies in Israel I think will hopefully get enough data to finally answer the question.... Even though those are not the current recommendations of the groups that put out guidelines..., I think that there [are] increasing data that it is probably worthwhile to do it."
Dr. Rubinstein reported an association with the speakers' bureau of Myriad Genetic Laboratories, Inc.
American Society of Human Genetics 57th Annual Meeting: Abstract 419/F. Presented October 26, 2007.
Giuliani’s Prostate Cancer Figure Is Disputed

In a radio advertisement playing in New Hampshire and in speeches along the campaign trail, Rudolph W. Giuliani has cited statistics to cut at the heart of his Democratic rivals’ health care proposals, which he has derided as European-style “socialist” plans that will lower the standard of care in the United States.
“I had prostate cancer five, six years ago,” Mr. Giuliani, a Republican presidential candidate, said in a speech that has been turned into the radio commercial. “My chance of surviving prostate cancer — and, thank God, I was cured of it — in the United States? Eighty-two percent. My chance of surviving prostate cancer in England? Only 44 percent under socialized medicine.”
Mr. Giuliani’s Democratic rivals would argue that they are not advocating government-run health care in their plans to extend coverage to the uninsured. But, beyond that, the 44 percent figure that Mr. Giuliani has been citing is in dispute.
The Office for National Statistics in Britain says the five-year survival rate from prostate cancer there is 74.4 percent. And doctors also say it is unfair to compare prostate cancer statistics in Britain with those in the United States because in the United States the cancer is more likely to be diagnosed in its early stages.
“Certainly, if you intensively screen for prostate cancer, you will find early disease,” said Dr. Ian M. Thompson, chairman of the department of urology at the University of Texas at San Antonio. “And simply because you find it earlier, you will always have longer survival after the disease is diagnosed.”
Maria Comella, a spokeswoman for Mr. Giuliani, said yesterday that the 44 percent figure came from an article in City Journal, a publication of the Manhattan Institute, a conservative research organization.
“The citation is an article in a highly respected intellectual journal written by an expert at a highly respected think tank which the mayor read because he is an intellectually engaged human being,” Ms. Comella said in an e-mail message.
That article, titled “The Ugly Truth About Canadian Health Care,” was written by Dr. David Gratzer, a senior fellow at the Manhattan Institute and an adviser to the Giuliani campaign.
In an interview, Dr. Gratzer said the statistic came from the Commonwealth Fund, a nonprofit group in New York specializing in health care policy issues, but he acknowledged that it was seven years old and “crude.”
But the Commonwealth Fund said yesterday that Dr. Gratzer had misused its research by calculating a five-year survival rate based on data on prostate cancer incidence and mortality rates in the United States and Britain.
“Five-year survival rates cannot be calculated from incidence and mortality rates, as any good epidemiologist knows,” the group said in a statement.
Dr. Gratzer dismissed the Commonwealth Fund’s statement, saying the group had “an ideological bias.” Asked if Mr. Giuliani would continue to repeat the statistic, and if the advertisement would continue to run, Ms. Comella responded by e-mail: “Yes. We will.”
High Dose Radiation for Prostate Cancer Won't Raise Sexual Dysfunction

By Alan MozesHealthDay ReporterTue Oct 30, 7:00 PM ET
TUESDAY, Oct. 30 (HealthDay News) -- Among prostate cancer patients undergoing a high-tech form of radiation therapy, exposure to a higher amount of radiation over a shorter time span poses no added risk for impaired sexual function, new research reveals.
"For men getting a high dose of radiation in a shorter amount of time than is typical -- meaning getting higher doses per day for fewer days -- a loss of sexual function is the chronic side effect that concerns most," noted study co-author Dr. Eric Horwitz, a clinical director in the department of radiation oncology at Fox Chase Medical Center in Philadelphia.
"But we found that sexual function wasn't any worse than when patients got radiation in the conventional high-dose way," he said.
Horwitz and lead author Mark Buyyounouski, also at Fox Chase, were expected to present their team's findings at the annual meeting of the American Society for Therapeutic Radiology and Oncology, in Los Angeles.
The finding comes on the heels of work conducted at Fox Chase last year. That study indicated that high-dose radiation should be considered the first line of attack in combating prostate cancer, given that it appears to be the most effective way to limit the disease's spread.
The team focused on a form of radiation therapy called intensity-modulated radiation therapy (IMRT). According to the American Cancer Society, IMRT is a cutting-edge, 3-D form of high-dose radiation therapy. The treatment is delivered by a computer-controlled machine that moves around the patient to target diseased tissue while avoiding healthy tissue, thereby allowing for the safer use of higher doses of radiation.
In the current study, Horwitz and his colleagues tracked the IMRT radiation treatment outcomes of 155 men diagnosed with intermediate to high-risk prostate cancer.
Half the men were assigned to receive 2 Gray (Gy -- a measurement of radiation) in 38 sessions spread over seven and a half weeks.
The other half were exposed to 2.7 Gy in 26 sessions spread over just five weeks.
All the patients then completed questionnaires regarding treatment side effects six months, 12 months, and 24 months following radiation.
Older age, as well as poor sexual function prior to radiation, did increase the risk for sexual impairment after radiation treatment, the researchers said. However, they report no appreciable difference in sexual function between the men receiving the shorter course/higher dose regimen or the more conventional regimen.
"The key to curing more prostate cancer is to give higher does of radiation," observed Horwitz. "And over the last few years, more and more men have been getting higher dose radiation, because the radiation oncology community knows that dose matters and that low dose radiation is just not effective compared to high dose. And this study shows that we have the ability to give these high doses in different ways, and in all these ways, men do very well."
Horwitz said he and his colleagues plan to take the current research to the next level.
"We will build on this experience and go with even higher doses," he said, "to see how that impacts not only sexual function but urinary and bowel function as well."
Dr. Peter T. Scardino is chairman of the department of urology and head of the Prostate Cancer Program at the Memorial Sloan-Kettering Cancer Center in New York City. He described the finding as a small but important step toward developing shorter course/higher dose radiation therapies.
"This is the trend nowadays," said Scardino. "This is where this is going: toward a time when perhaps we will be giving radiation therapies all in a single day."
"Animal studies have already indicated that you may be able to achieve as much or more with a single dose of radiation than with a protracted course," Scardino noted. "So, the big question is, are you going to find more complications as a result of this kind of a shift in dosage? Now, cutting back from seven and a half weeks to five weeks is a slight move in this direction, but they found no difference in sexual side effects, and that's valuable. And I certainly think we'll be seeing a lot more research in this area."
More information
There's more on radiation therapy for prostate cancer at the American Cancer Society.
Study estimates 2.4 million with Alzheimer's in U.S.

By Will DunhamTue Oct 30, 6:22 PM ET
About 10 percent of Americans aged 71 and up, or 2.4 million people, have Alzheimer's disease and 1 million more have some other form of dementia, researchers said on Tuesday, offering figures lower than some widely cited estimates.
The National Institutes of Health, which funded the study, called it the first to gauge U.S. rates of Alzheimer's and other dementia using a nationally representative sample of elderly people.
"Most studies have been limited to a small region of the country or a few cities within the country, and then have used the findings from local regions to project the estimates of dementia," Brenda Plassman of Duke University Medical Center, one of the researchers, said in a telephone interview.
"Our study has examined people in all regions of the U.S. and then estimated the prevalence," Plassman added.
The researchers based their findings on evaluations of 856 people ages 71 and older from 42 states, all of whom were interviewed and evaluated at their homes from 2001 to 2003.
Alzheimer's is difficult to diagnose, with a conclusive diagnosis only possible with a brain biopsy. But there are tests that doctors can perform to give them a good idea.
The researchers assessed each person's cognitive status and symptoms, medications, medical history and family history of memory problems. Brain imaging was also examined. Experts then judged if a person had dementia and, if so, what type.
Alzheimer's disease accounted for about 70 percent of dementia cases among people 71 and older, with vascular dementia the next most common form, the researchers said.
The researchers estimated that 13.9 percent of Americans age 71 and older have some type of dementia, including 9.7 percent suffering from Alzheimer's. That translates to 3.4 million Americans -- one in seven people age 71 and older -- with dementia, including 2.4 million with Alzheimer's.
The researchers said the rate of Alzheimer's rises with age: 2.3 percent of those aged 71 to 79; 18.1 percent of those ages 80 to 89; and 29.7 percent of those ages 90 and up.
The study was published in the journal Neuroepidemiology.
A leading U.S. advocacy group, the Alzheimer's Association, in March reported that there were more than 5 million people in the United States living with the disease. The group said the number included 4.9 million people over the age of 65 and between 200,000 and 500,000 people under age 65 with early onset Alzheimer's disease and other types of dementia.
Other estimates also have been higher than in the new study.
Richard Suzman, director of the Behavioral and Social Research Program at the NIH's National Institute on Aging, said the new estimates are the best to date.
"It's somewhat lower, yes," Suzman said in a telephone interview. "There are different methodologies around so there is some level of uncertainty."
Suzman said regardless of the differences, the number of elderly Americans with Alzheimer's is large. "But that's not the number to keep your eye on. The real number is what it's going to be in 30 or 40 years because the population of people age 85 and over -- who are at the highest risk for the disease -- is going to quadruple or quintuple," he said.
Bill Thies, the Alzheimer's Association vice president for medical and scientific relations, played down the differences between his group's earlier estimates and the new ones, while saying the problem has already reached crisis dimensions.
"It's in the right range for all the studies," Thies said of the new data. "Do I think any one of the studies has exactly the right number? The answer is no. None of them do."
Vitamin D does not prevent death from cancer

By Anthony J. Brown, MDTue Oct 30, 8:25 PM ET
Contrary to what many people believe, vitamin D may not be a strong anti-cancer agent, the results of a new study suggest.
The one possible exception is colon cancer: high blood levels of vitamin D do seem to correlate with a reduced risk of death from this cancer.
"This study was the first, to our knowledge, to look at the relationship between measured vitamin D in blood and subsequent total cancer (deaths) in a population," lead author Dr. D. Michal Freedman, from the National Cancer Institute in Bethesda, Maryland, told Reuters Health.
"The key finding was the lack of an association between vitamin D levels in the blood and subsequent total cancer risk. We were uncertain what association we would find, partly because there were no previous studies that had looked at overall cancer mortality after vitamin D blood measurements," he added.
The findings, which appear in the Journal of the National Cancer Institute, are based on an analysis of data for 16,818 subjects who participated in the Third National Health and Nutrition Examination Survey. The subjects were at least 17 years of age when the survey was undertaken between 1988 and 1994 and they were followed through 2000. Vitamin D levels were measured with a standard test when the study began.
During the study period, 536 cancer deaths occurred, the report indicates. As noted, no association between vitamin D levels and total cancer deaths was apparent. This held true in the overall analysis as well as in analyses confined to various ethnic and age groups.
By contrast, there was some evidence that vitamin D may help prevent colon cancer. In the study, people with the highest vitamin D levels were 72 percent less likely to die from this cancer than were people with the lowest levels.
"Among the questions to be addressed in future studies is the relationship between vitamin D levels and future cancer risk both for individual cancer sites and for total cancer risk." The NCI and other institutes currently have a number of these studies underway, Freedman said.
In a related editorial, Dr. Cindy D. Davis, from the NCI, and Dr. Johanna T. Dwyer, from Tufts University in Boston, comment that "while vitamin D may well have multiple benefits beyond bone, health professionals and the public should not in a rush to judgment assume that vitamin D is a magic bullet and consume high amounts of vitamin D."
SOURCE: Journal of the National Cancer Institute, November 7, 2007.
More young adults on cholesterol drugs

By LINDA A. JOHNSON, AP Business WriterTue Oct 30, 9:56 PM ET
Use of cholesterol and blood pressure medicines by young adults appears to be rising rapidly — at a faster pace than among senior citizens, according to an industry report being released Tuesday.
Experts point to higher rates of obesity, high blood pressure and high cholesterol problems among young people. Also, doctors are getting more aggressive with preventive treatments.
"This is good news, that more people in this age range are taking these medicines," said Dr. Daniel W. Jones, president of the American Heart Association.
Still, he said many more people should be on the drugs that lower cholesterol or blood pressure and which have been shown to reduce risks for heart attack and stroke.
The new data, from prescription benefit manager Medco Health Solutions Inc., indicate use of cholesterol-lowering drugs among people aged 20 to 44, while still low, jumped 68 percent over a six-year period.
The rate rose from 2.5 percent in 2001 to just over 4 percent in 2006 among Medco customers. That means roughly 4.2 million Americans in that age group are now taking cholesterol medicines.
Meanwhile, use of blood pressure medicines increased 21 percent, from about 7 percent of 20- to 44-year-olds in 2001 to over 8 percent in 2006. That translates into about 8.5 million Americans in that age group taking drugs to lower their blood pressure.
"It was a surprise to us," said Dr. Robert Epstein, chief medical officer at Franklin Lakes, N.J.-based Medco. "Maybe the fact that we're seeing more young people with high cholesterol and blood pressure is indicative of the epidemic of obesity and overweight that we're seeing in this country."
Among people 65 and older, use of blood pressure drugs increased only 9.5 percent and use of cholesterol drugs by 52 percent. That's because half the seniors were already taking blood pressure drugs and more than one in four were taking cholesterol drugs in 2001.
Jones, dean of the University of Mississippi School of Medicine, said he has seen some increase in young adults with blood pressure or cholesterol problems, but not of the magnitude suggested by Medco's data.
Dr. Howard Weintraub, the heart disease prevention expert at the American College of Cardiology, said he's "thrilled" by the dramatic increase, which he says is tied to requests from patients with "a brand new sense of urgency" and referrals from other doctors to his private practice.
"If you wait until a heart attack or stroke, it's a little bit late," Weintraub said.
He and Epstein both said patients with problems should first work with their doctors on lifestyle changes — more exercise, a better diet and weight loss. But Weintraub said many people need medication to achieve and maintain the ever-lower levels of blood pressure and cholesterol that experts now recommend.
However, Dr. John LaRosa, president of SUNY Downstate Medical Center, said, "particularly for young people, lifestyle change is worth a try."
Once patients start taking these medicines, they usually stay with them and there are some side effects, LaRosa said.
"It's amazing what (losing) five or 10 pounds will do" to reduce blood pressure and cholesterol levels, he said.
Federal health statistics show that while the percentage of people with high cholesterol has dropped overall in recent years, it has risen among younger people, especially those 20 to 34 years old.
Meanwhile, the prevalence of high blood pressure was flat or up slightly among those age groups; among women in the 35 to 44 age group, the rate of high blood pressure rose significantly.
Medco processes prescription claims for about 60 million insured Americans. The report's findings are based on a representative sample of data from 2.5 million members.
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Tuesday, October 30, 2007

Higher Education Delays Dementia Onset but Is Linked to More Rapid Progression

October 29, 2007 — Higher education delays the onset of accelerated cognitive decline, but once it begins, deterioration is more rapid in better-educated individuals, new research suggests. Investigators at the Albert Einstein College of Medicine, Bronx, New York, found that for each additional year of formal education, the rapid accelerated memory decline associated with oncoming dementia was delayed by about 2-1/2 months.
However, once that accelerated decline stopped, individuals with more education had their rate of cognitive decline accelerate 4% faster for each additional year of education.
"Higher levels of education delay the onset of dementia, but once it begins, the accelerated memory loss is more rapid in people with more education. Our study showed that a person with 16 years of formal education would experience a rate of memory decline that is 50% faster than someone with just 4 years of education," principal investigator Charles B. Hall, PhD, said in a statement from the American Academy of Neurology.
The study is published in the October 23 issue of Neurology.
Brain Maintains Function Despite Damage
According to Dr. Hall and colleagues, this is the first study to confirm the long-held hypothesis of "cognitive reserve," which postulates that individuals with more education begin to experience acceleration in cognitive decline closer to the time of diagnosis than those with lower reserve but that their rate of decline is more rapid after the time of acceleration due to increased disease burden.
"This rapid decline may be explained by how people with more education have a greater cognitive reserve, or the brain's ability to maintain function in spite of damage. So while they're often diagnosed with dementia at a later date, once the cognitive reserve is no longer able to compensate for the damage that's occurred, then the symptoms emerge," he said.
To determine the influence of education on rates of memory decline, researchers studied 117 subjects who developed incident dementia during their participation in the Bronx Aging Study, which included 488 healthy, community-dwelling individuals aged 75 to 85 years without baseline dementia enrolled between 1980 and 1983.
Study subjects had detailed cognitive assessments, including the Busche Selective Reminding Test (SRT), which has shown to be a predictor of prevalent and incident dementia, and annual follow-up visits.
Using a change-point model, the investigators estimated the time at which the rate of decline began to accelerate. In addition, using longitudinal study data, they calculated the preacceleration and postacceleration rates of decline.
Such models, the authors explain, consider the date of diagnosis as time zero and look backward in time at cognitive trajectories that precede diagnosis.
"If the cognitive-reserve hypothesis is correct, memory decline will accelerate closer to the time of dementia diagnosis and that decline will be more rapid in persons with more education," they write.
Possible Masking Effect
The median follow-up time before dementia diagnosis was 5.6 years. A total of 61 (52%) of study participants received a clinical diagnosis of probable or possible Alzheimer's disease (AD), 24 (21%) were diagnosed with vascular dementia (VaD), 24 (21%) had a combination of both AD and VaD, and 8 (7%) were diagnosed with other subtypes.
According to the article, of the total study population, 9 participants had 3 or fewer years of formal education, 23 had 4 to 6 years, 37 had 7 to 9 years, and 27 had 10 to 11 years. Of 21 individuals who had completed high school, 2 had some college education, 4 had college degrees, and 7 had both college degrees and at least some postgraduate education.
The investigators found that each additional year of formal education delayed the time of accelerated decline on the SRT by 0.21 years. Postacceleration, the rate of memory decline was increased by 0.10 points per year for each additional year of formal education.
According to the authors, the findings' generalizability may be limited by the fact that the participants were mainly middle class and white. Furthermore, because study subjects were born between 1894 and 1908, their life experiences may not be representative of today's population.
"Nevertheless," they write, "this is the first study to confirm important predictions of the cognitive-reserve hypothesis in persons with preclinical AD. A potential implication is that early signs of dementia may be masked in persons with higher educational achievement."
They add that their future research will examine other measures of cognitive reserve, including IQ and occupational achievement, as well as factors that may preserve cognitive reserve, such as participation in leisure activities.
The study was supported by the National Institute of Aging. The study authors have disclosed no relevant financial relationships.
Neurology. 2007;69:1657-1664.
Higher-Than-Expected Suicide Rate Following Bariatric Surgery

October 29, 2007 — Extremely obese Pennsylvania residents undergoing weight loss surgery over a 10-year period had a higher-than-expected mortality rate from suicide, according to a new study appearing in the October issue of Archives of Surgery. The study also uncovered an excess of deaths due to coronary heart disease among these surgery patients.
The large number of deaths from suicides and drug overdoses is "a cause for concern," the authors, led by Bennet I. Omalu, MD, from the University of Pittsburgh, in Pennsylvania, write. The fact that most of these deaths occurred at least 1 year after surgery suggests that "careful follow-up, especially the need to recognize and treat depression, should be provided for patients who have undergone bariatric surgery," they write.
Substantial Excess of Suicide Deaths
Bariatric surgery is the most effective treatment for morbidly obese patients (those with a body mass index [BMI] of 40 kg/m2 or more), the authors write. Patients typically lose up to 80% of their excess body weight 1 to 2 years following the operation.
In this study, Dr. Omalu and colleagues examined data from the Pennsylvania Health Care Cost and Containment Council on 16,683 Pennsylvania residents who underwent bariatric surgery (gastric bypass) between January 1, 1995, and December 31, 2004. There were 440 deaths among these patients, or 2.6% of the total. Death rates increased with age, especially after the age of 65 years. The mean age of the surgery patients was 48 years. The study also looked at comparable death rates among Pennsylvania residents from the Division of Vital Records at the Pennsylvania State Department of Health.
In the study, less than 1% of the deaths occurred within the first 30 days. Therapeutic complications accounted for 38 of 150 natural deaths within 30 days, including pulmonary embolism in 31 (20.7%), coronary heart disease in 26 (17.3%), and sepsis in 17 (11.3%).
The 1-year case fatality rate was 1% and rose to almost 6% by the 5-year mark. The percentage of men dying was almost 3 times that of women.
There were 16 deaths listed as suicides, but the actual suicide rate was likely higher, since some of the 14 deaths listed as drug overdoses on death certificates may have been suicides as well. Based on statistics for the general US population, only 2 suicides would have been expected in this number of people. "There was a substantial excess of suicide deaths, even excluding those listed only as drug overdose," the authors write.
Overall, coronary heart disease was the leading cause of death in the study, listed as the cause of death in 76 patients, or 19.2%. "A more thorough examination of cardiac morbidity and mortality, including more detailed clinical evaluation of cardiac pathophysiological characteristics before and after surgery, is indicated because of the continuing high mortality due to cardiovascular disease in this population," write the study authors.
This high death rate could be reduced by better coordination of follow-up after the surgery, they write, "especially control of high risk factors such as hypertension, diabetes mellitus, hyperlipidemia, and smoking, as well as efforts to prevent weight regain by diet and exercise."
View the Deaths in Context
Asked for comment on these findings, Anita Courcoulas, MD, who did not take part in the study but is an associate professor of surgery and chief of the section of minimally invasive bariatric and general surgery at the University of Pittsburgh School of Medicine, agrees that bariatric-surgery patients "need to be followed carefully." She adds that they need social and psychological support and follow-up as well as medical follow-up.
Dr. Courcoulas noted that there is a high rate of depression among obese people, especially those seeking surgery. "There is a subset in this population that doesn't get better with respect to depression, and it could actually get worse," she told Medscape Psychiatry, adding that this group seems to be particularly at risk for suicide. "I think we have to identify who these people are."
However, the deaths in the study should be viewed in context, said Dr. Courcoulas who, as an epidemiologist, says she is familiar with studies such as this one and their limitations. She noted that it might not be so much the surgery that is killing these patients but their obesity. She points out that the study compared death rates of obese patients undergoing bariatric surgery with an age- and sex-matched population — that is, with people who do not have the same comorbid medical conditions — and not with obese people in the state who did not undergo surgery.
The 1%-per-year mortality rate is "not widely different from what bariatric surgeons know to be the expected mortality of a group of patients who are otherwise quite ill," she said. She pointed to 2 recent studies that compared mortality among bariatric-surgery patients with obese, nonsurgery patients in the population using drivers' licenses, which document age as well as BMI. Those studies, she said, found "a much reduced incidence of mortality when you compared the surgery patients with equally obese patients" who did not undergo surgery.
The study authors have disclosed no relevant financial relationships.
Arch Surg. 2007;142;923-928.
Advanced Bronchoscopic Techniques Significantly Improve Diagnosis and Staging of Lung Cancer

October 29, 2007 (Los Angeles) — Advanced bronchoscopic techniques such as autofluorescence are significantly improving the diagnosis and staging of lung cancer, Michael Simoff, MD, senior staff physician in pulmonary and critical care medicine and director of the bronchoscopy and interventional pulmonary program at Henry Ford Hospital, in Detroit, Michigan, told attendees at the American Society for Therapeutic Radiology and Oncology (ASTRO) 49th Annual Meeting.
Dr. Simoff said that autofluorescence appears to be more effective than white-light bronchoscopy at detecting subtle changes and can highlight areas that otherwise would be difficult to see clearly.
Dr. Simoff outlined several other techniques that improve the diagnostic yield in lung cancer. Endobronchial ultrasound, which allows the endoscopist to look beyond the airways, is increasingly used as a diagnostic tool, Dr. Simoff added. Meanwhile, transbronchial needle aspiration is "one of the best techniques for doing initial staging but is underused," he said.
Dr. Simoff told his audience that endobronchial ultrasound-guided transbronchial needle aspiration yielded a diagnosis in 95.5% of cases and was able to access lymph nodes that could not otherwise be reached. The technique is particularly effective at diagnosing malignancy in lymph nodes of less than 1 cm. Simoff said he has found that 22% of such nodes diagnosed as negative through positron emission tomography–computed tomography (PET-CT) are in fact positive, but endoscopists would have no way of knowing this without advanced techniques.
Session attendee Bulent Aydogan, PhD, assistant professor of medical physics in the department of radiation and cellular oncology at the University of Chicago in Illinois, commented to Medscape Oncology after Dr. Simoff's presentation that techniques such as endobronchial ultrasound "are going to change the way we treat lung cancer patients, particularly [those with] small peripheral lung cancers."
Using techniques such as those outlined by Dr. Simoff, "we are going to be able to pinpoint exactly where the small peripheral tumor is and better target, localize, and deliver radiation therapy to these tumors," Dr. Aydogan added.
Dr. Simoff noted that another technique, confocal microendoscopy, "is something I'm very interested in and excited about."
Dr. Simoff said advanced diagnostic techniques are moving the state of the art toward the optical biopsy. In the future, the goal is treatment without surgery, Dr. Simoff added. He said that physicians at Henry Ford Hospital expect to be able to perform precise radiosurgical techniques within 5 years.
Neither Dr. Simoff nor Dr. Aydogan have disclosed any relevant financial relationships.
American Society for Therapeutic Radiology and Oncology 49th Annual Meeting. Presented October 28, 2007.
Prognosis: Cancers Not Affected by Emotional Health

The idea that emotional well-being can affect the course of disease finds no support in a new report on head and neck cancer.
The study involved more than 1,000 men and women older than 18 with cancers of the mouth, tongue and throat that had not spread. A questionnaire assessed quality of life, including physical health, family and social connections and emotional status. The patients were followed for an average of nine years, until death or until they stopped participating.
Although age, tumor classification, cigarette smoking and other variables were predictors of survival, scores on emotional well-being tests had no predictive value.
“A fighting spirit has its advantages, but one of them is not, apparently, cancer survival,” said James C. Coyne, lead author of the study, which appeared online Oct. 22 in the journal Cancer. “We looked at whether exceptionally high emotional well-being or exceptionally low emotional well-being had an effect. We found absolutely no evidence for either.”
Dr. Coyne is a professor of psychology at the University of Pennsylvania.
The authors acknowledge that participants had to be judged mentally fit to consent, follow instructions and keep appointments, which may make the sample somewhat unrepresentative.
But its large size — there were 646 deaths in the group, which is larger than the entire sample in most previous studies — gives the work considerable strength.
Zinc Helps Elderly Ward Off Pneumonia

Mon Oct 29, 7:00 PM ET
MONDAY, Oct. 29 (HealthDay News) -- Maintaining normal zinc concentrations in the blood may help prevent pneumonia in elderly nursing home residents, a new study shows.
A team at Tufts University looked at 617 people 65 and older in 33 nursing homes in the Boston area.
They found that those with normal blood zinc concentrations were about 50 percent less likely to develop pneumonia than those with low concentrations.
The study, published in the October issue of the American Journal of Clinical Nutrition, also found that people with normal zinc concentrations had a 39 percent lower rate of death from all causes.
"Not only did (people with lower zinc concentrations) have a higher risk of developing pneumonia, when they did become sick, they did not recover as quickly and required a longer course of antibiotics," corresponding author Simin Nikbin Meydani, director of the nutritional immunology laboratory at the U.S. Department of Agriculture's Human Nutrition Research Center on Aging at Tufts, said in a prepared statement.
The Tufts researchers took blood samples from the participants at the start and conclusion of the one-year study. All the participants received daily supplements containing 50 percent of the recommended dietary allowance of several vitamins and minerals, including zinc, for one year.
"Zinc is already known to strengthen the immune system; however, there needs to be further investigation of zinc and its effect on pneumonia development and prevention in nursing homes. The next step would be a clinical trial," Meydani said.
Red meat, poultry, whole grains, beans, dairy products, and oysters are examples of foods that provide zinc.
More information
The American Lung Association has more about pneumonia.
Tasigna Approved for Chronic Myeloid Leukemia

Mon Oct 29, 7:00 PM ET
MONDAY, Oct. 29 (HealthDay News) -- Tasigna (nilotinib) has been approved by the U.S. Food and Drug Administration to treat chronic myeloid leukemia (CML) in people who are resistant or intolerant to other therapies, maker Novartis AG said Monday.
CML, among the most common forms of leukemia, affects about 4,500 people in the United States each year. Some have become resistant to or cannot tolerate a standard therapy for CML, Gleevec.
Tasigna, taken twice daily, targets a protein that is produced only by cells that have an abnormal chromosome in people with Philadelphia chromosome-positive CML, Novartis said in a statement. The protein is a key cause of the over-production of the white blood cells that characterizes this form of CML.
Reported side effects of the drug include rash, nausea, fatigue, headache, constipation, diarrhea, and vomiting. Users should avoid food two hours before and one hour after taking Tasigna, Novartis said.
Brain scans of obese show hunger hormone at work

By Maggie Fox, Health and Science EditorMon Oct 29, 6:21 PM ET
Giving the body's natural appetite suppressant to morbidly obese volunteers de-activated their brain's response to tasty food -- and the new brain activity lasted for as long as the hormone was delivered, U.S. researchers reported on Monday.
They said their imaging tests show some of the brain circuits activated by leptin, a hormone that helps control appetite, and may lead to new and better treatments for obesity, the researchers wrote in their report, published in the Proceedings of the National Academy of Sciences.
"While they were off leptin they got really hungry when they saw pictures of high-calorie food, and that was associated with high activation in a part of the brain that is related to food craving," said Edythe London of the University of California Los Angeles, who led the study.
With leptin, the executive centers involved in self-control were more activated. "The findings suggest that leptin strengthens the executive centers," London said in a telephone interview.
The discovery of leptin in the 1990s created a furor, because when injected into rodents it caused them to eat less and lose weight. But the same rarely occurs in humans.
So experts are trying to find out how it works in people and find ways to better harness its effects.
London and colleagues examined three members of a family with a rare genetic defect that causes their bodies to produce no leptin. Such people become extremely obese.
Earlier studies had shown that when injected with leptin, these people lose up to 50 percent of their body weight -- unlike most people, who usually continue to over-eat even when injected with leptin.
London wanted to see what was going on in their brains.
"In 2005 we found that leptin actually changes the structure of their brain," London said in a telephone interview. They found the area of the cerebral cortex involved in self-control actually grew after repeated leptin administrations.
But they wondered what else was going on.
They set up an experiment using functional magnetic resonance imaging, a type of brain scan that can see the brain's activity in real time. They recorded the brain activity before and after giving leptin, a study that continued for two years.
Pictures of food treats got the brain busy.
But different areas of the brain lit up with and without leptin, they reported.
One surprise was the activation of the cerebellum -- a section of the brain at the base of the head.
"Although the cerebellum has not traditionally been linked with eating behavior, it is thought to play a role in reinforcement and drug craving," they wrote.
"With leptin supplementation, the cerebellum showed enhanced activation," they wrote.
London said she is not sure what to make of this.
Doctors test hot sauce for pain relief

By LAURAN NEERGAARD, AP Medical Writer 40 minutes ago
Devil's Revenge. Spontaneous Combustion. Hot sauces have names like that for a reason. Now scientists are testing if the stuff that makes the sauces so savage can tame the pain of surgery.
Doctors are dripping the chemical that gives chili peppers their fire directly into open wounds during knee replacement and a few other highly painful operations.
Don't try this at home: These experiments use an ultra-purified version of capsaicin to avoid infection — and the volunteers are under anesthesia so they don't scream at the initial burn.
How could something searing possibly soothe? Bite a hot pepper, and after the burn your tongue goes numb. The hope is that bathing surgically exposed nerves in a high enough dose will numb them for weeks, so that patients suffer less pain and require fewer narcotic painkillers as they heal.
"We wanted to exploit this numbness," is how Dr. Eske Aasvang, a pain specialist in Denmark who is testing the substance, puts it.
Chili peppers have been part of folk remedy for centuries, and heat-inducing capsaicin creams are a drugstore staple for aching muscles. But today the spice is hot because of research showing capsaicin targets key pain-sensing cells in a unique way.
California-based Anesiva Inc.'s operating-room experiments aren't the only attempt to harness that burn for more focused pain relief. Harvard University researchers are mixing capsaicin with another anesthetic in hopes of developing epidurals that wouldn't confine women to bed during childbirth, or dental injections that don't numb the whole mouth.
And at the National Institutes of Health, scientists hope early next year to begin testing in advanced cancer patients a capsaicin cousin that is 1,000 times more potent, to see if it can zap their intractable pain.
Nerve cells that sense a type of long-term throbbing pain bear a receptor, or gate, called TRPV1. Capsaicin binds to that receptor and opens it to enter only those pain fibers — and not other nerves responsible for other kinds of pain or other functions such as movement.
These so-called C neurons also sense heat; thus capsaicin's burn. But when TRPV1 opens, it lets extra calcium inside the cells until the nerves become overloaded and shut down. That's the numbness.
"It just required a new outlook about ... stimulation of this receptor" to turn those cellular discoveries into a therapy hunt, says NIH's Dr. Michael Iadarola.
Enter Anesiva's specially purified capsaicin, called Adlea. Experiments are under way involving several hundred patients undergoing various surgeries, including knee and hip replacements. Surgeons drip either Adlea or a dummy solution into the cut muscle and tissue and wait five minutes for it to soak in before stitching up the wound.
Among early results: In a test of 41 men undergoing open hernia repair, capsaicin recipients reported significantly less pain in the first three days after surgery, Aasvang reported this month at a meeting of the American Society of Anesthesiologists.
In a pilot U.S. study of 50 knee replacements, the half treated with capsaicin used less morphine in the 48 hours after surgery and reported less pain for two weeks. Ongoing studies are testing larger doses in more patients to see if the effect is real.
There's a huge need for better surgical pain relief, says Dr. Eugene Viscusi, director of acute pain management at Thomas Jefferson University in Philadelphia, one of the test sites. Morphine and its relatives, so-called opioid painkillers, are surgery's standby. While they're crucial drugs, they have serious side effects that limit their use.
Specialists are watching the capsaicin research because it promises a one-time dose that works inside the wound, not body-wide, and wouldn't tether patients to an IV when they're starting physical therapy.
"It's in and it's done," Viscusi explains. "You can't abuse it. You can't misuse it."
"There's been an enormous effort to try and develop alternatives to opioids with the same strength but not too much success," adds Dr. Clifford Woolf of Harvard and Massachusetts General Hospital. "We think we're moving toward it."
His team is trying a different approach: Standard lidocaine injections numb all the surrounding tissue. Woolf and colleagues slipped lidocaine inside just pain-sensing neurons, by opening them with a tiny dose of capsaicin. Rats given the injections ran around normally while not noticing heat applied to their paws, they reported in the journal Nature this month.
That's years away from trying in people, and would have to be done in a way to avoid even a quick capsaicin burn.
In a third approach, Iadarola and NIH colleagues hope to soon test a capsaicin cousin called resiniferatoxin in advanced cancer patients whose pain no longer is relieved by opioids. Injections into the spinal columns of cancer-riddled dogs did more than temporarily numb — it severed some nerve connections.
China says breast cancer on rise in Beijing, Shanghai

Tue Oct 30, 1:29 AM ET
Breast cancer has risen sharply in China's capital and its top financial centre during the last decade due to unhealthy diets, a poor environment and increased stress at work, state media reported on Tuesday.
In Beijing, the incidence of breast cancer has increased 23 percent in 10 years, with about 45 women out of every 100,000 diagnosed with the disease, the China Daily said, citing the Beijing Center for Disease Control and Prevention.
In Shanghai, the figures are even worse, at 55 out of 100,000, up 31 percent in the past decade.
"Unhealthy lifestyles are mostly to blame for the growing numbers," Qiao Youlin, a professor at the Cancer Institute and Hospital of the Chinese Academy of Medical Sciences, was quoted as saying.
Another survey, carried out by the Chinese Anti-Cancer Association, revealed 4,500 new cases in Shanghai every year, or 60 women in 100,000 suffering from breast cancer compared to 17 in 100,000 in 1972.
The findings suggest that 10 percent of the cases are due to heredity, the researchers said.
A separate media report said that a large proportion of men in Shanghai suffered from "bad living habits," which medical experts say can often lead to cardiovascular problems and other common diseases.
"(Men) live in poorer 'mental circumstances' and have poorer life quality than women in general," Shan Li, a Shanghai-based psychologist said.
A study conducted at the 411 Hospital in Shanghai found that 90 percent of men were not aware of the importance of annual check-ups, while 20 percent said they never exercise.
"Common diseases kill more men than women," Huang Qiming, a urologist at the hospital said.
Rapid growth in heart meds seen in younger patients

By Bill Berkrot 40 minutes ago
Growth in prescription drug use among younger adults for heart disease-related conditions, such has high cholesterol and high blood pressure, is outpacing that among older adults, according to a study by Medco Health Solutions Inc.
While heart disease is usually associated with an older population, people are beginning to take medicines that could help prevent heart problems at a much younger age, according to data collected by Medco, a pharmacy benefit manager.
High cholesterol and high blood pressure are among the leading risk factors for heart disease, heart attack and stroke.
"We were pretty surprised by the rapid increase in a short time frame in this age group," Dr. Robert Epstein, Medco's chief medical officer, said in an interview. "Certainly it's a sign of the epidemic of overweight and obesity in this country, which are underlying factors."
Between 2001 and 2006, the number of 20-to-44-year-olds taking prescription medicines to treat high cholesterol increased 68 percent. The estimated number of patients on lipid-lowering drugs in that age group nationwide rose to 4.2 million in 2006 from 2.5 million in 2001, said Medco, which has a large mail-order pharmacy operation.
The use of anti-hypertensives jumped 21 percent among the age group, with those on medication to control high blood pressure rising to 8.5 million from 7 million in the six-year period, according to Medco's analysis of the data.
Those numbers should put a smile on the faces of drug company executives, as these medications, once started, are usually taken for life. An earlier start translates into many more years of sales.
"In general, people are less bothered by taking prescription drugs than they used to be," Epstein said.
The increase in the number of 20-to-44-year-olds on lipid-lowering medications was 37 percent higher than it was for those ages 45 to 64, and 31 percent higher than among patients 65 and older.
Growth in those on blood pressure medicines among the younger age group was 52 percent greater than among 45-to-64-year-olds and more than double the growth seen among senior citizens.
"It's another signal that we have an issue in this country that we have to get our arms around sooner rather than later because we are destining these young people to lifelong therapy," Epstein said, stressing the importance of diet and exercise lifestyle adjustments.
But the findings also are a sign that people are addressing medical problems sooner and possibly heading off suffering and much higher health care costs down the road.
"The good news part of the story is that prevention is really important," Epstein said. "It's not bad that people get these problems controlled at a younger age because it will reduce the lifelong complications."
In addition, he noted: "A lot of these therapies are going or have gone generic, so the actual costs are not going to be as high as they had been five or 10 years ago."
Medco got its data from a representative sample database of 2.5 million of the 60 million people for whom it serves as a benefits manager.

Monday, October 29, 2007

A (Sometimes) Deadly Scourge


TWO weeks ago, the government released a startling new estimate that nearly 19,000 people in the United States had died in a single year after being infected with the virulent superbug known as methicillin-resistant Staphylococcus aureus, or MRSA.
Within days, the nasty little bacteria seemed to be everywhere. News reports told of cases in schools and prisons and locker rooms, including the announcement on Thursday that a Brooklyn middle school student had died with an MRSA infection on Oct. 14. Across the country, classrooms were closed for disinfection as politicians and health officials scrambled to calm an anxious public. Suppliers of sanitizers and disposable blood pressure cuffs seized the moment to gin up demand.
Lost in the frenzy were a few fundamental truths reinforced by the new research, which was conducted by the Centers for Disease Control and Prevention.
The most significant is that while MRSA clearly can kill, it rarely does so when contracted in the general public, where it typically appears as an easily treatable skin infection. The vast majority of lethal cases occur in hospitals and nursing homes, where open wounds and punctures provide the opportunistic staph a ready path to the bloodstream and organs.
Another truth is that while the new study found that MRSA was perhaps twice as prevalent as previously thought, there is no evidence yet that its assault on the human immune system is accelerating.
Researchers have no way of knowing whether the rising numbers demonstrate that the MRSA threat is growing, or whether more precise measurements simply yielded the first true accounting. Indeed, the study’s mission was to establish a baseline against which future studies can measure MRSA’s growth or decline.
In an interview this week, the disease control agency’s top MRSA experts, Dr. John A. Jernigan and Dr. Rachel J. Gorwitz, emphasized that antibiotic resistance is hardly new to Staphylococcus aureus, a bacteria they said has always plagued humans. Indeed, the introduction of the antibiotic methicillin around 1960 was followed only a few months later by the first reports of MRSA in the United Kingdom, they said. Similarly, resistance to penicillin developed quickly after doctors began using it in the 1940s.
“We know that antimicrobial resistance will follow antimicrobial use as sure as night follows day,” said Dr. Jernigan, deputy chief of prevention and response in the agency’s division of healthcare quality promotion. “It’s just a biological phenomenon.”
That being said, Dr. Jernigan and Dr. Gorwitz stressed that MRSA can largely be controlled with basic hygiene and prevention measures in both community and healthcare settings, and that while MRSA is resistant to some drugs it can still be treated with others, including some oral antibiotics. There is, however, no standard treatment because of epidemiological differences among various strains of MRSA.
Some infections found among the public can be treated merely by draining and bandaging wounds that typically appear as an insect bite. Others require oral antibiotics like levofloxacin or moxifloxacin.
To avoid transmission, the agency recommends frequent hand-washing, and showering after exercise; covering cuts and abrasions with bandages until healed; not sharing personal items like razors and towels that come into contact with bare skin; placing barriers between skin and shared equipment like weight-lifting benches; and sanitization of frequently touched surfaces.
In hospitals, the infections are more likely to be invasive and serious, in part because they attack immune systems that may already be compromised. Treatment may require stronger antibiotics, like vancomycin, which is administered intravenously.
The agency advises that health care workers wear gloves, masks and gowns when treating patients, and that they wash their hands after contact. If hospitals fail to reduce their infection rates using such standard precautions, it recommends other methods like testing high-risk patients and isolating those found positive.
Perhaps the greatest threat posed by MRSA is its ease of transmission. MRSA can pass from person to person through simple touch, or the sharing of personal objects. It can navigate its way into the body through breaks in the skin, even microscopic ones, and through nasal passages.
Not surprisingly, community outbreaks have occurred in places where people gather in close quarters and where they may have physical contact, like schools, prisons, military barracks and storm shelters.
In 2003, researchers documented an outbreak among players for the St. Louis Rams, with the bacteria attacking sites of turf burn. “MRSA infection was significantly associated with the lineman or linebacker position,” said a study in The New England Journal of Medicine.
Dr. Gorwitz said that the community strains, which first appeared in the 1990s, are genetically distinct from those that emerged in hospitals two decades earlier. “It doesn’t appear that MRSA in the community occurred as a result of MRSA sort of spreading out from hospitals,” she said. “What likely happened is that some of these strains of Staph aureus that were already in the community acquired the genes that confer resistance.”
The recent study looked only at the most serious MRSA cases, those in which the infection invaded the body as opposed to merely colonizing the skin. The researchers projected there were 94,360 such cases in 2005. Of those, 27 percent clearly began in hospitals while another 58 percent involved strains associated with health care that attacked within a year of a medical procedure. Only 14 percent were found to be community strains.
A previous study, published in 2005, projected that one of every three people were colonized with Staphylococcus aureus, but that only 1 percent carried a drug-resistant strain.
Dr. Jernigan pointed out that MRSA represents only a fraction of all health-care-associated infections, perhaps 10 percent of the total. Earlier this year, the disease control agency projected that 1 of every 22 hospital patients would get an infection — 1.7 million cases a year — and that 99,000 would die.
Arthritis Patients Don't Share in Life Expectancy Gains

ROCHESTER, Minn., Oct. 29 -- Life expectancy for patients with rheumatoid arthritis has not improved over the past four decades, despite the overall gains in the general population, researchers here have found.
A study comparing mortality rates in all residents of Rochester, Minn., diagnosed with RA from 1955 through 1995, and expanded to include all residents of Olmsted County diagnosed from 1995 through 2000, with national trends showed that the mortality gap between those with RA and those without has widened, said Sherine E. Gabriel, M.D., M.Sc., of the Mayo Clinic, and colleagues.
"We found no evidence indicating that RA patients experienced improvements in survival over the last four to five decades," the authors wrote in the November issue of Arthritis & Rheumatism.
"In fact, RA patients did not even experience the same improvements in survival as their peers without arthritis, resulting in a worsening of the relative mortality in more recent years, and a widening of the mortality gap between RA patients and the general population throughout time," they continued.
Although some recent studies of survival in RA patients have demonstrated improved longevity and have suggested that the improvement may be the result of earlier diagnosis and more aggressive therapies, at least some of the studies may be subject to survival bias, the authors noted. Because they examine survival not in newly diagnosed patients (incidence cohorts), but in prevalence cohorts, such studies exclude patients who die or leave the population shortly after the index diagnosis, the authors noted.
"This potential bias is particularly important in studies of RA, given the increased risk of cardiovascular events and mortality early in the course of RA," they wrote.
The authors examined inpatient and outpatient medical records for all incident cases of RA among residents of the city of Rochester, home of the Mayo Clinic, from 1955 through 1995, and for residents of Olmsted County from 1995 through the start of 2000.
They identified a total of 822 cases (71.5% female), with a mean age of 57.6 years at RA diagnosis. All patients were followed prospectively through their entire medical records until death or until Jan. 1, 2007.
The median follow-up was 11.7 years, during which 445 of the RA patients died. In Cox regression models adjusted for age and gender, the authors compared the survival rates of patients diagnosed from 1955-1964, 1965-1974, 1975-1984, 1985-1994, and 1995-2000.
They found that across all of the five time periods, there were no significant differences in survival rates for patients with RA. For women, the death rate was relatively consistent at 2.4 per 100 person-years across all time points; for men, the rate was 2.5 per 100 person-years.
In contrast, the mortality rate for white women in the general population in Minnesota declined from 1 per 100 person-years in 1965 to 0.2 per 100 in 2000. Among white men in the general population, the mortality went from 1.2 per 100 person-years in 1965 to 0.3 per 100 in 2000.
The difference between the observed mortality of the patients with RA and the mortality that would be expected based on population norms in more recent years suggest a widening of the mortality gap, rather than stasis, the authors wrote.
"Although the reasons for the widening mortality gap are unclear," Dr. Gabriel said, "cardiovascular deaths constitute at least half of the deaths in subjects with RA, and it is possible that the cardiovascular interventions that improved life expectancy in the general population may not have had the same beneficial effects in persons with RA."
Potential limitations, the authors noted, included the possibility of missing patients who did not seek medical attention for RA, and the use of a predominantly white cohort that may limit generalizability of the findings.
The study was funded in part by the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Author conflicts of interest were not listed in the study. Primary source: Arthritis & RheumatismSource reference: Gonzalez A, et al "The Widening Mortality Gap Between Rheumatoid Arthritis Patients and the General Population" Arthritis & Rheumatism. 56; 11: 3583-3587.
New Guidelines Should Improve Ovarian Cancer Detection

By Dennis ThompsonHealthDay ReporterSun Oct 28, 6:59 PM ET
SUNDAY, Oct. 28 (HealthDay News) -- Ovarian cancer has long had a reputation as a silent killer, because many people believed it gave no warning signs until far advanced.
But women suffering from the disease knew differently. They knew they had certain symptoms that were common from patient to patient.
"Survivors for years have said there are symptoms for the disease, but no one listened to them," said Jane Langridge, chief executive officer for the National Ovarian Cancer Coalition.
Now, doctors have agreed with them.
A screening test has been developed that, in one study, accurately detected early stage ovarian cancer 57 percent of the time.
Based on that and similar studies, experts from the American Cancer Society, the Gynecologic Cancer Foundation and the Society of Gynecologic Oncologists have agreed on a set of symptoms that can be signs of early ovarian cancer.
"We want people to know it's not the silent killer. There are symptoms women can bring to their doctors that are important to pay attention to," said Dr. Linda Duska, a member of the National Ovarian Cancer Coalition's medical advisory board and a gynecologic oncologist at Massachusetts General Hospital Cancer Center, in Boston.
"This agreement is significant in the fact that, maybe if we pay more attention to symptoms, we can catch them sooner and have more success in treating them," she continued.
Early detection of ovarian cancer is crucial.
More than 22,000 U.S. women will be diagnosed with the disease this year, and three-fourths of them -- more than 15,000 -- will die from it, according to the National Cancer Institute.
If caught in the early stages, the five-year survival rate for ovarian cancer is 90 percent. But 75 percent of women are still diagnosed in the advanced stages, when the prognosis is poor.
Ovarian cancer is the eighth most common cancer among American women, not including skin cancer, according to the American Cancer Society. An estimated two-thirds of women with ovarian cancer are 55 or older.
"It is a disease that is detected in stage 3 and above, and that is unacceptable," said Sherry Salway Black, executive director of the Ovarian Cancer National Alliance and a survivor of the disease. "Our mortality figures are unacceptable."
The symptoms of ovarian cancer can be subtle and hard to assess, because they often mimic common digestive and gastrointestinal disorders. They include persistent swelling, bloating, pressure or pain in the abdomen, gastrointestinal upset, difficulty eating or feeling full quickly, and the frequent or urgent need to urinate.
Because these symptoms are so common, women should be careful not to assume the worst, Duska said.
"The goal of this is not to make everyone think they have ovarian cancer," she said. "If women have these symptoms, and they persist over time, they should have them investigated. Everyone with bloating does not have ovarian cancer."
Typically, two or more symptoms occur simultaneously and increase in severity over time, according to the National Ovarian Cancer Coalition.
The screening test developed late last year involves an extensive checklist of symptoms and their frequency. It picked up early stage ovarian cancer 56.7 percent of the time, and late stage ovarian cancer 80 percent of the time. The test also produced "false-positive" findings 10 percent to 13 percent of the time.
The test searches for many of the symptoms agreed upon by cancer experts as indicative of ovarian cancer.
"When women go to their doctors and have had some of these symptoms, and they are new and have persisted for two or more weeks, perhaps a doctor now would be willing to perform some pretty simple tests to rule out ovarian cancer," Langridge said.
Women who have a family history of breast or ovarian cancer are at increased risk and should pay particular attention to the symptoms, Duska said.
Treatment of ovarian cancer usually involves a combination of surgery and chemotherapy. Advances in chemotherapy have made the late-stage disease more survivable, Duska said.
In a more intensive regimen recently shown to improve survival, standard intravenous chemotherapy is combined with chemotherapy injected directly into the abdominal cavity. The abdominal injection exposes hard-to-reach cancer cells to higher levels of chemotherapy than can be reached intravenously.
"That was a breakthrough, I think," Duska said.
Other treatments being explored include new chemotherapy drugs, vaccines, gene therapy and immunotherapy, which boosts the body's own immune system to help combat cancer, according to the Mayo Clinic.
More information
To learn more about ovarian cancer, visit the U.S. National Library of Medicine.

Sunlight may cut breast cancer risk for some women

By Anthony J. Brown, MD2 hours, 4 minutes ago
Exposure to sunlight may reduce the risk of advanced breast cancer in women with light skin pigmentation, according to the results of a population-based study appearing in the American Journal of Epidemiology.
"We believe that sunlight helps reduce women's risk of breast cancer because the body manufactures the active form of vitamin D from exposure to sunlight," lead author Dr. Esther M. John, from the Northern California Cancer Center in Fremont, said in a statement.
"It is possible that these effects were observed only among light-skinned women because sun exposure produces less vitamin D among women with naturally darker pigmentation."
The study is not the first to link sun exposure with a reduced risk of breast cancer, but the way that sun exposure was measured was new, according to John.
"We measured women's skin pigmentation on the forehead (usually exposed to the sun) and on the upper inner arm (usually not exposed to the sun) and used the difference between the two measurements as a measure of past sun exposure. Other studies have usually relied on self-reported sun exposure," she told Reuters Health.
The study included 1788 women with breast cancer and a comparison group of 2129 "controls" - women without breast cancer, living the San Francisco Bay Area of California (1995-2003). In addition to the sun exposure test mentioned, skin specimens were obtained and analyzed in a subgroup of subjects in each group.
High levels of sun exposure were associated with a 47-percent reduced risk of advanced breast cancer in light-skinned women, the results show. Mutations of the vitamin D receptor gene did not affect the association.
However, this association was not seen in women with medium or dark skin and was only apparent for advanced disease, not localized breast cancer.
The results could have important public health implications, but they will require confirmation in other studies, the authors conclude.
"While the public needs to be advised to avoid excessive sun exposure and sun burns in particular because of the known risk of skin cancer and melanoma, never getting any sun exposure leads to vitamin D deficiency," John said.
The evidence is increasing that vitamin D may decrease the risk of certain cancers, such as breast, prostate and colon cancers. A safe way to get vitamin D is from supplements."
SOURCE: American Journal of Epidemiology October 18, 2007.

Sunday, October 28, 2007

Changing The Way Doctors Do Business

LOS ANGELES, Oct. 27, 2007
(CBS) If you ask most patients how much their doctor visit costs, it's a good bet they won't know until the bill comes in the mail. Now the largest state's largest private physicians practice, Southern California-based HealthCare Partners Medical Group, is changing the way doctors do business by listing on its Web site the prices of 58 of the most common procedures, reports CBS News correspondent Bill Whitaker. Listings include a chest X-ray for $61, a flu shot for $15, and a physical exam for $100 to $120. "An informed patient becomes an empowered consumer," said Dr. Rob Blackman, a partner in the group. They call it "transparency in pricing." "I think the patients need to know that medicine is a business, and it does cost, and to the extent they know what it costs, they can work with their doctor to minimize costs and yet maximize quality of care," said Blackman. "For once we are not being kept clueless," said patient Maisha Pajardo. Pajardo says patients can comparison shop. "I think it's great when the consumer has all the information up front, especially when they are paying for their own bills and their own health care," she said. Which is happening more and more, either because patients have no insurance, or employers are pushing medical costs off on them with higher deductibles and co-payments. "If you know what the price is, then you can plan for that in your budget," said patient Sandy Britton. In the past, doctors considered listing prices crass commercialism, until big pharmacy chains, even Target, started offering routine medical services and listing flu shot prices right along with toothpaste and T-shirts. Still, some doctors say it's a good idea but ... "If patients begin to focus just on price, then they may forego certain preventative services or little problems that might become big problems and that in the long run may drive up the cost of health care," said Dr. Rick Kellerman, president of the American Academy of Family Physicians. The California doctors see price listing as a booster shot for an ailing medical system, and predict doctors around the country will soon agree that giving patients the cure and the cost is the right prescription.
Defensive Medicine: Cautious Or Costly?

RICHMOND, Va., Oct. 22, 2007
(CBS) It started as a simple stomach ache, but Alexandra Varipapa, a sophomore at the University of Richmond, decided to go to the emergency room. There, doctors ordered a full CT scan, a radiation imaging test, which found a harmless ovarian cyst. She never questioned the CT scan, CBS News correspondent Wyatt Andrews reports. But her father did - when he got the $8,500 bill, $6,500 of which was that CT scan. “I was pretty flabbergasted,” said Robert Varipapa, himself a physician. Varipapa says his daughter's pain could have been diagnosed far more easily and cheaply with a $1,400 ultrasound. “A history, a pelvic examination and probably an ultrasound,” he said. And he would have started with the ultrasound. But the hospital defends the CT scan, saying an ultrasound might have missed something more serious. “It would not have ruled out appendicitis obviously, it would not have ruled, necessarily, out a kidney stone,” said Dr. Bob Powell, ER medical director of Bon Secours St. Mary’s Hospital. Varipapa agrees, but asks why not start simple - and do the CT scan only if necessary? “Well it's my opinion this is defensive medicine,” Varipapa said. Defensive medicine is what happens when doctors order too many tests because they are afraid of missing a diagnosis and later losing a multi-million dollar lawsuit for malpractice. Defensive medicine these days is so pervasive, some estimate its yearly cost at more than $100 billion. Dr. Kevin Pho runs the popular medical blog, Kevin M.D., where doctors routinely confess exactly how they run up costs by practicing defensive medicine. “Defensive medicine is bad medicine,” Pho said. In a post, one ER doctor says he's just admitted two patients to the hospital - when he was sure "neither was having cardiac (problems), but what am I to do?" Another admits that in his practice, “every patient with a headache gets a (CT) scan.” “It's much easier to defend the fact that you ordered a test than it is to not order the test at all,” Pho said. And the costs of defensive medicine today are increasingly paid by patients, even those with insurance - because of rising deductibles and co-payments. “There’s no doubt in my mind this is a significant driver in health care costs today,” Pho said.
Twist and Ouch

Not long after a typically underwhelming showing by the British contingent at the Wimbledon championships in July, the British Journal of Sports Medicine published the results of a study that suggested to beleaguered English tennis fans that things are only going to get worse. In the study, researchers from the Royal National Orthopaedic Hospital scanned the spines of 33 elite adolescent tennis players, male and female, who trained at the National Tennis Centre, the club of choice for Britain’s most promising young prospects. None of the players had reported back pain. But their backs, it turned out, were a mess.
Twenty-eight of the teenagers — 85 percent — were found to have serious spinal abnormalities, ranging from cysts to fractures. Twenty-three had early-stage joint disease and 13 had herniated discs or desiccated, shriveled discs, common in septuagenarians but much less prevalent in teenagers. These kids, the cream of the next generation of British tennis, had backs 60 years older than they were.
“Tennis requires more frequent, repetitive and rapid rotation from the lumbar spine than other sports,” the authors wrote. Playing it is particularly detrimental “during the growth spurt.” High-level tennis, in other words, can be brutal on the young.
But as many of us know from debilitating firsthand experience, back problems don’t afflict just teenage tennis players. According to various studies, at least a third of all competitive football players will hurt their lower backs during play, as will a third of gymnasts and 25 percent of serious rowers. About 40 percent of divers will develop a spinal stress fracture, and many cyclists will experience constant, grinding back pain while riding. In one study, six out of seven rhythmic gymnasts — those madly grinning ribbon twirlers — reported severe lower back problems. The harshest sport, however, seems to be golf. Ninety percent of injuries to professional golfers involve the lower back and the neck, and almost 80 percent of professionals will miss at least one tournament because of back pain.
If you’re a runner, do a backbend of thanksgiving: runners statistically have a lower risk than most athletes of developing back problems. But for everyone else, the news is . . . painful. So what, if anything, can you do to preserve and protect your spine?
To build a better back, most experts agree, you need a solid core. “The core” is one of those areas of the body that coaches and athletes refer to constantly but few people can accurately locate. “It’s not just the abdominal area, as many people think,” says Vijay Vad, a sports medicine specialist at the Hospital for Special Surgery in New York City and a back-care adviser to the PGA Tour and the professional men’s tennis circuit. “To really include all of the elements that move and stabilize the spine, you have to go from your knees to your nipples. That’s the core.”
The muscles, ligaments and tendons that make up the elaborate core muscle system provide rigging for the spine. The rectus, transverse and oblique abdominals, for instance — the big muscles at the front and sides of the spine — are particularly important in stabilizing the back. So are the less familiar intertransversi, interspinalis and multifidus muscles, which link to the larger abdominal group but which rarely figure in magazine articles about washboard abs. Each of these muscles must be strong and supple if the spine is to remain stable.
Endurance is important, too. It’s perhaps the most crucial element of core health, since it keeps the stabilizing muscles and connective tissues going through a long workout or game. “You have to have enough muscular endurance to be able to maintain spinal stability throughout the entire length of an activity,” says Michael Higgins, the director of athletic-training education at Towson University in Maryland and the author of several prominent academic articles about back injuries in athletes. “Without endurance, what you often see is that near the end of a game, the muscles can’t quite control the movement of the spine adequately anymore.” Whether you’re playing four quarters of football, three sets of tennis, 18 holes of golf or riding 100 miles on a bike, if your core can’t keep up, your back is sure to let you know about it.
Many lower back problems are caused by the very athleticism that modern sports demand. “The forces involved in sports nowadays are enormous,” Higgins says. “What you see in some of these sports are very powerful athletes creating high levels of extension and compression of the spine.”
Consider the forces applied to the lower back during certain activities: The torque created by a proper golf swing can produce almost 1,700 pounds of pressure on the lower spine. Rowers can put about 1,300 pounds of pressure on their backs at the catch of their stroke. And the “peak compressive load,” as the scientific parlance goes, created by a football lineman slamming into his opponent can be close to 2,000 pounds.
Often, the muscles that produce such power are accompanied by a relative weakness and inflexibility — ever see a lineman touch his toes? — in muscle groups not being used. Sprinters, for instance, tend to have mountainous quadriceps but weaker, tighter hamstrings. The hamstrings, which, like the quads, are tied into the lumbar spine system, can’t balance the force being produced by stronger muscles. As a result, the spine loses stability.
Something similar occurs in golfers, especially the good ones. “If you’re a bad golfer, like me, and you use your shoulders to power the swing, instead of your back, you probably won’t hurt yourself,” says Christopher Bono, an assistant professor of orthopedic surgery at Harvard Medical School and the chief of spine services at Brigham and Women’s Hospital in Boston. “If, though, you’ve got a good swing, you’re probably going to hurt your back.”
Just ask Arron Oberholser, the PGA Tour golfer who has ranked as high as 22nd in the world but who has also, at the advanced age of 32, endured multiple ruptured discs in his lower spine.
“I thought a couple of times that my career might be over,” he says. “There seems to be something about the repetitive golf swing that primes you for this injury.”
Power and consistency, in other words, can be your back’s undoing. “Strength, by itself, is not the answer,” Higgins says. As the authors of the British study pointed out, those young tennis players were strong. But they were strong only in terms of their tennis muscles, particularly those in the shoulders. Compared with their counterparts in other national junior programs, British players rarely visit the weight room. They typically don’t stretch or cross-train. Instead they hit and hit and hit, repetitively, propulsively, their strokes becoming faster and sharper, even as their backs insidiously break down.
Having a strong back, you will be happy to hear, means not doing sit-ups. Ever. “Sit-ups are not healthy for the back,” Higgins says. “They can severely compress the lumbar spine.”
Abdominal crunches, on the other hand, in which you raise your head and trunk slightly from the ground without pulling yourself upright, improve back health significantly. “Crunches build core endurance and strength without stressing the spine,” Higgins says.
A complete back-health exercise regimen must include more than crunches, of course (see sidebar, right). “You need to activate and strengthen all of the muscles that circle the spine like a belt,” Higgins says. You can do this by slightly contracting your abdominal muscles during workouts. Don’t suck in your gut; that narrows the band of support around the spine. “You only need to contract the abdominal muscles by about
10 percent to get the spinal benefits of the abdominal bracing,” Higgins says.
Don’t forget flexibility, either. In 2004, Vad and other researchers led a study of 42 professional golfers and found that those with the smallest range of motion in their lead hip and lower back had the highest frequency of back pain. “If you have a loss of flexibility in the hips, the back will take up the slack and absorb more of the pressures of the swing than it should,” Vad says. “Yoga, Pilates, dance — they’re all good for core flexibility.”
If your back aches for more than a few weeks, or if the pain is acute or radiating, visit a doctor. “Most back injuries will clear up on their own within six to eight weeks, if you rest adequately,” Vad says. “Surgery is very rarely necessary, maybe in 3 to 5 percent of cases.”
Finally, don’t despair if your back hurts. For many athletes, pain has been a necessary prelude to wisdom. “Before my back injuries, I really thought this golf thing was so easy,” Oberholser says, almost wistfully. “I thought, ‘I can do this into my 50s, no problem.’ ” Now, after reinjuring his back yet again last spring, he’s in the midst of an elaborate overhaul of his swing mechanics, his strength training, his posture — in short, his entire game. “I’m being a lot more careful than I used to be,” he says. “I’m doing the exercises, following the advice. I’m really optimistic about next season, but cautious, too. I’ve learned that you have to take care of your back, because, otherwise, boy, it’ll take you down with you if it goes out.”
The best exercises for strengthening your back
Entire books have been devoted to workout routines for the back. But you can save yourself some trouble by focusing on these three exercises, which work most of the large muscles in the body’s core. Do them four times a week, breathing slowly and steadily throughout.
Lie on your back with your knees bent. Slide your hands under your lower back to provide support; you don’t want your spine flat against the floor. Straighten one leg. Then, while keeping your neck and lower spine straight and unmoving, lift your shoulders and chest off the floor. Hold the position for about eight seconds. Repeat 10 times, then switch legs and do another 10.
Lie on your side, with your legs bent at the knee and your upper hand across your chest. Bend your lower arm so that your elbow is pointing away from your chest. Slowly raise your shoulders, keeping your spine straight, and hold for 8 to 10 seconds. Repeat on the other side. After a few weeks, do the exercise with your legs straight.
Start on all fours, then slowly lift your right arm and left leg until each is parallel to the ground. Hold for eight seconds. Repeat with the opposite arm and leg. Do 10 reps on each side. Keep your spine straight, hips level and abdominal muscles slightly contracted. And don’t forget to breathe. — G.R.