Salubrious Components of Mediterranean Diet Identified

A population-based cohort study in BMJ highlights the individual components of the Mediterranean diet that appear to have the greatest effect on mortality.

29 june 2009--Researchers interviewed some 23,000 healthy Greek adults about their dietary habits and followed them for 8.5 years. They found that the following elements of the Mediterranean diet contributed the most to a mortality risk reduction:

• moderate consumption of alcohol;
  
• low intake of meat;
  
• high consumption of vegetables, fruits, nuts, monounsaturated fats, and legumes.
  

In contrast, high intake of cereals, fish, and seafood — and low consumption of dairy products — showed little effect on mortality.

LINK(S):

BMJ article (Free)

Previous Physician's First Watch coverage of link between Mediterranean diet and reduced mortality (Free)

Markers Of Inflammation Are More Strongly Associated With Fatal Than Non-fatal Cardiovascular Events In The Elderly

29 june 2009--A study published this week in the open access journal PLoS Medicine shows that for elderly people at risk of cardiovascular disease, the presence of inflammatory markers in the blood can identify that an individual is at a higher risk of a fatal rather than a non-fatal heart attack or stroke.

Inflammation is an immune response to injury. However, inflammation is also thought to play a role in cardiovascular disease. Previous studies have shown an association between high levels of markers of inflammation in the circulation with a greater risk of a cardiovascular event, such as a heart attack or stroke. In this study, Naveed Sattar of the University of Glasgow and colleagues used data from an existing trial known as PROSPER (the Prospective Study of Pravastatin in the Elderly at Risk), which involved participants aged between 70 and 82 who had or were at risk of cardiovascular disease. They examined if three inflammatory markers-interleukin-6 (IL-6), C-reactive protein (CRP) and fibrinogen-were each more strongly associated with fatal cardiovascular events than with non-fatal cardiovascular events in the period of over three years in which the patients in the trial were monitored.

Using several statistical models, the researchers found that in this group of elderly patients increased levels of all three inflammatory markers, and in particular IL-6, were more strongly associated with a fatal heart attack or stroke than with a non-fatal heart attack or stroke. They also investigated the predictive value of these inflammatory markers-in other words, whether it was useful to include these markers in tools designed to distinguish between individuals with a high and a low risk of heart attacks, strokes and other cardiovascular events. They report that adding IL-6 to the established risk factors in predictive tools-including lifestyle factors such as smoking, high blood pressure and high blood cholesterol, all of which greatly increase the risk of cardiovascular disease-could help better identify those individuals at a risk of a fatal stroke or heart attack, but not those at risk of a non-fatal cardiovascular event.

The findings of the study suggest inflammatory markers may be more strongly associated with fatal heart attacks and strokes than non-fatal cardiovascular events. The researchers acknowledge that these findings now need to be confirmed in younger populations and larger studies to demonstrate an outright association and the design of the current study cannot show whether the proposed association is a causal one. Nevertheless, the findings should stimulate further investigation into whether the application of inflammatory markers may help better predict the risk of deaths from cardiovascular disease, and whether novel treatments which dampen inflammation might help prolong life.

Competing Interests: SC received research funding and honoraria from Astra Zeneca, makers of rosuvastatin. JS is a consultant to Astra Zeneca, GlaxoSmithKline, MSD, and Pfizer, and is on the Speakers Bureau for Astra Zeneca and Pfizer.

Funding: Funded by Chest, Heart, & Stroke Association, Scotland, and The Stroke Association, UK. The funding bodies had no role in the study or writing of the manuscript.

Citation:
"Are Markers of Inflammation More Strongly Associated with Risk for Fatal Than for Nonfatal Vascular Events?"
Sattar N, Murray HM, Welsh P, Blauw GJ, Buckley BM, et al. (2009)
PLoS Med 6(6): e1000099

Source
PLoS Medicine

Thousands Of Older People Dying Prematurely From Cancer, Say Researchers

29 june 2009--As many as 15,000 people over 75 could be dying prematurely from cancer each year in the UK, according to research presented today at the National Cancer Intelligience Network (NCIN) conference.

These premature deaths could be prevented if cancer mortality rates in the UK dropped to match countries in Europe and America which have the lowest rates.

The researchers from the North West Cancer Intelligence Service (NWCIS) in Manchester compared cancer death rates in the UK with Europe and America.

They found that over the past decade the numbers of people dying from cancer in the under 75s has significantly dropped in the UK. But, little progress has been made in the over 75s and the gap in death rates with other countries is getting wider.

Dr Tony Moran, lead researcher from NWCIS, said "It's worrying that so many older people die from cancer in the UK compared with other countries. But, it's not clear why this is. Research is urgently needed to understand the reasons for the extra deaths so that steps can be taken to prevent them.

"Cancer is largely a disease of older people, with about half of all cancers diagnosed in those aged 70 or older. Most 75 year olds could be expected to live for at least another ten years and we would expect them to benefit from improvements in treatment."

Chris Carrigan, head of the NCIN, said: "This study indicates that a worrying number of older cancer patients are dying unnecessarily and likely reasons include going to the doctor late, delayed diagnosis and treatment. It's really important that people are aware of cancer symptoms and feel able to go to the doctor if they notice anything that feels wrong for them. We believe many deaths could be avoided each year in the UK if cancers were diagnosed sooner."

Professor Mike Richards, national cancer director, said: "This is an important study and urgent action needs to be taken on the findings. We need to ensure that cancer patients of all ages are diagnosed as early as possible and receive appropriate treatment.

"The findings have already been shared with the National Cancer Equality Initiative and we will be working with the NHS and other interested parties to tackle any age inequalities."

North West Cancer Intelligence Service

The North West Cancer Intelligence Service (NWCIS) collects data from many sources to provide population-based cancer information for the North West of England. This information is used to improve cancer services, and to support research into the prevention and treatment of cancer. It is hosted by The Christie, one of Europe's leading cancer centres based in Manchester.

About the National Cancer Intelligence Network (NCIN)

The NCIN was established in June 2008 and its remit is to coordinate the collection, analysis and publication of comparative national statistics on diagnosis, treatment and outcomes for all types of cancer

As part of the National Cancer Research Institute, the NCIN aims to promote efficient and effective data collection at each stage of the cancer journey

Patient care will be monitored by the NCIN through expert analyses of up-to-date statistics

The NCIN will drive improvements in the standards of care and clinical outcomes through exploiting data

The NCIN will support audit and research programmes by providing cancer information

The NCIN receives the bulk of its funding through the NHS

Source
Cancer Research UK

Age, Education Affect Post-Sick Leave Transition to Disability

Twenty percent of Norwegian group with two-month work absence later went on disability

28 june 2009-- In adults with musculoskeletal disorders who had a lengthy sickness-related work absence, their age, diagnosis, and socioeconomic factors predicted their transition to disability pension in following years, according to research published in the June 15 issue of Spine.

Sturla Gjesdal, M.D., of the University of Bergen in Norway, and colleagues analyzed data from more than 60,000 individuals with musculoskeletal disorders who had an episode of sickness absence lasting more than eight weeks in 1997. Participants were followed up for five years to track their transition to disability pension.

The researchers found that 20 percent overall obtained disability pension during follow-up. Compared to fractures and injuries, relative risk of disability pension was higher for rheumatoid arthritis (4.2), myalgia/fibromyalgia (3.3), osteoarthrosis (2.8), and back problems (2.0). The authors further note that age most strongly predicted disability pension, followed by education and income.

"The study showed that the long-term prognosis differed substantially between subgroups of musculoskeletal disorders. This points to the need to go beyond the general label musculoskeletal, when the risk of permanent disability among sickness absentees is studied," the authors write. "The estimates in this article for Norwegians on sick leave cannot be directly generalized to the United States, but the main results regarding diagnostic and social risks may have a bearing on cases with similar medical conditions, who meet the Social Security Disability Insurance earnings criteria."

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Cardiac Rehabilitation Is Beneficial for Seniors

Survival is significantly greater among those who enroll in 25 or more rehabilitation sessions

28 june 2009-- In older coronary patients, survival is significantly greater in those who attend multiple cardiac rehabilitation sessions, according to a study published in the June 30 issue of the Journal of the American College of Cardiology.

Jose A. Suaya, M.D., of Brandeis University in Waltham, Mass., and colleagues analyzed data on 601,099 Medicare beneficiaries who were hospitalized for coronary conditions or cardiac revascularization procedures.

The researchers found that only 12.2 percent of patients used cardiac rehabilitation, and that they used it for an average of 24 sessions. But they also found that cardiac rehabilitation users with 25 or more sessions were 19 percent less likely to die over the next five years than those who had 24 or fewer sessions.

"This was a well-designed, sophisticated study," state the authors of an accompanying editorial. "It provides evidence that there is indeed a clinically important effect of cardiac rehabilitation in actual practice. We can debate whether the true size of the effect is 10 percent or 30 percent, but both are large when translated into absolute population numbers. The central issue becomes how to improve cardiac rehabilitation referral and compliance, given that fewer than 50 percent of patients access these programs even in publicly funded systems."

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Editorial (subscription or payment may be required)

Aquatic Exercise May Be Helpful for Low Back Pain

Subjects in water-based program showed better improvements than those in land-based program

28 june 2009-- Exercising in water may be particularly beneficial for people with chronic low back pain, according to research published in the June 15 issue of Spine.

Umit Dundar, M.D., of the Kocatepe University in Afyonkarahisar, Turkey, and colleagues analyzed data from 65 adults, ages 20 to 50 years, with low back pain of more than three months' duration. They were randomized to participate in 20 sessions of an aquatic exercise program over four weeks or a self-directed land-based program for four weeks.

The researchers report that both groups showed improvements on a variety of outcomes, including pain measured on a visual analog scale; disability (measured on the modified Oswestry low back disability questionnaire); and quality of life (measured with the Short Form-36 Health Survey). However, at weeks four and 12, the aquatic group showed better improvement on the Oswestry questionnaire and the physical function and role limitations due to physical functioning sections of the Short Form-36.

"Movement in water is often less painful than similar movement on land. Sensory input from water pressure and temperature may decrease feelings of pain. A desired exercise intensity can be achieved by adjusting the velocity of movement in the water. Water-based physical activity enhances balance and coordination, while stimulating, visual, vestibular, and perceptual systems. Buoyancy reduces stress on joints and muscles and enables greater range of movement via supporting the weight of the body," the authors write.

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Functional Status Declines Over Time After First Stroke

Decline independent of stroke severity; seen especially in Medicaid and uninsured groups

27 june 2009-- In the five years following a first stroke, patients have modest declines in functional status, which are more noticeable in those with Medicaid or who are uninsured, according to research published online June 25 in Stroke.

Mandip S. Dhamoon, M.D., of Columbia University in New York City, and colleagues analyzed data from 525 survivors of a first ischemic stroke, all at least 40 years of age. The researchers evaluated subjects at six months and annually for five years, assessing functional status with the Barthel Index, terming it favorable or unfavorable based on the score. Follow-up was censored at death, a recurrent stroke or a heart attack.

The researchers found that the proportion of patients with favorable functional status declined annually after adjusting for demographics, risk factors, and stroke characteristics (odds ratio per year after stroke, 0.91). The functional status of those with Medicaid or no insurance declined, but the status of those with Medicare or private insurance did not.

"Functional decline in our study was seen particularly among those who were uninsured or insured with Medicaid. This decline began to be apparent at approximately three years," the authors write. "Over time after stroke, however, functional status among those with private insurance and Medicare and those with Medicaid or no insurance may diverge due to disparities in care and more limited access to rehabilitative services, information about health, and ongoing management of risk factors and chronic conditions that are known to have an impact on functional status."

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Study shows 1 in 25 deaths worldwide attributable to alcohol

CAMH researcher sees glass 'as half full'

Toronto, 27 june 2009-- Research from Canada's own Centre for Addiction and Mental Health (CAMH) featured in this week's edition of the Lancet shows that worldwide, 1 in 25 deaths are directly attributable to alcohol consumption. This rise since 2000 is mainly due to increases in the number of women drinking.

CAMH's Dr Jürgen Rehm and his colleagues found that alcohol-attributable disorders are among the most disabling disease categories within the global burden of disease, especially for men. And in contrast to other traditional risk factors for disease, the burden attributable to alcohol lies more with younger people than with the older population.

Dr. Rehm still takes an optimistic 'glass half full' response to this large and increasing alcohol-attributable burden. "Today, we know more than ever about which strategies can effectively and cost-effectively control alcohol-related harms," Dr. Rehm said today. "Provided that our public policy makers act on these practical strategies expeditiously, we could see an enormous impact in reducing damage."

The study showed that Europe had a high proportion of deaths related to alcohol, with 1 in 10 deaths directly attributable (up to 15% in the former Soviet Union). Average alcohol consumption in Europe in the adult population is somewhat higher than in North America: 13 standard drinks per person per week (1 standard drink = 13.6 grams of pure ethanol and corresponds to a can of beer, one glass or wine and one shot of spirits) compared to North America's 10 to 11 standard drinks. The recent Canadian consumption rate is equivalent of almost 9 standard drinks per person per week age 15 plus, and has been going up, as has high risk drinking. Globally, the average is around 7 standard drinks per person per week (despite the fact that most of the adult population worldwide actually abstains from drinking alcohol).

Most of the deaths caused by alcohol were through injuries, cancer, cardiovascular disease, and liver cirrhosis.

"Globally, the effect of alcohol on burden of disease is about the same size as that of smoking in 2000, but it is relatively greatest in emerging economies. Global consumption is increasing, especially in the most populous countries of India and China."

CAMH is known for its pioneering research in the most effective ways of reducing the burden of alcohol. For example, CAMH endorsed the legislative change implemented this year requiring young Ontario drivers to maintain a 0% blood alcohol content; in many jurisdictions this measure has reduced alcohol-related crashes and saved lives.

Other evidence-based policies proven to reduce harms include better controls on access to alcohol through pricing interventions and outlet density restrictions as well as more focused strategies such as violence reduction programs in licensed premises. Within health care, provision of screening and brief interventions for high risk drinkers has enormous potential to reduce the contribution of alcohol to the onset of cancer and other chronic diseases.

"There are significant social, health and economic problems caused by alcohol," said Gail Czukar, CAMH's executive vice-president, Policy, Education and Health Promotion. "But research gives us sound, proven interventions that governments and health providers can use to address these problems."

###

To arrange an interview please contact Kirk LeMessurier, CAMH Media Relations, at 416 595 6015 or kirk_lemessurier@camh.net

The Centre for Addiction and Mental Health (CAMH) is Canada's largest mental health and addiction teaching hospital, as well as one of the world's leading research centres in the area of addiction and mental health. CAMH combines clinical care, research, education, policy development, prevention and health promotion to help transform the lives of people affected by mental health and addiction issues.

Latin America must cut blood pressure to thrive

Therapeutic Advances in Cardiovascular Disease paper published today by SAGE

Los Angeles, London, New Delhi, Singapore and Washington DC , 27 june 2009– Combating high blood pressure is a global challenge. But while developed countries have enjoyed reductions in cardiovascular disease over recent decades, Latin America has been less fortunate. In fact new research published in the journal Therapeutic Advances in Cardiovascular Disease shows that high blood pressure is on the increase in many Latin American countries, a situation set to worsen unless immediate action is taken.

Adolfo Rubinstein from Hospital Italiano de Buenos Aires, Luis Alcocer from Universidad Nacional Autónoma de México and Hospital General de México, and Antonio Chagas from University of São Paulo Medical School Heart Institute have detailed the evidence in their article High blood pressure in Latin America: a call to action, and offer specific recommendations to remedy the situation.

Despite major healthcare problems in terms of equity and efficiency in the majority of Latin American countries, the overall health indicators of Latin America's population have been on an upward trend over the last 50 years, a trend that continues today.

Yet as life expectancy increases the most common health issues are shifting from dealing with acute disease to more expensive and complex chronic diseases. The chronic disease scenario is already common in developed countries, evidenced by the fact that cardiovascular disease makes up 11% of the global disease burden, leading to some 17.7 million deaths each year. Rapidly developing nations, like many in Latin America, still have a relatively high burden of infectious and communicable disease. The added increase in cardiovascular disease means these countries shoulder a 'double burden' of disease. In fact experts have noted that middle- and low-income regions have a five-fold greater disease burden, but have access to less than one tenth of global treatment resources.

Increasing rates of hypertension and chronic diseases, coupled with expected increases in population growth, then, present a mounting threat to Latin American economies.

"These dismal observations warrant a call to action for improved control of high BP and other cardiovascular risk factors across Latin America," says Alcocer. "Achieving these ambitious goals will require collaborative efforts by many groups, including policymakers, international organizations, healthcare providers, schools and society as a whole."

The report provides a comprehensive overview of the burden of high blood pressure across Latin America, but "it alone cannot bring about change," say the authors. Accepting and instituting core policy changes are key to galvanize action, and results.

In terms of core policy, regional policy makers must be alerted to the benefits of high blood pressure detection and control and make this a major public health priority. Leaders must provide resources to empower and train health professionals to detect, diagnose, treat and control high blood pressure, and these must include effective drugs and interventions. It is vital to launch high blood pressure detection and management campaigns. Education and awareness promotion is another critical step, and must include healthy lifestyle advice, and explain the links to risk factors such as smoking and obesity.

In treatment terms, policy makers must encourage therapeutic drug use based on clinical- and cost-effectiveness, acceptability, and affordability for Latin American countries. Healthcare professionals must manage high blood pressure in the context of other cardiovascular risk factors, and work to ensure treatment compliance and adherence.

Government officials and others bearing the cost must be sold the benefits of campaigns to prevent, identify and treat hypertension. The authors also recommend more research, specifically studies that include Latin American patients in large, long-term, clinical-outcome and epidemiological studies to improve clinical outcomes in specific regional context. This research needs support in the form of funding, including patient-oriented acceptance and compliance issues within the Latin American context.

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High blood pressure in Latin America: a call to action by Adolfo Rubinstein, Luis Alcocer and Antonio Chagas is published online today in Therapeutic Advances in Cardiovascular Disease, published by SAGE.

The article will be free to access online for a limited period from http://tak.sagepub.com/.

Will individuals with Alzheimer's disease benefit from cataract surgery?

CLEVELAND, 26 june 2009—A multi-institutional team of researchers, led by the Mandel School of Applied Social Sciences at Case Western Reserve University, will begin a five-year, $2.9 million National Institutes of Health-funded study. They will examine the lives of patients with both cataracts and Alzheimer's disease (AD) to document how restored vision improves everyday life for people with dementia.

"This project addresses a major social justice issue in the disparity in vision care of persons diagnosed with Alzheimer's disease," said Grover "Cleve" Gilmore, dean of the Case Western Reserve Mandel School and principal investigator of the study.

Gilmore will lead faculty from the departments of Ophthalmology and Visual Sciences and Neurology at the Case Western Reserve University School of Medicine and physicians from the Eye Institute and Neurological Institute at University Hospitals and the Division of Ophthalmology at MetroHealth Medical Center.

In 20 years of research, Gilmore has found people with dementia lose their ability to see objects in medium- and low-contrast environments, but boosting the contrast of objects improves their ability to move around their homes; eat better; read; and do other simple, everyday tasks.

Cataracts cloud and blur the vision in the eye causing AD patients additional problems. If untreated, the cataracts lead to blindness, but sight can be restored with surgery to remove the cataract.

Co-investigator Jonathan Lass, M.D., the Charles I Thomas Professor and chair of the department of ophthalmology and visual sciences at the Case Western Reserve School of Medicine and director of the Eye Institute at University Hospitals, says, surprisingly, a preliminary study has shown 10 percent of patients over 65 who have an eye exam have some memory impairment along with cataracts. Most people start to show signs of cataracts in their early 60s.

"This research is important because we are a visual world," said Thomas Steinemann, M.D., professor of ophthalmology at the School of Medicine and ophthalmologist in the ophthalmology division at Metrohealth Medical Center.

Steinemann said he has observed improvements in AD patients following cataract surgery. Some who were combative before surgery are more cooperative following it. And even though they still are cognitively impaired to some degree, Steinemann said improved vision may even help AD patients recognize family members.

"Ultimately, if you can't perceive something, it is hard to remember it," says Alan Lerner, associate professor of neurology at the Case Western Reserve School of Medicine and director of the Memory and Cognition Center in University Hospital's Neurological Institute. "If the vision is blurry, then your memory may be more faulty than necessary. The cataract removal may offer benefits of improved quality of life which is a major aim in AD therapeutics overall."

"This grant demonstrates that the NIH recognizes a major disparity in healthcare for individuals with Alzheimer's disease and cataracts," said Gilmore. "We hope to provide evidence that AD patients also benefit from cataract surgery."

In the randomized controlled NIH-funded study, half of the 210 patients will receive cataract surgery and the other half will have surgery delayed for six months. The researchers will follow the progress of the two groups. During this time, the primary caregivers associated with these patients also will supply information about the patient's quality of life and activity levels by answering surveys and other measures.

In addition to finding scientific evidence that cataract surgery helps AD patients, the researchers hope to identify a warning sign of AD. They will test changes in the thickness of the retina, a part of the eye that is an extension of the brain. Using a technology called optical coherence tomography (OCT), they will track changes in the retinal thickness of these patients over six months to determine if there is a connection with AD.

By using the technology, Gilmore says they hope to find an indicator of the onset of AD and prompt referrals to neurologist for early interventions and medicines to delay memory loss.

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In addition to Gilmore, Lass, Lerner and Steinemann, Julie Belkin, M.D., assistant professor of ophthalmology at the Case Western Reserve School of Medicine and of the Eye Institute at University Hospitals, will work with the co-investigators.

First-Degree Atrioventricular Block Shows Heightened Risk

Patients have elevated long-term risk of atrial fibrillation, pacemaker implantation, and death

26 june 2009-- Patients with first-degree atrioventricular block may have an increased risk of atrial fibrillation, pacemaker implantation, and all-cause mortality, according to a study published in the June 24 issue of the Journal of the American Medical Association.

Susan Cheng, M.D., of the Framingham Heart Study in Massachusetts, and colleagues studied 7,575 subjects who underwent baseline examinations in 1968 to 1974. During follow-up through 2007, they observed 481 cases of atrial fibrillation, 124 cases requiring pacemaker implantation, and 1,739 deaths.

The researchers' multivariable analyses showed that each 20-millisecond increment in PR was associated with an increased risk of atrial fibrillation, pacemaker implantation, and death (hazard ratios, 1.11, 1.22, and 1.08, respectively). Overall, they found that patients with first-degree atrioventricular block had a two-fold adjusted risk of atrial fibrillation, a three-fold adjusted risk of pacemaker implantation, and a 1.4-fold adjusted risk of all-cause mortality.

"These results suggest that the natural history of first-degree atrioventricular block is not as benign as previously believed," the authors conclude. "Additional studies are needed to determine appropriate follow-up for individuals found to have prolongation of the PR interval on a routine electrocardiogram."

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Total Knee Arthroplasty Found Cost-Effective

Across all risk levels, surgery is associated with higher quality-adjusted life expectancy

26 june 2009 -- Among Medicare patients, total knee arthroplasty is cost-effective, especially when performed at high-volume hospitals, according to a study published in the June 22 issue of the Archives of Internal Medicine.

Elena Losina, Ph.D., of Brigham and Women's Hospital in Boston, and colleagues analyzed claims data from Medicare and cost and outcomes data from national and multinational sources with a Markov, state-transition, computer simulation model.

The researchers found that total knee arthroplasty was associated with significant increases in quality-adjusted life years (from 6.822 to 7.957 overall, and from 5.713 to 6.594 in high-risk patients) and that it had an incremental cost-effectiveness ratio of $18,300 per quality-adjusted life year overall and $28,100 per quality-adjusted life year in high-risk patients. Compared to total knee arthroplasty performed at high-volume centers, they found that the surgery was more costly and less effective when performed in low-volume centers across all risks levels.

"There is no doubt that total knee arthroplasty will continue to benefit numerous patients with disabling arthritis of the knee by improving their quality of life and allowing them to return to a more active role in society," states the author of an Invited Commentary. "However, concerns about rising procedure volumes and the continual introduction of newer, more expensive total knee arthroplasty implant technologies necessitate careful consideration and evaluation of the incremental cost-effectiveness of these procedures. A multi-stakeholder approach to delivering high-quality, cost-efficient care will be essential to ensuring future generations of patients access to these life-altering procedures."

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Elements of Mediterranean Diet Add Up to Lower Mortality

Single unidimensional diet score successfully integrates different factors

25 june 2009-- Different elements of the Mediterranean diet contribute to its beneficial effect on overall mortality, according to a study published online on June 23 in BMJ.

Antonia Trichopoulou, M.D., of the University of Athens Medical School in Greece, and colleagues conducted a study of 23,349 men and women with no previous diagnosis of cancer, coronary heart disease or diabetes, who gave information on their diet and who were followed up for a mean 8.5 years.

Among the 12,694 subjects with Mediterranean diet scores of zero to four, there were 652 deaths during follow-up, and among the 10,655 participants with scores of five and above there were 423 deaths, the researchers found. The different components of the Mediterranean diet contributed to the overall reduction in total mortality, including 23.5 percent contributed by low alcohol consumption, 16.6 percent by low consumption of meat and meat products, and 16.2 percent from high vegetable intake, the investigators note.

"An analysis of this type cannot provide universally applicable results, because diet varies across populations and also between sections of the same population," the authors write. "Nevertheless, our results indicate that the Mediterranean diet score that has been widely used is an effective predictor of mortality because it integrates associations with mortality of many individual components in a single unidimensional score."

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Monitoring May Be Unnecessary After Bisphosphonate Treatment

Bone scans of postmenopausal women treated with the drug may be misleading

25 june 2009-- Postmenopausal women treated with a potent bisphosphonate should not undergo bone mineral density monitoring within the first three years of starting treatment because such tests can give misleading results, according to a study published online on June 23 in BMJ.

Katy J.L. Bell, of the University of Sydney in Australia, and colleagues conducted a trial of 6,459 postmenopausal women with low bone mineral density who were randomized to receive either placebo or the bisphosphonate alendronate, and who were followed up to undergo hip and spine bone density measurements one, two and three years later.

After three years of treatment, hip bone mineral density increased by a mean 0.030 g/cm² and treatment gave 97.5 percent of patients an increase of at least 0.019 g/cm², the researchers found. There was no substantial variation in treatment response from one individual to another, the investigators discovered.

"Clinicians may cite other reasons for monitoring besides estimating the intended effects of treatment," the authors write. "One common reason given is to assess adherence to treatment. However, the large background within-person variation for bone mineral density means that monitoring is unlikely to give reliable information about whether the drugs were taken as prescribed."

The study was supported by Merck. Authors reported relationships with Merck and other pharmaceutical companies.

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Editorial

Secondary Causes for Low Bone Mineral Density Common

Many postmenopausal breast cancer survivors had low vitamin D, high parathyroid hormone

24 june 2009-- Many postmenopausal breast cancer survivors may have secondary causes of low bone mineral density that are potentially treatable, according to research published online on June 22 in the Journal of Clinical Oncology.

G. Bruce Mann, Ph.D., of the Royal Women's Hospital in Victoria, Australia, and colleagues analyzed data from 200 women -- median age at diagnosis, 62 years -- who'd been diagnosed with breast cancer within the previous five years. Subjects' bone mineral density (BMD) was checked, and blood samples were tested for serum calcium, vitamin D, thyroid function, and parathyroid hormone.

The researchers found that roughly 47 percent of the women had osteopenia and 12.8 percent had osteoporosis. Many had insufficient (37 percent) or deficient (27 percent) vitamin D, and 21 percent had higher than normal parathyroid hormone concentrations. Six women had primary hyperparathyroidism (PHPT) and two had recent surgery for the condition, while 27 had secondary hyperparathyroidism from vitamin D deficiency and six had normocalcemic hyperparathyroidism. Of the patients with low BMD and hormone receptor-positive cancer, the authors note that 8 percent had recent or new PHPT.

"Secondary causes of osteoporosis should be sought and corrected, particularly in patients with hormone receptor-positive breast cancer and low BMD. Vitamin D should be measured and supplemented if low; repeat testing is appropriate to confirm adequate vitamin D replacement. Calcium levels should be checked, PHPT should be specifically sought if calcium levels are high, and PHPT should be treated appropriately," the authors conclude.

Two co-authors reported financial associations with Novartis Pharmaceuticals.

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Big US study will test vitamin D, fish oil

24 june 2009--Two of the most popular and promising dietary supplements — vitamin D and fish oil — will be tested in a large, government-sponsored study to see whether either nutrient can lower a healthy person's risk of getting cancer, heart disease or having a stroke.

It will be one of the first big nutrition studies ever to target a specific racial group — blacks, who will comprise one quarter of the participants.

People with dark skin are unable to make much vitamin D from sunlight, and researchers think this deficiency may help explain why blacks have higher rates of cancer, stroke and heart disease.

"If something as simple as taking a vitamin D pill could help lower these risks and eliminate these health disparities, that would be extraordinarily exciting," said Dr. JoAnn Manson. She and Dr. Julie Buring, of Harvard-affiliated Brigham and Women's Hospital in Boston, will co-lead the study.

"But we should be cautious before jumping on the bandwagon to take mega-doses of these supplements," Manson warned. "We know from history that many of these nutrients that looked promising in observational studies didn't pan out."

Vitamins C, E, folic acid, beta carotene, selenium and even menopause hormone pills once seemed to lower the risk of cancer or heart disease — until they were tested in big studies that sometimes revealed risks instead of benefits.

In October, the government stopped a big study of vitamin E and selenium pills for prostate cancer prevention after seeing no evidence of benefit and hints of harm.

Vitamin D is one of the last major nutrients to be put to a rigorous test.

For years, evidence has been building that many people are deficient in "the sunshine vitamin." It is tough to get enough from dietary sources like milk and oily fish. Cancer rates are higher in many northern regions where sunlight is weak in the winter, and some studies have found that people with lower blood levels of vitamin D are more likely to develop cancer.

Fish oil, or omega-3 fatty acid, is widely recommended for heart health. However, studies of it so far have mostly involved people who already have heart problems or who eat a lot of fish, such as in Japan. Foods also increasingly are fortified with omega-3, so it is important to establish its safety and benefit.

"Vitamin D and omega-3s have powerful anti-inflammatory effects that may be key factors in preventing many diseases. They may also work through other pathways that influence cancer and cardiovascular risk," Manson said.

However, getting nutrients from a pill is different than getting them from foods, and correcting a deficiency is not the same as healthy people taking large doses from a supplement.

The new study, which will start later this year, will enroll 20,000 people with no history of heart attacks, stroke or a major cancer — women 65 or older and men 60 or older. They will be randomly assigned to take vitamin D, fish oil, both nutrients or dummy pills for five years.

The daily dose of vitamin D will be about 2,000 international units of D-3, also known as cholecalciferol, the most active form. For fish oil, the daily dose will be about one gram — five to 10 times what the average American gets.

Participants' health will be monitored through questionnaires, medical records and in some cases, periodic in-person exams.

"We're hoping to see a result during the trial, that we won't have to wait five years" to find out if supplements help, Manson said.

Researchers also plan to study whether these nutrients help prevent memory loss, depression, diabetes, osteoporosis and other problems, Buring said.

The $20 million study will be sponsored by the National Cancer Institute, with the National Heart, Lung and Blood Institute and other federal agencies. Pharmavite LLC of Northridge, Calif., is providing the vitamin D pills, and Ocean Nutrition Canada Ltd. of Dartmouth, Nova Scotia, is providing the omega-3 fish oil capsules.

Motor Function Declines Faster in Less Socially Active Elders

Effect of low participation in social activities like adding years to age

23 june 2009-- Older adults who do not participate frequently in social activities are likely to experience a more rapid decline in motor function than their more socially active counterparts, according to a study published in the June 22 issue of the Archives of Internal Medicine.

Aron S. Buchman, M.D., and colleagues at the Rush University Medical Center in Chicago conducted a study of 906 older adults without stroke, dementia or Parkinson's disease at baseline, who gave information about their levels of social activity and who were followed up for a mean 4.9 years. A composite measure of motor function was derived from nine measures of muscle strength and nine motor performances.

At baseline the mean social activity score was 2.6, and each one-point drop in social activity was associated with a one-third increase in the rate of motor function decline, and was equivalent to being five years older at baseline, the investigators found. The association held after controlling for confounders and regardless of demographic factors, the researchers note.

"The basis for the association between social activity and decline in motor function is uncertain. Emerging evidence suggests that efficient goal-directed movement requires the orchestration and integration of a wide range of sensory, motor, and cognitive functions," the authors write. "Both successful social and motor behavior depend on the structural and functional integrity of neural systems."

Abstract
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Body Responds to Changes in Musical Rhythms

Study finds that blood pressure, heart rate and skin vasomotion all affected

23 june 2009 -- Regardless of individual musical preference, changes in musical tempo cause autonomic respiratory and cardiovascular responses, according to a study published on June 22 in Circulation.

Luciano Bernardi, M.D., of Pavia University in Italy, and colleagues conducted a study of 24 young healthy adults, of whom 12 were choristers and 12 were not musicians. The subjects listened to a selection of music with different tempos, as well as silence, in random order while their heart rate, respiration, blood pressure, skin vasomotion, and middle cerebral artery flow velocity were measured.

In both the musician and the non-musician groups, there was a significant correlation between respiratory and cardiovascular signals and the musical profile of vocal and orchestral crescendos, notably in terms of blood pressure and skin vasoconstriction, the investigators discovered. Uniform emphasis in the music produced skin vasodilation and a lowering of blood pressure, the researchers found.

"An externally driven autonomic modulation could be of practical use to induce body sensation (e.g., increase in heart rate or by skin vasoconstriction), which might finally reach the level of consciousness or at least create a continuous stimulus to the upper brain centers," the authors write. "This may better explain the efficacy of music in pathological conditions such as stroke, and it opens new areas for music therapy in rehabilitative medicine."

Abstract
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Urinary Symptoms Linked to Metabolic Syndrome in Men

Even mild symptoms associated with significantly increased odds of metabolic syndrome

23 june 2009-- In men, there is a significant association between lower urinary tract symptoms and metabolic syndrome, according to a study published online June 18 in the Journal of Urology.

Varant Kupelian, Ph.D., of the New England Research Institutes in Watertown, Mass., and colleagues used the American Urological Association symptom index and a modification of the Adult Treatment Panel III guidelines to assess 1,899 men.

Compared to men with symptom index scores of zero to one, the researchers found that those with scores of two to 35 were significantly more likely to have metabolic syndrome (multivariate odds ratio, 1.68). They also observed a significant association between metabolic syndrome and a voiding symptom score of five or higher (multivariate adjusted odds ratio, 1.73), and even mild symptoms such as incomplete emptying, intermittency and nocturia.

"Further research is needed to understand the common pathophysiology of lower urinary tract symptoms and metabolic syndrome, especially longitudinal studies to determine a temporal sequence and investigation of this association in women as a relationship between chronic illnesses and lower urinary tract symptoms has been reported previously in men and women," the authors conclude. "Additional studies are needed to explore the treatment impact and correlation of comorbid conditions and symptoms associated with the individual components of metabolic syndrome."

This study was supported by Pfizer Inc.; two authors reported financial relationships with Pfizer.

Abstract
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Statins Don't Lower Risk Of Pneumonia In Elderly

22 june 2009--Taking popular cholesterol-lowering statin drugs, such as Lipitor® (atorvastatin), does not lower the risk of pneumonia. That's the new finding from a study of more than 3,000 Group Health patients published online on June 16 in advance of the British Medical Journal's June 20 print issue.

"Prior research based on automated claims data had raised some hope-and maybe some hype-for statins as a way to prevent and treat infections including pneumonia," said Sascha Dublin, MD, PhD, a physician at Group Health and assistant investigator at Group Health Center for Health Studies. "But when we used medical records to get more detailed information about patients, our findings didn't support that approach."

In fact, Dublin's population-based case-control study found that pneumonia risk was, if anything, slightly higher (26%) in people using a statin than in those not using any; and this extra risk was even higher (61%) for pneumonia severe enough to require being hospitalized.

"As a doctor, I'm a fan of statins for what they've been proven to do: lowering cholesterol and risk of heart disease and stroke in people who've had either disease or are at risk for them," said Dublin. Statins are HMG coenzyme A reductase inhibitors, which also include Zocor® (simvastatin) and Mevacor® (lovastatin). This class of medications lessens inflammation, which plays a role in infections.

"But now we and some others have found that statins may have gotten some unearned credit for health benefits that they don't actually have, including preventing pneumonia," Dublin said. Suggestions from prior research had led to calls for expensive randomized controlled trials of statins to prevent or treat infection. "But our study indicates that such trials would be an ill-advised use of limited research funds at this time," she added.

Why the discrepancy between this new study and earlier ones? "Healthy-user bias is one reason," said Dublin. In other words, compared to people who don't take statins, those who do may be healthier and have healthier habits that lower their risks of unrelated diseases such as pneumonia. And that's just what she found: Study patients who were on statins were less frail or disabled and also more likely to be vaccinated against flu or pneumococcal pneumonia. They were less likely to smoke, to have dementia, or to need help with bathing or walking.

Unlike the previous research on statins and pneumonia, Dublin's study made great efforts to control for this bias, including reviewing medical records in detail for every study subject. It confirmed that every pneumonia event was a true case of pneumonia, which prior studies rarely did. And it focused on relatively healthy elderly people. All had intact immune systems and none lived in a nursing home. She studied the same 65- to 94-year-old patients, with their records coded to protect their privacy, as in earlier Group Health research, published in The Lancet in 2008. That work showed the flu vaccine didn't protect the elderly from pneumonia as much as had been thought.

"We did an old-fashioned 'chart review,'" said Dublin. "By reading the text in the medical records, you catch crucial details."

CANCER RATES IN MEN

22 june 2009--Men are 16% more likely to develop cancer and 40% more likely to die from cancer than women, newspapers have reported. The BBC said, “there is no known biological reason for this but it may be because women take better care of themselves.” The Daily Mail reports a cancer expert as saying there is a divide because “the NHS prefers saving women”.

The news stories are based on a report that found that men are more likely to develop and to die from cancer than women. The researchers say, “the reasons men seem to be so much more at risk of so many cancers are complex and still only partially understood.” While lifestyle, genes, immunity and knowledge and behaviour (such as knowing of family members with cancer and “help-seeking behaviour”) are given as possible contributors, the full reason is unknown. The report does not suggest that the NHS is biased in favour of women.

Optimistically, the report also found that, while the cancer rate in UK men rose between 1975 and 2006, the rate of cancer death fell by about a quarter, which was mainly attributed to earlier diagnosis, better diagnostic methods and improvements in treatment and care.

What is the basis for these current reports?

These news stories are based on a report prepared by the National Cancer Intelligence Network (NCIN), Cancer Research UK (CRUK), Leeds Metropolitan University and the Men's Health Forum as part of Men's Health Week. The report used data from the CRUK Cancerstats webpages.

It was already known that men are generally at greater risk than women for almost all common cancers that affect both men and women (except breast cancer). The current report looked at recent figures to see how common cancer is in men in the UK and whether there are differences in cancer rates and deaths from cancer between men and women.

What did the report find?

The report carried out many analyses and key results include the following:

• The number of new cancer cases diagnosed in the UK in 2006 was similar for men and women: about 146,000 men and 147,000 women (non-melanoma skin cancers were excluded from all analyses). However, when these figures were adjusted to take age into account (age-standardisation), the rate of cancer was higher in men (409.7 per 100,000 men) than in women (354.6 per 100,000 women). The researchers say that this difference is because women generally live longer than men.
• In 2007, cancer caused 29% of all deaths in men and 25% of all deaths in women. The age-standardised rate of cancer death was higher in men (211.3 per 100,000 men) than in women (153.1 per 100,000 women). This difference was reportedly due to women’s longer life expectancy and the greater likelihood that men will develop more fatal cancers.
• The rate of cancer diagnosis in men in the UK rose from 353.7 per 100,000 in 1975 to 409.5 per 100,000 in 2006. However, the rate of cancer death in men dropped from 278.5 per 100,000 to 211.3 per 100,000 in the same period. A similar trend was seen in women. This is because earlier diagnosis, better diagnostic methods and improvements in treatment and care have resulted in more people surviving cancer.
• The most common cancers in men in 2006 were prostate cancer (24% of all cancers), lung cancer (15%) and bowel cancer (colorectal cancer) (14%). These three types of cancer were also the most common causes of cancer death in men in 2007, with lung cancer the most common cause (24% of cancer deaths), followed by prostate cancer (13%) and bowel cancer (10%). This leaves 53% of cancer deaths caused by other less common cancers.
• Overall, the rate of death from cancer in 2007 was 1.38 times higher in men than in women (which is the same as saying that cancer deaths were 38% more common in men than women). This difference was most pronounced among people aged 65 years and over, where cancer deaths were 1.57 times higher in men than in women. The rate was 1.05 times greater in men than in women in the younger (15 to 64) age group. This increased risk in men was seen for a range of different cancers.
• When the researchers excluded lung cancer deaths (as men have tended to smoke more than women over the past 60 years), they found that the difference in the ratio of deaths between men and women was smaller. The overall difference in the death rate between men and women was 1.31. In those aged 65 and above it was 1.51, and in those aged 15 to 64 it was 0.98. The researchers suggest that the higher overall death rate in men for all cancers in the younger age group could, therefore, be due to lung cancer.
• When the researchers excluded deaths from breast cancer and cancers that only occur in either men or women, overall cancer deaths were 69% more common in men than women. Cancers in men aged 15 to 64 were 60% more common than in women, and in men aged 65 or over they were 73% more common. The researchers suggest that these figures can be explained by the fact that cancer deaths in younger women are largely due to breast cancer and other genital cancers, whereas deaths among men due to male-specific cancers in this age group are uncommon.
• Overall, men were 16% more likely than women to have a new diagnosis of cancer in the UK in 2006. More women than men in the 15 to 64 age group were diagnosed with cancer, but in the 65 and over group, new diagnoses of cancer were more common in men. Once breast cancer and female- or male-specific cancers were excluded, the overall rate of new cancer diagnoses was 62% higher in men than women, and 44% higher in men than women in the 15 to 64 age group.

Why are men’s cancer rates worse than women’s?

The researchers report that, “the reasons men seem to be so much more at risk of so many cancers are complex and still only partially understood.” They say that differences in the levels of smoking and alcohol consumption in men and women will affect the rates of related cancers (such as lung cancer and bladder cancer). They say that other factors probably contribute to the differences, such as other lifestyle factors, genetics and immunity. Health knowledge and behaviours, such as knowledge of cancer and genetic links within families, uptake of available cancer screening and willingness to seek help, may also have an effect. They say that more research is needed to investigate how these and other factors affect differences in risk.

Does this show that men and women have different quality cancer treatment?

This study did not look at whether the quality of cancer treatment differs between men and women, and the researchers do not suggest that this is a possible reason for these differences. To investigate this and other possible reasons for the differences in cancer rates and deaths between men and women, further data about the characteristics of individuals diagnosed with cancer and their outcomes will be needed.

What can people do to reduce their risk of cancer?

Men as well as women can reduce their exposure to the lifestyle factors that are known to influence cancer risk, such as smoking, high alcohol consumption, being overweight or obese and having an unhealthy diet.

The NHS offers help with quitting smoking and also free screening programmes for certain types of cancer, and men and women who are eligible should consider taking part in this screening. Men can also monitor their health and be aware of any changes that may be possible signs of cancer. The earlier a cancer is detected, the better the chance of curing it, and people who have any symptoms they are worried about should see their doctor sooner rather than later.

Links to the headlines

The cancer divide: Men are most at risk because the NHS prefers saving women, says cancer expert. Daily Mail, June 16 2009

Cancer 40 per cent more likely to kill men. Daily Mirror, June 15 2009

'Men 40% more likely to die from cancer due to fear of doctors'. Daily Mail, June 15 2009

Stiff upper lip means men more likely to die from cancer than women. The Times, June 15 2009

Men warned of greater cancer risk. BBC News, June 15 2009

Terence Blacker: When it comes to health, men are second-class citizens. Independent, June 16 2009

Links to the science

The Excess Burden of Cancer in Men in the UK. Press releases

Men hit by ‘inexplicable’ greater cancer death risk. Men's health forum, June 15 2009

Cancer Research UK Press Release. June 15 2009

The battle for CRTC2: How obesity increases the risk for diabetes

La Jolla, CA, 22 june 2009—Obesity is probably the most important factor in the development of insulin resistance, but science's understanding of the chain of events is still spotty. Now, researchers at the Salk Institute for Biological Studies have filled in the gap and identified the missing link between the two. Their findings, to be published in the June 21, 2009 advance online edition of the journal Nature, explain how obesity sets the stage for diabetes and why thin people can become insulin-resistant.

The Salk team, led by Marc Montminy, Ph.D., a professor in the Clayton Foundation Laboratories for Peptide Biology, discovered how a condition known as ER (endoplasmic reticulum) stress, which is induced by a high fat diet and is overly activated in obese people, triggers aberrant glucose production in the liver, an important step on the path to insulin resistance.

In healthy people, a "fasting switch" only flips on glucose production when blood glucose levels run low during fasting. "The existence of a second cellular signaling cascade—like an alternate route from A to B—that can modulate glucose production, presents the potential to identify new classes of drugs that might help to lower blood sugar by disrupting this alternative pathway," says Montminy.

It had been well established that obesity promotes insulin resistance through the inappropriate inactivation of a process called gluconeogenesis, where the liver creates glucose for fuel and which ordinarily occurs only in times of fasting. Yet, not all obese people become insulin resistant, and insulin resistance occurs in non-obese individuals, leading Montminy and his colleagues to suspect that fasting-induced glucose production was only half the story.

"When a cell starts to sense stress a red light goes on, which slows down the production of proteins," explains Montminy. "This process, which is known as ER stress response, is abnormally active in livers of obese individuals, where it contributes to the development of hyperglycemia, or high blood glucose levels. We asked whether chronic ER stress in obesity leads to abnormal activation of the fasting switch that normally controls glucose production in the liver." The ER, short for endoplasmic reticulum, is a protein factory within the cell.

To test this hypothesis the Salk team asked whether ER stress can induce gluconeogenesis in lean mice. Glucose production is turned on by a transcriptional switch called CRTC2, which normally sits outside the nucleus waiting for the signal that allows it to slip inside and do its work. Once in the nucleus, it teams up with a protein called CREB and together they switch on the genes necessary to increase glucose output. In insulin-resistant mice, however, the CRTC2 switch seems to get stuck in the "on" position and the cells start churning out glucose like sugar factories in overdrive.

Surprisingly, when postdoctoral researcher and first author Yiguo Wang, Ph.D., mimicked the conditions of ER stress in mice, CRTC2 moved to the nucleus but failed to activate gluconeogenesis. Instead, it switched on genes important for combating stress and returning cells to health. On closer inspection, Wang found that in this scenario CRTC2 did not bind to CREB but instead joined forces with another factor, called ATF6a.

What's more, like jealous lovers CREB and ATF6a competing for CRTC2's affection—the more ATF6a is bound to CRTC2, the less there is for CREB to bind to. "This clever mechanism ensures that a cell in survival mode automatically shuts down glucose production, thus saving energy," says Wang.

This observation led the researcher to ask what happens to ATF6a following the kind of persistent stress presented by obesity? They found that the levels of ATF6a go down when ER stress is chronically activated, compromising the cells' survival pathway and favoring the glucose production pathway; hyperglycemia wins in conditions of persistent stress.

Explains Wang, "Our study helps to explain why obese people have a stronger tendency to become diabetic. When ER stress signaling is abnormal glucose output is actually increased."

"It is possible that mutations in the highly conserved CRTC2 lead to a predisposition to inappropriate gluconeogenesis," says Montminy, who is now trying to identify natural mutations in CRTC2 that may lead to insulin resistance in carriers.

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In addition to Drs. Wang and Montminy, researchers contributing to this study include research technician Liliana Vera, and Wolfgang H. Fischer, Ph.D., director of the Mass Spectrometry Core Facility.

The work was supported by grants from the National Institutes of Health, the Clayton Foundation for Medical Research, the Kiekhefer Foundation and the Vincent J. Coates Foundation.

Atrial fibrillation in endurance athletes still poses problems for sports cardiologists

New research efforts to prevent and treat arrhythmias associated with endurance sports

22 june 2009--The fulfilment which so many people increasingly derive from competitive sports and endurance training comes with a real – even if rare – twist. Because, while most people will enjoy the benefits and pleasures of exercise, there are a few for whom regular athletic training will increase the risk of cardiac arrhythmias and even sudden death, especially among those in middle-age or with pre-existing cardiac diseases.

"It's for this reason that sports medicine has focused on pre-participation screening," says Dr Luis Mont from the Hospital Clínic de Barcelona, Spain, "in an attempt to detect any hidden heart disease." On the other hand, disturbances in heart rhythm, particularly atrial fibrillation, which represent one of the major cardiovascular reasons for hospital admission, is more common among cyclists, marathon runners and other athletes with a long history of endurance training.

Dr Mont reports that atrial fibrillation is more frequent in middle-aged individuals who formerly took part in competitive sports and continue to be active, or simply in those involved in regular endurance training without having actually participated in competitive sports. "So we have to look at the effects of endurance or athletic training with a more open view," says Dr Mont.

However, he adds that the cost-effectiveness of routine pre-participation screening in a broad population of athletes and endurance sports participants has not yet been clarified. A debate on the subject takes place at this Congress on Sunday 21st June at 16.00.

What does seem clearer, however, is that long-term endurance sport participation may well increase the incidence of cardiac arrhythmias, particularly atrial fibrillation, atrial flutter, sinus node dysfunction, and right ventricular premature beats. "Given the fact that an increasing number of individuals engage in regular endurance sports," says Dr Mont, "it is certainly of great interest to define which recommendations for sport should be implemented in an individual patient, and how best to manage arrhythmias in participants." Atrial fibrillation is the most common arrhythmic condition, and sudden cardiac death remains a risk.

Three papers presented at this congress by Dr Mont's group reflect the research effort now being directed towards sports cardiology and the prevention and treatment of rhythm disorders.

1. Efficacy of the circumferential pulmonary vein ablation of atrial fibrillation in endurance athletes. CPVA is a recently introduced technique which identifies the signals causing the atrial fibrillation and isolates their source in the pulmonary veins from the left ventricle of the heart. The technique has been successfully used in routine patients with atrial fibrillation and, according to new data presented here in Berlin, is now as effective in AF secondary to endurance sports as in other causes. A series of 182 patients in Dr Mont's Barcelona clinic found that freedom of arrhythmias following CPVA was similar in the sports participants as in the regular patients. Left atrial size and long-standing atrial fibrillation were the only independent predictors for arrhythmia recurrence after the treatment, not sports participation.

2. Deconditioning reverses expression of cardiac fibrosis markers in an animal model of endurance training. A more basic science study from Dr Mont's group in Barcelona also suggests that those with a history of arrhythmias following endurance training may benefit from a period of "deconditioning" following their efforts. The suggestion follows a study in animal models which found that markers of cardiac fibrosis in rats whose treadmill exercise was followed by a period of inactivity returned to control levels. Endurance exercise causes cardiac structural changes, including atrial and right ventricular fibrosis – and this fibrosis may play a role in the development of arrhythmias. Although it has been noted that the athlete's heart regresses after inactivity it is not known if the sport-induced atrial and right ventricular fibrosis also reverses after deconditioning. This study suggests that it does and that a period of inactivity might be of benefit in those with a history of fibrillation.

3. Losartan attenuates heart fibrosis induced by chronic endurance training in an animal model. Just as inactivity after training may inhibit cardiac fibrosis in animal models, a similar study suggests that the anti-hypertensive drug losartan prevents the heart fibrosis induced by endurance exercise. The anti-fibrotic effect of losartan, an angiotensin type-II receptor antagonist, appears to be mediated suppression of angiotensin II-induced proliferation of fibroblasts. Again, markers of fibrosis were reduced by administration of losartan.

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Notes:

1. EHRA, the European Heart Rhythm Association, aims to serve as the leading organisation in the field of arrhythmias and electrophysiology in Europe, and to attract physicians from all of Europe and beyond to foster the development of this area of expertise. EHRA is a registered branch of the European Society of Cardiology (ESC). EHRA is based in Sophia Antipolis, France. Visit us at www.escardio.org/EHRA

2. The European Society of Cardiology (ESC) represents more than 50,000 cardiology professionals across Europe and the Mediterranean. Its mission is to reduce the burden of cardiovascular disease in Europe. Visit us at www.escardio.org

Big disparities in the treatment of arrhythmias across Europe

The latest statistics regarding the use of pacemakers and implantable cardiac devices in Europe was presented on Sunday 21 June, at EUROPACE 2009, the meeting of the European Heart Rhythm Association (EHRA)¹ which takes place in Berlin, Germany from 21 to 24 June.

22 june 2009--These facts and figures, including the current status of healthcare systems across the continent, were included in the EHRA White Book².

"This document is intended to be the starting point in a move towards a homogeneous way of looking at data, resources, physicians, etc., across Europe. Comparison among the countries belonging to the European Society of Cardiology (ESC)³, should help to standardise health resources by promoting knowledge of the status and bringing it to the attention of all public authorities" explained Christian Wolpert, Chairman of the National Societies who contributed the information gathered in the White Book.

"One of the roles of a European Association like the European Heart Rhythm Association (EHRA), a registered branch of the European Society of Cardiology (ESC), is to promote equal access to therapy for all patients across Europe. To do so, the first step is to compile data on the current situation in various ESC membership countries, compare them, and propose actions to move towards harmonization. The current leadership of EHRA agreed on the importance of obtaining as much current information as possible concerning the situation of the practice of electrophysiology in Europe" stressed Wolpert.

Under the leadership of Professors Christian Wolpert from Germany, Panos Vardas from Greece and Josep Brugada from Spain, a group worked to collect the most recent figures. To ensure up to date data, Presidents of the different Working Groups and National Societies were contacted and asked not only to provide data, but also to verify and authorize all the information that became available through various sources.

Wolpert declared that this data is also the point of comparison for the future: " By knowing where we are today, we will be able to benchmark in the future and see how diverse countries evolve. This means that this book must be an ongoing process, with updated information, new and additional data, and the inclusion of information from those countries that have not yet been able to collect and transmit their records."

Explaining the data, Prof Wolpert highlighted certain trends, such as the fact that "more and more, cardiologists represent the majority of implanters while surgeons are decreasingly active in these procedures."

There is a disparate coverage of diseases and treatments within the European Union and the European Society of Cardiology member countries outside of the EU. Some of the countries have no reimbursement e.g. for ICD or pacemaker therapy and the penetration of catheter ablation of atrial fibrillation is very different. Data shows big differences across ESC member countries in:

• Guideline implementation.
• The number of trained physicians and specialised centres
• The number of implantations which seems to depend not only on reimbursement and financial resources, but also to be a function of the number of centres and physicians dedicated to electrophysiology and implantation of devices.
• The numbers of ICD implanting centres range from less than 1 to 6.87 per million citizens.
• Pacemaker therapy is performed in the range of 88 to a maximum of around 1200/ million inhabitants.
• ICD implant rates including CRT-D devices range from approx. 2.5 to 354 per million inhabitants. The data shows an increase for a subset of 16 western and northern European countries around 15% from 2006 to 2007.
• Regarding a potentially different medical consensus in specific countries the use of biventricular pacemakers vs. biventricular ICDs shows a 8:1 ratio at the highest down to 1:1.2 ratio as the lowest.
• In the field of invasive electrophysiology and catheter ablation for supraventricular and ventricular arrhythmias the number of centres available is variable ranging from less than 0.2 to more than 3 centres/ million. The total number of catheter ablations is increasing and reaches a maximum of more than 200/ million in approx. half of the countries. However, there is a strong discrepancy comparing all 35 countries, displaying a wide range from less than 20 to more than 450/ million.
• The same is true for catheter ablation of atrial fibrillation which varies tremendously, linked to reimbursement policies but also to different approaches in the various EP societies.

"As an example, Germany, hosting the EUROPACE meeting this year, has one of the highest implant rates for ICD's in Europe with a total of 1037 centres which implant pacemakers; 200 centres implanting CRT resynchronisation devices and a total of 360 ICD implanting institutions" highlights Prof Wolpert.

"Within the Non-EU ESC member countries, there has been a steady increase of therapy availability and disease coverage, however, there are still many countries that struggle with reimbursement, trained personnel and technical support, which requires a strong effort and leaves much space for improvement. It is the task and the intention of EHRA to support any initiative to improve steadily the situation for these countries in order to reduce the disparities".

The first EHRA White Book was published in 2008 containing information for 2006 and 2007 from 35 of the 51 ESC member countries from all sites of Europe and parts of the Middle East. The book was made fully available to the public in an electronic version and within short time it became one of the most popular downloads in the EHRA website.

"We hope that this book will be useful to all electrophysiologists and health care providers in Europe and will initiate an era of evolution towards a more unified Europe in terms of equal access to therapy for all patients, regardless of their country origin", concluded Prof Wolpert.

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NOTES:

1 EHRA, the European Heart Rhythm Association, aims to serve as the leading organisation in the field of arrhythmias and electrophysiology in Europe, and to attract physicians from all of Europe and beyond to foster the development of this area of expertise. EHRA is a registered branch of the European Society of Cardiology (ESC). EHRA is based in Sophia Antipolis, France. Visit us at www.escardio.org/EHRA