Time spent on meaningful pursuits may cut risk of physician burnout

Faculty physicians at academic medical centers may be less likely to experience burnout if they spend at least one day per week on the aspect of their work that is most meaningful to them, according to a report in the May 25 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.

26 may 2009--"Physicians are responsible for caring for the nation's sick, promoting the public health, advancing the science of medicine and passing the torch of knowledge to the next generation of physicians," the authors write as background information in the article. "Unfortunately, despite the value and importance of these pursuits, an expanding body of literature reports growing personal distress among physicians and a decrease in their satisfaction with the practice of medicine. Specifically, numerous studies have documented high rates of burnout and poor mental health among U.S. physicians and have suggested that physician distress can have a profound impact on patient quality of care as well as on a physician's personal health."

In addition to factors affecting all physicians, such as increased administrative work and less time with patients, academic faculty must navigate a variety of requirements that compete for their time. Each individual physician derives varying levels of satisfaction from these components, which include research, education and administrative responsibilities. To better understand how career fit—the extent to which an individual is able to focus on those aspects they find they most meaningful—influences burnout, Tait D. Shanafelt, M.D., and colleagues at Mayo Clinic, Rochester, Minn., conducted a survey of faculty physicians in the Department of Internal Medicine at a large academic medical center in the fall of 2007.

Of 556 physicians selected to participate, 465 (84 percent) returned surveys. When asked which aspect of work they found most meaningful, most (68 percent) reported patient care, whereas 19 percent selected research, 9 percent education and 3 percent administration. Overall, 34 percent of faculty members met criteria for burnout, which include emotional exhaustion, depersonalization and low personal accomplishment.

A total of 385 of 437 physicians (88 percent) spent at least 20 percent (about one day per week) of their effort on the activity they reported to be most personally meaningful; those who did had about half the rate of burnout as those who spent less than 20 percent of their time on this activity (29.9 percent vs. 53.8 percent). "The association between time spent in the most meaningful activity and burnout was strong and was the largest predictor of burnout on multivariate analysis after other factors were controlled for," the authors write.

"These findings have important implications for the administrative leadership and department chairs at academic medical centers. These centers are responsible for training the next generation of physicians, for serving as the primary origin of scientific discovery and advances in the fields of medicine and health care delivery, and for providing tertiary medical care to patients with complex and unusual health care problems. Their physician faculty is the most critical resource for academic medical centers to discharge these responsibilities to society," they conclude. "Efforts to optimize career fit may promote physician satisfaction and help to reduce attrition among academic faculty physicians."

(Arch Intern Med. 2009;169[10]:990-995. Available pre-embargo to the media at www.jamamedia.org.)

Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

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Editorial: Career Fit Should Be a Goal of Academic Leaders

"The high prevalence of burnout in the academic setting (34 percent of surveyed physicians) noted by Shanafelt and colleagues requires that we pay attention," writes Mark Linzer, M.D., from the University of Wisconsin, Madison, in an accompanying editorial. "In this issue of the Archives, Shanafelt and colleagues introduce a new method to prevent burnout: maximizing career fit. How well do physicians' career aspirations match their actual workday?"

"Determining the presence or absence of career fit in annual review meetings with faculty members is a necessary first step. Once we, as leaders, know what is required, we will need to find ways to finance the investment," Dr. Linzer concludes. "Although formal cost-effectiveness analyses have yet to be performed, Shanafelt and colleagues' data suggest that providing an additional 10 percent of time to allow faculty physicians to pursue their career goals could have strikingly positive consequences not only for the physicians and their families but also for their learners and potentially their patients as well as for the bottom line."

(Arch Intern Med. 2009;169[10]:927-928. Available pre-embargo to the media at www.jamamedia.org.)

Inner ear balance disorders common, associated with falls among older Americans

26 may 2009--An estimated 35 percent of U.S. adults age 40 and older have vestibular dysfunction (inner ear balance disorders), and those who do may have a higher risk of falling, according to a report in the May 25 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.

The vestibular system helps control an individual's balance, according to background information in the article. The two vestibular organs, within the temporal bone at the side and base of the skull, provide input to the brain about head motion and orientation relative to gravity. "Vestibular dysfunction is typically characterized by vertigo (i.e., an illusory sense of motion) and imbalance owing to disturbances in gaze and postural stability," the authors write. "In some cases, vestibular dysfunction can culminate catastrophically in a fall, which is associated with serious injury and restricted mobility and ranks among the leading causes of death among older individuals."

Despite these concerns, little has previously been known about the prevalence of vestibular dysfunction in the United States, in part because of the difficulty of diagnosis. Yuri Agrawal, M.D., and colleagues at the Johns Hopkins University School of Medicine, Baltimore, analyzed data from a nationally representative sample of 5,086 adults who participated in the 2001-2004 National Health and Nutrition Examination Surveys. Participants completed a balance questionnaire, which determined history of dizziness and falls, and underwent in-person balance testing that involved standing on different surfaces under varying conditions (for instance, with their eyes closed).

As determined by these tests, the overall prevalence of vestibular dysfunction in the U.S. population aged 40 and older from 2001 through 2004 was 35.4 percent. "Odds of vestibular dysfunction increased significantly with age, were 40.3 percent lower in individuals with more than a high school education and were 70 percent higher among people with diabetes mellitus," the authors write.

Individuals with vestibular dysfunction were more likely to report having dizziness and a history of falls. The 26.8 percent of participants who had symptoms of vestibular dysfunction, including dizziness, had an eight-fold increase in the odds of falling. Individuals who were asymptomatic also had significantly increased odds of falling. In addition, participants with vestibular dysfunction had an increased risk of hearing loss, which likely reflects the similar anatomic locations of the vestibular and hearing organs as well as their common blood supply.

"These findings suggest the importance of diagnosing and treating vestibular deficits to reduce the burden of fall-related injuries and deaths," the authors write. "Given the high prevalence of this impairment, notably among the elderly, and the extraordinary costs associated with falls (exceeding $20 billion annually), screening for vestibular dysfunction in assisted living or nursing home facilities, for example, could be a life-saving and cost-effective practice. Screening may be particularly effective in groups at heightened risk of vestibular dysfunction, specifically non-whites, individuals with less than a high school education, people with diabetes and the hearing impaired."

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(Arch Intern Med. 2009;169[10]:938-944. Available pre-embargo to the media at www.jamamedia.org.)

Hospice care under-used by many terminally ill patients, study finds

BOSTON, Mass., 26 may 2009— Hospice, a well-established approach to palliative care, has enabled countless people worldwide to die with dignity. Through focusing on the patient rather than the disease, individuals can spend the last weeks of their lives in an environment where hospice caregivers minimize their pain, maximize their comfort, and provide bereavement services for loved ones and family members.

A new study led by researchers at Harvard Medical School, however, found that only about half the patients diagnosed with metastatic lung cancer discuss hospice with their physician within 4 to 7 months of their diagnosis.

"Many terminally-ill patients who might benefit from hospice aren't discussing it with their physicians and may not be aware of the services hospice could offer," says Haiden Huskamp, lead author on the study and HMS associate professor of health care policy. Findings were published in the May 25 Archives of Internal Medicine.

Through the Cancer Care Outcomes Research and Surveillance Consortium, the researchers surveyed 1,517 patients diagnosed with metastatic lung cancer. For reasons not clear, blacks and Hispanics were less likely to discuss hospice than whites and Asians. Forty-nine percent of blacks and 43 percent of Hispanics discussed hospice with their doctors; for whites and Asians the percentages were 53 and 57, respectively. Married people were also less likely than unmarried people to have this discussion (51 percent compared with 57 percent, respectively).

In general, the longer patients expected to live after their diagnosis, the less likely they were to have explored hospice care with their doctor. However, the researchers also found that patients tended to overestimate how long they had to live. For example, about 30 percent of the patients thought that they would live up to two years. In reality though, only about 6 percent of patients with metastatic lung cancer will survive that long.

What's more, patients who preferred care that eased their pain and suffering at the end of life over care that extended life (roughly 50 percent of patients) were no more likely to have discussed hospice than patients who had the opposite preference.

"These conversations can be difficult for everyone involved—patients, families, and physicians," says Huskamp. "But discussing prognosis and end-of-life care options in advance is essential to make sure that patients receive care that reflects their wishes."

"Patients with advanced lung cancer understandably hope that cancer treatments can extend their lives," notes John Ayanian, senior author on the study and HMS professor of medicine and health care policy. "When these treatments are no longer working, their doctors have an important role to play in offering them hospice care that will ease their symptoms as they approach the end of life."

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This study was funded by the National Cancer Institute.

Written by David Cameron

Full citation

Archives of Internal Medicine, May 25, Vol 169, number 10

"Discussions with Physicians about Hospice among Patients with Metastatic Lung Cancer"

Haiden A. Huskamp, Ph.D., Nancy L. Keating, M.D., M.P.H., Jennifer L. Malin, M.D., Ph.D., Alan M. Zaslavsky, Ph.D., Jane C. Weeks, M.D., M.Sc., Craig C. Earle, M.D., Joan M. Teno, M.D., M.S., Beth A. Virnig, Ph.D., M.P.H., Katherine L. Kahn, M.D., Yulei He, Ph.D., and John Z. Ayanian, M.D., M.P.P.

Scientists find shared genetic link between the dental disease periodontitis and heart attack

26 may 2009--Vienna, Austria: The relationship between the dental disease periodontitis and coronary heart disease (CHD) has been known for several years. Although a genetic link seemed likely, until now its existence was uncertain. Now, for the first time, scientists have discovered a genetic relationship between the two conditions, a researcher told the annual conference of the European Society of Human Genetics today (Monday 25 May).

Dr. Arne Schaefer, of the Institute for Clinical Molecular Biology, University of Kiel, Germany, said that his team had discovered a genetic variant situated on chromosome 9 which was shared between the two diseases. "We studied a genetic locus on chromosome 9p21.3 that had previously been identified to be associated with myocardial infarction, in a group of 151 patients suffering from the most aggressive, early-onset forms of periodontitis, and a group of 1097 CHD patients who had already had a heart attack. The genetic variation associated with the clinical pictures of both diseases was identical," he said. The scientists went on to verify the association in further groups of 1100 CHD patients and 180 periodontitis patients.

"We found that the genetic risk variant is located in a genetic region that codes for an antisense DNA called ANRIL", said Dr. Schaefer, "and that it is identical for both diseases."

When a gene is ready to produce a protein, the two strands of DNA in the gene unravel. One strand produces messenger RNA, and will express a protein. Antisense RNA is complementary to the mRNA, and is often carried by the reverse strand, the 'anti-sense' strand of the DNA double helix. This strand does not encode for a protein, but can bind specifically to the messenger RNA to form a duplex. Through this binding, the antisense strand inhibits the protein expression of the mRNA .

Coronary heart disease is the leading cause of death worldwide, and periodontitis, which leads to the loss of connective tissue and the bone support of teeth, is the major cause of tooth loss in adults over 40 years. Periodontitis is very common, and around 90% of people aged over 60 suffer from it. Research has already shown a genetic basis for both diseases.

"We intend to push ahead with our work to try to understand more about the function of this RNA molecule and the pathway in which it operates in healthy gums and also in periodontitis. In the meantime, because of its association with CHD, we think that periodontitis should be taken very seriously by dentists and diagnosed and treated as early as possible", said Dr. Schaefer.

Both CHD and periodontitis are propagated by the same risk factors – most importantly smoking, diabetes and obesity – and there is also a gender relationship, with men possibly more liable to these diseases than women. Researchers have also shown similarities in the bacteria found in the oral cavity and in coronary plaques, and both diseases are characterised by an imbalanced immune reaction and chronic inflammation.

"These factors already indicated a possible mutual genetic basis underlying the two diseases", said Dr. Schaefer. Now we know for sure that there is a strong genetic link, patients with periodontitis should try to reduce their risk factors and take preventive measures at an early stage", he said. "We hope that our findings will make it easier to diagnose the disease at an early stage, and that in future a greater insight into the specific pathophsyiology might open the way to effective treatment before the disease can take hold."

Low Vitamin D Levels May Initiate Cancer Development

26 may 2009 -- Low levels of vitamin D may contribute to cancer development, U.S. researchers have found.

"The first event in cancer is loss of communication among cells due to, among other things, low vitamin D and calcium levels," study leader Cedric Garland, an epidemiologist at the Moores Cancer Center at the University of California, San Diego, said in a university news release.

Garland and colleagues developed a scientific model that suggests "this loss may play a key role in cancer by disrupting the communication between cells that is essential to healthy cell turnover, allowing more aggressive cancer cells to take over."

This cellular disruption could account for the earliest stages of many cancers, according to the study, which was published online in the Annals of Epidemiology.

Maintaining adequate levels of vitamin D may help stop cancer development, Garland suggested.

"Vitamin D may halt the first stage of the cancer process by re-establishing intercellular junctions in malignancies having an intact vitamin D receptor," Garland said.

He noted that appropriate vitamin D levels can be restored and maintained through diet and supplements. More research into the link between vitamin D and cancer is required, but Garland recommended that people get their vitamin D levels tested during annual check-ups.

More information

The Office of Dietary Supplements at the U.S. National Institutes of Health has more about vitamin D.

Older Adults Often Inaccurately Report Their Own Stroke History

25 may 2009--The responses of older adults who are asked whether they had a stroke frequently do not agree with diagnoses obtained by magnetic resonance imaging (MRI) of the brain, according to a report posted online today that will appear in the July print issue of Archives of Neurology, one of the JAMA/Archives journals.

Self-administered questionnaires are frequently used to obtain information about an individual's history of stroke, according to background information in the article. "In general, self-reports on medical conditions that are well defined and relatively easy to diagnose often have a high positive predictive value, in contrast to conditions characterized by complex symptoms," the authors write. "Stroke is associated with motor impairment but can also be accompanied by impairments in memory, sensation and speech or language, diminishing the ability of an individual to accurately report a history of stroke."

Christiane Reitz, M.D., Ph.D., of Columbia University Medical Center, New York, and colleagues acquired MRIs for 717 Medicare recipients 65 years and older (average age 80.1) living in northern Manhattan. Participants underwent an in-person interview about general health and functioning, medical history, a physical and neurological examination and psychological testing. They or their caregivers also completed an eight-question survey about stroke history, including whether they had ever had symptoms of or been told by a physician they had a stroke.

A total of 85 individuals (11.9 percent) reported a history of stroke. On the MRI, evidence of a stroke was observed in 225 participants (31.4 percent). The sensitivity of self-reported stroke-meaning number of individuals who reported having had a stroke divided by the total number of individuals with stroke detected on MRI-was 32.4 percent. The specificity, or the number of individuals who reported having no history of stroke divided by the total number of individuals who had no evidence of stroke on MRI, was 78.9 percent.

"Lower-functioning memory, cognitive or language ability or presence of hypertension [high blood pressure] or myocardial infarction [heart attack] were associated with an increased frequency of false-negative reports," the authors write.

In addition, younger individuals were more likely to accurately report their stroke history than older adults, and sensitivity was higher among African American than white or Hispanic individuals. Older adults may have more difficulty recalling prior events, contributing to lower sensitivity, the authors note. Rates of cerebrovascular disease are higher among African Americans, so individuals in this population may have an increased awareness of stroke signs and symptoms due to previous discussions with clinicians or contact with individuals who have had strokes.

"Our results indicate that sensitivity and specificity of stroke self-report are low when using MRI scans as validation," the authors conclude. "In stroke research, sensitive neuroimaging techniques rather than stroke self-report should be used to determine stroke history."

Arch Neurol. 2009;66[7]:(doi:10.1001/archneurol.2009.83

Source
Archives of Neurology

Age-Related Eye Disease May Be Associated With Cognitive Impairment

25 may 2009--Older adults with low scores on tests of cognitive function, including thinking, learning and memory appear more likely to have the early stages of the eye disease age-related macular degeneration, according to a report in the May issue of Archives of Ophthalmology, one of the JAMA/Archives journals.

Age-related macular degeneration (AMD)-the leading cause of visual impairment in industrialized nations-has long been thought to share a common pathway with Alzheimer's disease, according to background information in the article. First, both conditions involve similar changes in the brain and eye, including the buildup of protein fragments known as beta-amyloid. "Second, clinical studies suggest that AMD and Alzheimer's disease share similar vascular risk factors, such as hypertension [high blood pressure] and cigarette smoking," the authors write. "Both AMD and Alzheimer's disease have been linked to an increased risk of stroke."

Michelle L. Baker, M.D., of the University of Melbourne, Victoria, Australia, and colleagues assessed 2,088 individuals age 69 to 97. Participants underwent cognitive testing, retinal photography for the detection of AMD and an extensive assessment of artery disease and its risk factors (including blood pressure, smoking status and body mass index).

After controlling for age, sex, race and the center at which they participated in the study, the one-fourth of individuals with the lowest scores on one cognitive test were twice as likely to have early-stage AMD as were individuals with higher scores. However, there was no association between AMD and scores on a second cognitive test, dementia or Alzheimer's disease.

"In conclusion, we found an association between low cognitive function and early AMD in this older population," the authors write. "These data, along with others, provide further support that AMD and cognitive impairment may share similar complex pathogenesis [development] and risk factors."

Arch Opthalmol. 2009;127[5]:667-673.

Elderly Persons Living With A Spouse Report Better Preventive Care Use Than Those Living Alone Or With Children

25 may 2009--Elderly persons living with a spouse have more timely preventive service use than those living alone or with offspring. The sole exception is in the case of hypertension screening.

Data were taken from 13,038 community-dwelling elderly persons who participated in the 2002 to 2005 Medical Expenditure Panel Survey.

The study's authors estimated the likelihood of preventive care use among elderly persons in four living arrangements: living with one's spouse only (52 percent), living alone (38 percent), living with one's spouse and with one's adult offspring (5 percent), and living with one's adult offspring (5 percent).

Preventive services included influenza vaccination; physical and dental checkups; and screenings for hypertension, cholesterol and colorectal cancer.

"Educational Outreach interventions should target not only those elderly adults who live alone but also those living with adult offspring" the authors said.

"The Relationship Between Living Arrangement and Preventive Care Use Among Community-Dwelling Elderly Persons."

Source
American Journal of Public Health

Dying At Home: A Trend That Could Make Hospitals More Efficient

25 may 2009--Hospitals across Canada are seeking ways to free up beds. University of Alberta researcher Donna Wilson has a suggestion: people should be encouraged to die at home rather than in hospital.

She looked at statistics dating back to 1950 and has found that there's been a dramatic change in the location of death of Canadians. Up until 1994, about 80 per cent of people dying each year were passing on in hospital. Now that number is down to 61 per cent, and Wilson is hoping the trend continues.

She'd like to see only 40 per cent of people passing on in hospital because, with an aging baby boom population, this could reduce wait lists and free up hospital beds for those who need life-saving treatment or surgery. In most cases, she says, it's also a much more dignified death for a family member.

Wilson says in the next 20 years the number of people dying could double and if death rates in hospital stay at 80 per cent. those numbers mean a potential tie-up of every single bed in Canada for three days of the year, because each person takes up a bed for an average of 10 days.

The professor in the Faculty of Nursing wants to see governments put more money into developing hospices, nursing homes and training for home care.

Source:
Quinn Phillips
University of Alberta

SUNSHINE "THE KEY TO LONG LIFE"

24 may 2009--The Daily Telegraph has claimed that “sunbathing could help older people reduce the risk of developing heart disease and diabetes”, while the Daily Express says that “sunshine can add years to your life”. The Express bases its claims on a study that found that “exposure to sunlight stimulates vitamin D in the skin”.

It is already well established that the skin produces vitamin D through exposure to sunlight, as well as through diet. This Chinese study reported in the newspapers did not assess exposure to sunlight, but observed low vitamin D levels in a middle-aged to elderly population and found they were associated with a combination of conditions that increase the risk of diabetes and heart disease. However, this study did not actually assess reasons for these low vitamin D levels and many features of the study limit its interpretation.

Based on this research, it is a great jump to conclude that increasing your exposure to sunlight will reduce your risk of developing these diseases or even prolong your life. The dangers of extensive exposure to sunlight are well known, and this study should not be taken as a reason to start sunbathing.

Where did the story come from?

This study was conducted by Oscar Franco and colleagues of Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences and Graduate School of the Chinese Academy of Sciences, Shanghai. The research was funded by Chief Scientist Program of Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences and other Chinese development funds. The study was published in the peer-reviewed medical journal Diabetes Care.

What kind of scientific study was this?

This was a cross-sectional study that examined the link between levels of a form of vitamin D and metabolic syndrome in the middle-aged to elderly Chinese population. Metabolic syndrome (MetS) is a group of conditions that increase the risks of developing cardiovascular disease, diabetes and liver disease. The conditions making up metabolic syndrome include high blood pressure, being obese or overweight, glucose intolerance, raised cholesterol and fatty liver.

The conditions comprising MetS, which is increasingly becoming a global health problem, have previously been noted to be associated with lower vitamin D levels. However, the reasons for this association are unclear, and to date there has been little evidence from Asian populations.

The research was part of the Nutrition and Health of Aging Population in China project, which involves a cross section of the Chinese population aged 50 to 70 years. The researchers recruited 3,289 participants (1,458 men and 1,831 women) and excluded those without adequate blood samples for vitamin D measurement, leaving 3,262 individuals.

Participants were interviewed on demographic details, education, smoking status, alcohol use and physical activity. They then received a physical examination calculating weight, height and blood pressure. Participants also self-reported diabetes, high blood pressure, lipid disorders, heart disease, stroke and medication use.

Based on the blood sample, vitamin D levels were classified as sufficient (above 75nmol/L), insufficient (50 to 75nmol/L) or deficient (less than 50nmol/L). MetS was determined according to threshold measurements of waist circumference, triglyceride and cholesterol levels in the blood, blood pressure (or use of blood pressure medications) and fasting glucose level (or use of diabetic medications or confirmed diagnosis of diabetes).

What were the results of the study?

In the population sample, 69.2% were deficient for vitamin D, 24.4% insufficient and 6.4% sufficient. The average vitamin D level of the whole sample was only 40.4nmol/L. The odds of having MetS were increased by 52% for the group with the lowest levels of vitamin D (below 28.7nmol/L) compared to in the group with the highest levels (above 57.7nmol/L) (odds ratio 1.52, 95% confidence interval 1.17 to 1.98).

The researchers also noted individual associations between certain components of metabolic syndrome and vitamin D level.

What interpretations did the researchers draw from these results?

The researchers conclude that vitamin D deficiency is common among middle-aged and elderly people of the Chinese population. They note that a low vitamin D level was associated with having metabolic syndrome.

What does the NHS Knowledge Service make of this study?

This large population study has observed an association between having a low vitamin D level and metabolic syndrome, which increases the risk of heart disease and diabetes.

It is a great leap to conclude from the findings of this study that exposure to sunlight will help to reduce the risk of heart disease and diabetes, or even prolong your life, as some newspapers have claimed. Indeed, the study did not explore the reasons why the population sample actually had low vitamin D, or look into whether increasing vitamin D level would have any effect on improving risk of heart disease or diabetes or duration of life.

While the Daily Express has made a front-page claim about the benefits of sun exposure, it is particularly worth noting that this factor was not assessed in any part of this study. The dangers of extensive exposure of the skin to sunlight are well known, and this study does not support sunbathing.

There are several important points to note when interpreting this study:

• The sample population had low vitamin D levels overall, with an average level of only 40.4nmol/L compared to a desirable level of 75nmol/L. The levels found are generally considered to be inadequate for overall health, and 94% of subjects would be considered to have either vitamin D deficiency or insufficiency.
• The reasons for the low vitamin D levels found in this research remain unclear, and might result from low dietary intake, low sun exposure or some other reason. As this study only took a single blood sample, it is possible that these results may not reflect the vitamin status of the participants over time.
• Being a cross-sectional study, it cannot prove causation, as it cannot establish that the vitamin deficiency was present before the onset of MetS. It may be, conversely, that the bodily changes associated with the conditions of MetS (for example, obesity, raised blood pressure and glucose) have contributed to the body becoming deficient in vitamin D for various unexplored reasons, or that the two observations are related to some other factor (for example, poor diet).
• Although the laboratory measures and clinical examinations performed at the time of assessment will have increased the reliability of diagnoses, the self-reported measures of health (including self-reported diagnoses of previous heart disease, stroke or diabetes) may have led to misclassification of whether or not people had MetS.
• As the study involves a Chinese population, cultural, ethnic and lifestyle differences mean that findings may not be easily extrapolated to other populations and ethnic groups.

Although there may be an association between vitamin D levels and metabolic syndrome, it is worth remembering that diabetes and heart disease are complex conditions determined by a number of medical, genetic and lifestyle-related factors. Sun exposure is not a single solution to these problems.

As the researchers themselves conclude, further study is needed to examine the physiological reason for the observed association between vitamin D and metabolic syndrome.

Links to the headlines

Sunshine can add years to your life. Daily Express, May 18 2009

Elderly need more 'sun vitamin'. BBC online, May 16 2009

Sunshine 'can help you live longer by cutting risk of heart disease and diabetes'. The Daily Telegraph, May 18 2009

Links to the science

Lu L, Pan AN, Hu FB et al. Plasma 25-hydroxyvitamin D Concentration and Metabolic Syndrome among Middle-aged and Elderly Chinese. Diabetes Care [Published online ahead of print]

THE THREE MINUTE PROSTATE TEST

24 may 2009--A three-minute test to diagnose prostate cancer “could save thousands of lives a year”, the Daily Express has said. The technique mixes a small amount of prostate gland fluid with a light-emitting chemical. The amount of light produced indicates levels of the natural substance citrate found in the fluid. Lower citrate levels are found in prostate cancer tissue than in normal prostate tissue.

This research is at a very early stage. Although the new method was able to measure the level of citrate in small amounts of prostate fluid, it has so far only been tested on samples from a small number of healthy men, and not men with prostate cancer.

Also, although other studies have shown that citrate is reduced in men with malignant prostate cancer, this method will now need to be tested further to see if it can accurately differentiate between prostate fluid from men with cancer and healthy men. If successful in such studies, the technique would need to be compared with established methods for detecting prostate cancer. It is too early yet to know whether this method will be effective for the detection or monitoring of prostate cancer, whether it will save lives or how much it would cost.

Where did the story come from?

Dr Robert Pal and colleagues from Durham University and the University of Maryland carried out this research. The study was funded by a number of organisations including the Engineering and Physical Sciences Research Council, the National Institutes of Health in the US, the Diagnostic Molecular Imaging research group and The Royal Society. The study was published as a communication in the peer-reviewed scientific journal Organic & Biomolecular Chemistry.

What kind of scientific study was this?

This was a laboratory study aimed at developing a test for measuring levels of two chemicals called lactate and citrate in bodily fluids.

The authors report that citrate levels are consistently lower in malignant prostate cancer tissue and, therefore, measuring levels of this chemical could be useful in screening for prostate cancer and monitoring progression of the disease. Citrate is a natural chemical produced and broken down in our cells as part of energy production. Lactate is another natural chemical, produced when our cells use glucose in conditions of no or low oxygen. Measuring lactate is important in sports medicine and in other medical situations.

The researchers wanted to develop a method of measuring lactate and citrate that would work on small amounts of biological fluids such as blood, urine, prostate fluid or semen.

They developed a method based on the reversible chemical binding of lactate and citrate (which are negatively charged molecules) to light-emitting compounds based on the element europium (Eu). These light emissions change when the light-emitting compounds bind to citrate and lactate.

The researchers made a number of salt solutions containing varying lactate and citrate levels, and mixed them with the europium compounds, looking at how their light emissions (luminescence) changed with each chemical. They also repeated this test using a simulated prostate fluid solution containing lactate, citrate and various salts and proteins, which was similar in chemical composition to real prostate fluid.

The researchers also used these tests to determine how strongly lactate and citrate bound to slightly different europium compounds. The researchers selected the compounds that performed the best in these tests to take forward to testing with biological fluids: one compound that bound to citrate much better than to lactate and one that bound to lactate much better than citrate.

The researchers mixed solutions with increasing concentrations of lactate or citrate in the simulated prostate fluid and measured the changes in light emission when these were added to the europium compounds. This allowed them to plot a graph showing how light emission changed in relation to increasing concentrations of lactate or citrate. This graph could be used to estimate concentrations of lactate or citrate in other solutions.

In order to test this, the researchers took samples of urine, seminal fluid (the fluid component of semen), prostate fluid, serum (the fluid component of blood) and saliva, measuring the levels of lactate using established methods. They then tested the lactate levels in these fluids using their light emission methods, and compared results. Similar experiments were performed using the europium compound that bound tightly to citrate to measure citrate concentrations.

The researchers then took 17 samples of prostate fluid from healthy male volunteers and measured the levels of citrate in these samples using established methods. These methods used 25 times the volume of fluid than was needed in the new test, which typically used a one-microlitre sample. The samples were then assessed using the new europium citrate test. The new and established tests were also used to determine levels of citrate in urine from healthy volunteers.

What were the results of the study?

The researchers found that their light emission test gave lactate concentrations in the biological fluids tested (urine, seminal fluid, prostate fluid and serum) to within 10% of the measurements taken with established methods. The test correctly identified the absence of lactate in saliva.

The new test also managed correctly to determine the levels of citrate in the prostate fluid of 17 healthy male volunteers, accurate to within 10% of the measurement using established methods. Similar results were found when comparing the new and established tests for measuring citrate levels in urine.

What interpretations did the researchers draw from these results?

The researchers conclude that they developed a rapid (less than five minutes) luminescence test to determine the concentration of citrate or lactate in small volumes of biological fluids.

They say that, in the case of citrate, the level of this chemical could be used to “confirm or indicate the onset or progression” of prostate cancer.

What does the NHS Knowledge Service make of this study?

This research is at a very early stage, and although the test has been able to measure the level of citrate in small amounts of prostate fluid this was on samples from a small number of healthy men. The technique developed in this preliminary research will now need further testing to see if it can accurately differentiate between prostate fluid from healthy men and men with prostate cancer.

It will also be necessary to determine whether the method would be able to detect cancer at an early enough stage for treatment to be effective. Even after this, the method would also need to be compared with existing tests, such as the prostate specific antigen (PSA) test, to see how it compares.

It is too early as yet to know whether this test will be effective for the detection or monitoring of prostate cancer, whether it will save lives or how much it would cost.

Links to the headlines

New three minute test for prostate cancer. Daily Express, May 19 2009

Hope of fast prostate cancer test. BBC online, May 18 2009

Three-minute test for £10 offers new hope on prostate cancer. Daily Mail, May 19 2009

Three minute exam for prostate cancer 'could herald simple semen test'. The Daily Telegraph, May 19 2009

Links to the science

Pal R, Parker D and Costello LC: A europium luminescence assay of lactate and citrate in biological fluids. Org. Biomol. Chem., 2009, 7, 1525 – 1528

Further reading

Review by Cochrane:
Screening for prostate cancer

COULD BEING FAT BE GOOD FOR YOU

24 may 2009--Overweight heart attack victims should stay fat as they are more likely to live longer”, the Daily Mail reported. It said that the controversial claim that being fat can be useful for heart attack patients has come from a review published in a journal.

This news report is based on a review that looked at selected studies describing the ‘obesity paradox’. The paradox is that, in some studies, overweight people have a better survival rate after heart disease than those who are a normal weight. The review itself does not claim that staying fat is good for health, but describes a few studies that have shown trends in people who already have heart disease.

The ‘obesity paradox’ will need more systematic research. People who have had a heart attack are advised to enrol in cardiac rehabilitation programmes where they will receive a physical activity programme and advice on the ideal diet for preventing future heart problems.

Where did the story come from?

The research was carried out by Dr Carl J Lavie, Richard V Milani and Hector O Ventura from the Ochsner Medical Center in New Orleans, Louisiana. Funding for the study is not reported. The study was published in the peer-reviewed Journal of the American College of Cardiology.

What kind of scientific study was this?

In this review, doctors from a cardiac rehabilitation and exercise laboratory discuss the impact of obesity on the risk of heart disease, including heart failure (HF), coronary heart disease (CHD), sudden cardiac death and atrial fibrillation, and how it is associated with reduced overall survival. They also investigate a phenomenon they refer to as the “obesity paradox”, in which overweight and obese people have a better survival rate after heart disease than those who are normal weight or underweight.

The authors do not report the methods they used in this review, but do refer to 87 other papers on obesity, its harmful effects and the various biological mechanisms and hormones involved.

What were the results of the study?

The authors begin by discussing how obesity might have an effect on cardiovascular health. They suggest that the hormone leptin, which is produced by fat cells and controls food intake and energy metabolism, may be particularly related to heart disease. They also refer to studies that suggest that C-reactive protein, a marker of inflammation that is associated with an increased risk of major cardiovascular events, such as heart attacks, may also play a role.

The authors list the adverse effects that obesity has on blood pressure, the lipids (fats) in the blood, the metabolism of glucose, the heart muscle and the lining of the blood vessels, and how it has an association with sleep disorders, arthritis and cancer. They say that obesity has reached global epidemic proportions in both adults and children. They say that, due to the harmful effect it has on various heart disease risk factors, obesity is also strongly associated with diseases such as heart failure, coronary heart disease, sudden cardiac death and atrial fibrillation. In addition, obesity is associated with increased overall mortality.

The authors say that numerous studies have documented an “obesity paradox” in which overweight and obese people who already have heart diseases, such as high blood pressure, heart failure or heart attacks, have a better prognosis compared with non-overweight or non-obese patients. They say that high blood pressure usually leads to a thickening of the muscular walls of the heart without increases in the volume of the pumping chamber (ventricle). However, obesity is conversely associated with an increase in chamber dilation without marked increases in wall thickness.

They refer to several studies that illustrate the “obesity paradox”. One example they mention is a recent study of 22,576 patients with known heart disease and high blood pressure. The study found that, after two years, overweight and obese patients had 30% lower deaths from all causes. This was despite their blood pressure being less well controlled than the normal weight group. They also refer to similar findings from selected studies in people with heart failure and peripheral arterial disease (narrowing of the arteries in the legs). However, the authors say that the pattern was not seen in studies of people with stroke, irregular heart beats or sleep disorders, which are all conditions that increase the risk of death for the obese.

What interpretations did the researchers draw from these results?

The researchers say that “overwhelming evidence supports the importance of obesity” as a cause of and contributor to the progression of heart disease. They say that, although a paradox exists, the data still support “purposeful weight reduction in the prevention and treatment of CV diseases”.

What does the NHS Knowledge Service make of this study?

This narrative review gives the authors’ views and also gives a presentation of both sides of the debate from selected papers on the topic. The suggestion that obesity may be protective in some cases is not new, and has been highlighted previously. There are several points to note about this research:

• As a narrative review it is not clear how the referenced papers were selected and if all the research, positive and negative, has been systematically identified and evaluated. This would require a systematic review.
• Although some suggestions are made about how obesity might protect the heart, these biological mechanisms are not yet certain and more research will be needed.
• The review is mostly based on observational studies. These types of study are subject to confounding, which means that there may be other explanations for the improved survival of obese people with heart disease. For example, obese people may be preferentially referred for cardiac rehabilitation or treated more intensively because of associated risk factors such as diabetes.

As the authors confirm, more research is needed in all of these areas. They warn that, if the current obesity epidemic continues, “we may soon witness an unfortunate end to the steady increase in life expectancy”.

Links to the headlines

For heart survivors, a big waistline could be a lifeline. Daily Mail, May 19 2009

Links to the science

Lavie CJ, Milani RV, and Ventura HO. Obesity and Cardiovascular Disease. Risk Factor, Paradox, and Impact of Weight Loss. J Am Coll Cardiol, 2009; 53: 1925-1932

Further reading

Shaw KA, Gennat HC, O'Rourke P, Del Mar C. Exercise for overweight or obesity. Cochrane Database of Systematic Reviews 2006, Issue 4.

Summerbell CD, Waters E, Edmunds L, et al. Interventions for preventing obesity in children. Cochrane Database of Systematic Reviews 2005, Issue 3

BLOOD PRESSURE TABLETS SHOULD BE GIVEN TO ALL OVER 55

24 MAY 2009--Blood pressure drugs should be given to everyone over 55 to reduce heart attacks and strokes”, the Daily Mail has reported. The newspaper said the medication should be prescribed even if blood pressure is normal, as new research estimates that common drugs reduce risk of heart attack by a quarter and stroke by a third.

This research was a large, thorough analysis combining the results from a number of trials on blood-pressure-lowering treatments, looking at how medication affected risk of future stroke or heart disease events such as heart attacks. The trials featured data on nearly half a million patients, including people both with and without a history of cardiovascular disease, as well as people with a range of blood pressure levels. These trials collectively demonstrated a reduction in risk of coronary heart disease and stroke regardless of a patient’s history of these conditions or high blood pressure. Based on this, the authors suggest that blood pressure medications should be offered to all people above a certain age, regardless of blood pressure or pre-existing disease.

This was a well conducted study, but its results will need to be considered alongside other issues, such as potential harms, before any change to current treatment practice and recommendations is made.

Where did the story come from?

This research was conducted by Professors MR Law, JK Morris and NJ Wald of the Centre for Environmental and Preventive Medicine, Wolfson Institute of Preventive Medicine, Barts and The London School of Medicine.

No sources of funding were reported for the study, but two of the authors declared holding patents on the formulation of a combined pill to reduce simultaneously four cardiovascular risk factors, including blood pressure. The study was published in the peer-reviewed British Medical Journal.

What kind of scientific study was this?

This was a systematic review and meta-analysis designed to determine how effective different drugs for lowering blood pressure (BP) are for preventing coronary heart disease (CHD) and stroke, and to decide who should receive these treatments.

The researchers searched the Medline database for randomised controlled trials (RCTs) investigating BP-lowering drugs where CHD events (fatal or non-fatal heart attacks or sudden cardiac death) or strokes had been recorded. They included studies published from 1966 to 2007, and excluded trials where patients had kidney failure or where other drugs, such as cholesterol-reducing statin medication, were given as part of the intervention in addition to BP medications.

All RCTs had to have a treatment duration of greater than six months and at least five CHD events or strokes recorded in the study period. Trials could include participants of any age or disease status, and those with prior BP treatment or use of other medications.

From each study, the researchers recorded the number of participants who had a CHD event, stroke or new diagnosis of heart failure or worsening of existing heart failure. Changes in BP in the treated and control groups were also recorded.

The authors categorised the RCTs based on the type of participants recruited: those with no history of CHD or stroke, a history of CHD (heart attack, coronary artery disease without recent heart attack or heart failure) or a history of stroke. In trials where the participants had no history of CHD or stroke, they usually had high BP and were usually being treated to reach a target BP.

The authors also categorised trials into:

• ‘Blood pressure difference trials’, which aimed to achieve a difference in BP between those randomised to the study drug and those receiving control (placebo or non-treatment) and show the effect this had on the incidence of CHD events and stroke.
• ‘Drug comparison trials’, where two different BP-lowering drugs were compared, and the aim was not to demonstrate a difference in BP between the groups, but to look at other effects of the treatments.

The researchers pooled the results of the trials using meta-analysis. In their analysis they also looked at the effect that taking one or more BP drug had on CHD and stroke risk according to age group and pre-existing BP status. In order to estimate the possible effect of BP medications at different doses, the authors combined their results with the results from a meta-analysis of placebo controlled RCTs looking at the effects of different doses of BP drugs and with data from the largest meta-analysis to date of epidemiological cohort studies observing how blood pressure changes affected risk of CHD events and stroke.

What were the results of the study?

Of the selected RCTs:

• 108 were ‘blood pressure difference trials’ (248,445 subjects),
• 46 were ‘drug comparison trials’ (230,491 subjects), and
• seven fell into both of these categories.

The trials included a total of 464,164 people divided into the three categories. The trials covered a total of 22,115 CHD events and 12,034 strokes. The average age of participants across all trials was 64 years.

Looking at the blood pressure difference trials, beta-blocker drugs were beneficial for reducing BP compared to a control treatment, but also for reducing risk of a further CHD event in those with a prior history of CHD (across all groups they gave an overall 29% reduction in risk compared to 15% in other drugs trialled). However, this benefit was mainly in those who were taking the beta-blocker following a heart attack in the previous few years, for whom their risk reduction of another CHD event was 31%. This risk reduction was only 13% for those who had a history of CHD but had not had a recent heart attack. Beta-blockers gave no significant reduction in CHD risk for those with no history of cardiovascular disease.

In all blood pressure difference trials (excluding trials of beta-blockers in CHD patients), reduction in systolic BP by 10mmHg, or reduction in diastolic BP by 5mmHg, reduced overall risk of CHD events by 22% and risk of stroke by 41%.

All classes of BP-lowering drugs (beta-blockers, angiotensin converting enzyme (ACE)-inhibitors, angiotensin receptor blockers, calcium channel blockers and thiazides) had a similar effect in reducing risk of CHD events and stroke, although calcium channel blockers reduced risk of stroke more than the other drugs.

Across all classes of drugs, risk reduction for CHD events and stroke was found to be similar in those with a history of CHD or stroke and those without prior cardiovascular disease, and also regardless of the BP level prior to treatment. This risk reduction extended to individuals not classified as having high blood pressure. The meta-analysis additionally showed that risk of heart failure was reduced by 19% by calcium channel blockers and 24% by all other drugs.

The researchers combined their results with a previous meta-analysis of cohort studies and with trials determining BP-lowering effect of different doses of the same drug. From this they found that three drugs given in combination at half standard dose reduced the risk of CHD by about 46% and of stroke by about 62% in people aged 60 to 69 (the age group generally covered by trials) who had a pre-treatment diastolic BP of 90mmHg. One drug at standard dose reduced CHD and stroke risk by about half this amount.

What interpretations did the researchers draw from these results?

The authors conclude that all classes of BP-lowering drugs have a similar effect in reducing risk of CHD events and stroke in relation to a given reduction in blood pressure. Calcium channel blockers appear to be slightly more effective than other drugs in preventing stroke, and beta-blockers appear to have added benefit in reducing further CHD events when taken in the immediate post-heart-attack period. The reduction in CHD and stroke appears to be similar regardless of pre-treatment BP and the presence or absence of existing cardiovascular disease.

The authors say that their results highlight the importance of lowering blood pressure in everyone above a certain age, rather than measuring BP and only treating it if it is elevated.

What does the NHS Knowledge Service make of this study?

This was a large and thorough meta-analysis that has examined trials of blood-pressure-lowering treatments and evaluated how they affect future risk of heart disease events (such as heart attack) or stroke. The trials included both people with a history of cardiovascular disease and those without, as well as people with a range of pre-treatment blood pressure levels. Collectively, these trials have demonstrated a reduction in risk of CHD and stroke through use of any medication to lower blood pressure, regardless of prior history or existing blood-pressure levels.

As the authors say, the combined results of the blood pressure difference trials demonstrated that a 10mmHg reduction in systolic pressure or a 5mmHg reduction in diastolic pressure reduced risk of CHD by 22% and stroke by 41%. These findings are consistent with results of a previous large meta-analysis of cohort studies, in which similar blood pressure reductions resulted in CHD risk being reduced by 25% and stroke risk being reduced by 30%.

The results of this review point to there being a benefit of disease prevention through lowering blood pressure, and this benefit did not seem to be affected by blood pressure at the start of the trial. From this, the authors suggest that guidelines may need to be changed so that the reviewed medications are offered to all people above a certain age, regardless of blood pressure or pre-existing disease.

A few points to note include:

• Meta-analysis can involve combining results of trials with different methods, study populations, follow-up and measured outcomes. This can create some inaccuracy in the quantified risk estimates.
• As the authors mention, across all trials, 25% of those allocated to take the study medication discontinued their treatment, which will affect the accuracy of the estimated effect of the drugs.
• Although some trials did include people with normal BP, most participants with no history of cardiovascular disease had elevated BP. Therefore, the study does not include wide representation of healthy people with normal BP and no other risk factors for cardiovascular disease.
• In people without history of cardiovascular disease there was not always an observed benefit in risk reduction.
• All medications carry the risk of adverse effects, and this must be taken into account when considering offering medications to a whole age group, including those who may have other medical conditions or take treatments that would make anti-BP medication unsuitable.
• Blood pressure is not the only risk factor for heart disease or stroke. Genetic factors, gender, smoking, raised cholesterol, obesity and diabetes are all factors that contribute to disease risk, and prevention strategies would ideally take into account all of these factors.

These review findings will undoubtedly prove invaluable, and are likely to lead to further study and consideration of the current treatment and practice for these common, serious conditions.

Links to the headlines

Blood pressure drugs 'should be given to everyone over 55 to reduce heart attacks and strokes'. Daily Mail, May 20 2009

Blood pressure drugs reduce heart attack and stroke risk regardless of raised blood pressure. The Daily Telegraph, May 20 2009

Blood pressure pill action urged. BBC online, May 20 2009

Links to the science

Law MR, Morris JK and Wald NJ: Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. BMJ 2009; 338:b1665

Editorial citing study
McManus RJ and Mant J: Management of blood pressure in primary care. BMJ 2009;338:b940

MANAGING DIABETES CUTS HEART ATTACKS

24 may 2009--Tighter control of blood sugar levels in people with diabetes may cut their risk of heart problems,” BBC News has reported. The news service said a study pooling data on 33,000 people with type 2 diabetes has shown that intensive control of blood sugar cuts heart attacks by 17% and heart disease by 15%.

This well designed study has shown that medication-based intensive care can reduce the risk of heart attacks, but, unsurprisingly, it also increases the risk of episodes where blood sugar falls too low. Intensive blood sugar control targets may not be appropriate for all patients, and can be difficult to achieve.

All people with type 2 diabetes will normally be assessed by their GP, with initial treatment being based on dietary control, followed by diabetes medication if necessary. The most appropriate medication is often selected based on a patient’s particular characteristics and medical history. Diabetics should never alter their blood sugar control regimen themselves, and should always discuss any possible changes with the medical staff directing their treatment.

Where did the story come from?

This research was carried out by Dr Kausik K Ray and colleagues from the Universities of Cambridge and Glasgow, and Addenbrooke’s Hospital in Cambridge. There was no funding source for this study, but the researchers were supported by grants from the British Heart Foundation, the Gates Cambridge Trust and the Overseas Research Studentship Awards Scheme. Some of the authors reported that they had previously received honoraria from various drug companies for giving lectures and acting as members of advisory boards. The study was published in the peer-reviewed medical journal The Lancet.

What kind of scientific study was this?

This was a systematic review and meta-analysis pooling the results of randomised controlled trials (RCTs) on people with type 2 diabetes, comparing the rates of death and cardiovascular events for groups controlling their blood sugar using standard treatment or intensive treatment. The aim of intensive treatment is to achieve a lower blood sugar level than usually aimed for with standard treatment.

The researchers report that RCTs have shown that intensive blood sugar control reduces the risk of adverse small blood vessel events, such as eye problems and poor kidney function (which are more common in diabetics). However, they have not consistently found that it reduces risk of cardiovascular adverse events (large blood vessel disease).

The researchers suggest that this may have been because, individually, the trials were too small to detect an effect and, therefore, they wanted to pool the data from the individual trials to see if there was an effect.

The researchers used databases of medical and scientific literature, expert recommendations and journal article references to find RCTs that compared intensive control with standard blood sugar control in diabetics.

The marker used to determine how well blood sugar levels are being controlled in the long-term is called HbA1c, as improving blood sugar control lowers this measurement. The researchers only included studies where there was a significant difference in HbA1c between the intensive control and standard control groups during follow-up, that is, those trials where intensive control was successfully improving blood sugar control.

They also restricted the studies in their analysis to those that included people whose diabetes was stable, that looked at cardiovascular event(s) as their main outcome(s) and that gave enough information about the specific, relevant outcomes.

The researchers extracted information from the included trials, including data on HbA1c measurements, all deaths, deaths from heart attack, non-fatal heart attacks, strokes and any side effects of treatment. Two researchers independently extracted data from each trial to ensure that the extracted data was accurate.

The authors then used statistical methods to pool these results and look at whether intensive control affected these outcomes compared with standard control. They also used statistical methods to look at whether the results from the trials were significantly different from each other, which would suggest that the trials differed in some important way and that it might not be appropriate to pool them all together.

What were the results of the study?

The researchers identified five RCTs that matched their inclusion criteria, which together provided data on 33,040 people with type 2 diabetes.

These RCTs tested different methods of intensive and standard control. Intensive control usually involved a combination of different diabetic medications, while standard treatment was defined as a “half-dose of intensive treatments” in one RCT, “current medication” in one trial, “dietary control” in another and not further defined for two RCT’s.

People receiving intensive blood sugar control had HbA1c measurements that were on average 0.9% lower than those receiving standard control.

Across all five RCTs there were 2,892 deaths, 2,318 cases of coronary heart disease (fatal and non-fatal heart attacks), 1,497 non-fatal heart attacks and 1,127 strokes. This was over a follow-up of 163,000 person years in total (across all participants).

In the intensive control group there were 10 non-fatal heart attacks per 1,000 person-years compared with about 12 per 1,000 person-years in the standard control group.

This means that if 200 people from each group were each followed for five years, there would be 10 non-fatal heart attacks in the intensive control group, compared with 12 in the standard control group. This equates to a 17% reduction in the odds of having a non-fatal heart attack for those in the intensive control group (odds ratio [OR] 0.83, 95% confidence interval [CI] 0.77 to 0.93).

In the intensive control group there were around 14 coronary heart disease events per 1,000 person-years, compared with approximately 17 events per 1,000 person-years in the standard control group. This means that if 200 people from each group were each followed for five years, there would be 14 coronary heart disease events in the intensive control group compared with 17 in the standard control group. This meant that intensive control also reduced the odds of coronary heart disease by 15% (OR 0.83, 95% CI 0.77 to 0.93).

However, intensive control did not affect the risk of stroke or of death from any cause.

As expected, more people receiving intensive control (38.1%) had an episode where their blood sugar fell too low (a hypoglycaemic episode) than those receiving standard control (28.6%). Twice as many people in the intensive control group (2.3%) had a severe hypoglycaemic episode than in the standard control group (1.2%). People receiving intensive control gained an average of 2.5kg more weight than those on standard treatment by the end of the study.

What interpretations did the researchers draw from these results?

The researchers conclude that intensive blood sugar control “significantly reduces coronary events without an increased risk of death” in diabetics when compared to standard blood sugar control. However, they also point out that the optimum blood sugar control targets, and methods of achieving these, might differ in different populations.

What does the NHS Knowledge Service make of this study?

This well designed study has illustrated that if intensive control is used successfully it can reduce the risk of heart attacks. However, there are a number of points to note:

• The risk of having a heart attack was quite low in both groups and, therefore, the difference in risk between the groups was also small. If 200 people used intensive treatment for five years, this would prevent three heart attacks compared with standard control over the same period.
• Two of the included RCT's used drugs called glitazones as part of intensive control treatment. Studies have suggested that these drugs increase the risk of heart failure. Although, overall, this review found no significant increase in heart failure with intensive control, statistical tests showed that the results of the individual trials were significantly different from each other, and that this was likely to be due to an increased risk in heart failure with the glitazones.
• The studies included in this review used differing methods of intensive control, and it is not possible to say which method is best. Also, with standard treatment it was unclear exactly what medications were being used.

All people with type 2 diabetes will normally be assessed by their GP and initially treated through dietary control, with oral diabetic medications commenced as necessary. The most appropriate medication is often selected based on an individual patient’s characteristics and comorbidity. All patients will then be followed up regularly, with the aim of keeping their blood sugar at a controlled level and monitoring for any complications or need for a change in treatment.

Intensive drug control may not be appropriate for all people with type 2 diabetes, and can be difficult to achieve. The review also showed that it increases the risk of episodes where blood sugar falls too low. Diabetics should never alter their blood sugar control regimen themselves, and should always first discuss any possible changes with the healthcare professionals in charge of their treatment.

Links to the headlines

Diabetes heart risk 'can be cut'. BBC News, 22 May 2009

Links to the science

Ray K, Kondapally Seshasai SR, Wijesuriya S et al. Effect of intensive control of glucose on cardiovascular outcomes and death in patients with diabetes mellitus: a meta-analysis of randomised controlled trials. The Lancet; Volume 373, Issue 9677, Pages 1765 - 1772

Vitamin D may reduce decline in mental agility

LONDON, 23 may 2009- Getting more of the "Sunshine vitamin" may make you brighter later in life, according to a study published on Thursday that bolsters evidence vitamin D may help older people stay mentally fit.

The findings also raise the prospect that people who do not get enough of the vitamin could use supplements to keep the brain fully functioning as they age, David Lee and colleagues at the University of Manchester reported.

"At the population level, we are talking about large numbers of people. If there is a link it could potentially have a significant effect," Lee, who led the study, said in a telephone interview. "It is so easy to rectify with supplementation."

Vitamin D, produced by the body when skin is exposed to sunlight, is also found in certain foods such as oily fish. It helps cells absorb calcium and is important for bone health.

Recent studies have also indicated vitamin D may protect against cancer, artery disease and tuberculosis.

While others have suggested a link with mental ability, the findings so far have been inconsistent, Lee and colleagues reported in the Journal of Neurology Neurosurgery and Psychiatry.

The researchers compared the cognitive performance of more than 3,000 European men aged 40 to 79 and found those with low vitamin D levels did more poorly on a task designed to test mental agility.

The findings are some of the strongest evidence yet of such a link because of the size of the study and because the researchers adjusted for a number of lifestyle factors believed to affect mental ability when older, Lee said.

"We were able to take into account their educational level, their depression, their levels of physical activity and measures of physical performance," he said.

"When we adjusted for all these other health and lifestyle factors we still found that there was a link between vitamin D and the cognitive outcome."

The researchers do not know exactly how vitamin D and mental agility may be connected but said possible suggestions include the vitamin's role in increasing certain hormonal activity or the protection of neurons in the brain.

They also stressed their findings should not spur people to bask in the sun, which can increase the risk of skin cancer.

Japan, San Marino top life expectancy league

GENEVA,23 may 2009– The World Health Organization says women in Japan have the highest life expectancy in the world with 86 years. WHO says men in San Marino have the longest life expectancy for their sex with 81 years.

The Geneva-based body says men from Sierra Leone are expected to live only 39 years. Women in Afghanistan will live to an average age of 42 years.

WHO says the figures are based on statistics gathered from 2007, the latest year available.

The global health agency says countries including Angola, Eritrea and Liberia have made remarkable progress while others including Botswana, Kenya and Lesotho have seen a drop in life expectancy since 1990.

The figures were among more than 100 health trends published Thursday by the World Health Organization.

Elderly may have greater swine flu immunity: US

WASHINGTON , 23 may 2009– Older people may have some kind of immunity to swine flu, US health officials said Thursday, as the number of confirmed and suspected cases of H1N1 virus rose again around the country.

A study by the US Centers for Disease Control and Prevention (CDC) found that more than 64 percent of US infections have occurred among patients between the ages of five and 24, with just one percent of flu victims aged 65 or older.

One possible explanation is that "older adults might have been in contact a long time ago with a virus related to the one that we see now," said Anne Schuchat, interim deputy director for science and public health programs at the US Centers for Disease Control and Prevention.

"Adults might have some degree of pre-existing ... antibodies to the H1N1 virus, especially older adults over 60 or 65," she added.

"The presence of pre-existing antibodies may be due to previous exposure to (influenza) infection or vaccination."

Health authorities around the world have been surprised that with the number of cases of swine flu now topping 11,000, with 85 deaths, many of those infected have been younger people.

The CDC's study suggests children and teens may be particularly vulnerable to contracting the disease -- a worrying prospect as officials brace for the possible return in a few months' time of a more virulent strain of the H1N1 virus.

Schuchat added the flu outbreak was still "far from over" in the United States, where the tally of confirmed or probable US cases is now 5,764.

"The virus continues to circulate in the US," Schuchat said, adding there have been "localized outbreaks" in various states.

US health officials also remain concerned at delays in beginning production of a vaccine that could prove effective against swine flu.

This is especially urgent since the current batch of season flu vaccine does not provide protection against the H1N1 virus.

"We remain hopeful that we'll have vaccine viruses to send to manufacturers by the end of May," the CDC official said.

But Schuchat added that there are "many steps involved, and it will still be several months before a vaccine against this new virus will be available."

Schuchat offered a scrap of upbeat news, noting that flu-related visits to doctors and hospitals were on the wane across the United States, in what she considers a "good sign."

Among Obese Diabetics, Sleep Apnea May Be Common

23 may 2009-- People who are obese and have type 2 diabetes often have undiagnosed sleep apnea as well, a new study has found.

In fact, of the 306 participants in the study, about 87 percent were found to have sleep apnea but had never been diagnosed with the disorder. The findings appear in the June issue of Diabetes Care.

People in the study, all obese and all with type 2 diabetes, had participated in a sleep study and answered questions about sleep apnea symptoms such as snoring and daytime sleepiness.

More than 30 percent of the study participants had 16 to 20 episodes per hour in which their breathing would stop during sleep, and 22 percent had more than 30 episodes an hour, which is considered severe sleep apnea, according to the researchers.

Most of those who were undiagnosed also had a larger waist circumference, which the researchers found to be significantly associated with sleep apnea, as is higher body-mass index (BMI).

"The high prevalence of undiagnosed and, therefore, untreated sleep apnea among obese patients with diabetes constitutes a serious public health problem," study author Gary D. Foster, director of the Center for Obesity Research and Education at Temple University, said in a school news release.

Sleep apnea increases the risk of heart disease and stroke, according to the release.

"Doctors who have obese patients with type 2 diabetes need to be aware of the possibility of sleep apnea, even if no symptoms are present, especially in cases where the patient has a high BMI or waist circumference," Foster said.

Elderly women with 'dowager's hump' may be at higher risk of earlier death

Hyperkyphosis, or "dowager's hump" — the exaggerated forward curvature of the upper spine seen commonly in elderly women — may predict earlier death in women whether or not they have vertebral osteoporosis, UCLA researchers have found.

22 may 2009--In a study published in the May 19 issue of Annals of Internal Medicine, researchers found that older white women with both vertebral fractures and the increased spinal curvature that results in the bent-over posture characteristic of hyperkyphosis had an elevated risk for earlier death. The finding was independent of other factors that included age and underlying spinal osteoporosis.

Women who had only hyperkyphosis, without vertebral fractures, did not show an increased risk for premature death.

Hyperkyphosis can be caused by a number of factors besides osteoporosis, including habitual poor posture and degenerative diseases of the muscles and intervertebral discs.

"Just being bent forward may be an important clinical finding that should serve as a trigger to seek medical evaluation for possible spinal osteoporosis, as vertebral fractures more often than not are a silent disease," said Dr. Deborah Kado, an associate professor of orthopedic surgery and medicine at the David Geffen School of Medicine at UCLA and the study's primary investigator. "We demonstrated that having this age-related postural change is not a good thing. It could mean you're likely to die sooner."

For the study, the researchers reviewed data on 610 women, age 67 to 93, from a cohort of 9,704 participants in the Study of Osteoporotic Fractures. The participants were recruited between 1986 and 1988 in Baltimore, Md.; Minneapolis, Minn.; Portland, Ore.; and Pennsylvania's Monongahela Valley. Researchers measured spinal curvature with a flexicurve and assessed vertebral fractures from spinal radiographs; they assessed mortality based on follow-ups averaging 13.5 years.

Adjusting for age, as well as osteoporosis-related factors such as low bone density, moderate and severe vertebral fractures, and the number of prevalent vertebral fractures, the researchers found that women with previous vertebral fractures and increasing degrees of spinal curvature were at increased mortality risk from the spinal condition, regardless of age, smoking, spinal bone-mineral density, or the number and severity of their spinal fractures.

These study findings provide evidence that it is not just vertebral fracture alone but the associated increased spinal curvature that may be most predictive of adverse health outcomes. Other studies linking hyperkyphosis to poor health, such as impaired physical function, increased fall risk, fractures and mortality, have been unable to exclude the possibility that vertebral fractures alone were the underlying explanation for the findings.

The researchers note several caveats. This study focused on women, though hyperkyphosis also affects men; measurements for vertebral fractures were based only on height ratios, which could lead to misclassification of other causes of height ratio decreases, such as Scheuermann disease; and the timing of the assessments could have affected the results, though it's unlikely to have made much difference.

However, this study demonstrates a possible association between hyperkyphosis and increased risk for earlier death independent of the number and severity of vertebral fractures or osteoporosis in older women, the researchers write.

"These results add to the growing literature that suggests that hyperkyphosis is a clinically important finding. Because it is readily observed and is associated with ill health in older persons, hyperkyphosis should be recognized as a geriatric syndrome — a 'multifactorial health condition that occurs when the accumulated effect of impairments in multiple systems renders a person vulnerable to situational challenges.'"

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Study co-authors include Arun S. Karlamangla of UCLA; Li-Yung Lui and Steven R. Cummings of the California Pacific Medical Center Research Institute; and Kristine E. Ensrud and Howard A. Fink of the University of Minnesota.

The National Institute of Arthritis and Musculoskeletal and Skin Diseases and the National Institute on Aging funded this study.