Chronic Kidney Disease Predicts Risk for Thromboembolism in Patients with Afib

Chronic kidney disease is an independent predictor of incident thromboembolism among patients with atrial fibrillation, according to a Circulation study published online.

06 mar 2009--Researchers examined data from a U.S. healthcare system on some 11,000 adults with nonvalvular afib and no previous kidney transplant. During roughly 33,000 person-years of follow-up, nearly 700 thromboembolic events occurred while patients were off anticoagulation.

In adjusted analyses, thromboembolism was significantly more common both among patients with reduced estimated glomerular filtration rates than among those with the highest eGFRs (hazard ratio, 1.4), and among those with proteinuria than among those with normal urine tests (HR, 1.5).

The authors say their study suggests that eGFR and proteinuria should be assessed in patients with afib in order to help "improve risk stratification and decision making about the use of antithrombotic therapy to prevent stroke."

LINK(S):

Circulation article (Free abstract; full text requires subscription)

Rectal Cancer Outcomes Best With Short-Course Radiation

06 mar 2009 -- For people with operable rectal cancer, the most effective treatment is a short course of radiation therapy followed by "high-quality surgery," according to a new study.

Surgery is the standard treatment for rectal cancer, but just removing the tumor leaves a risk of cancer recurrence in the same area, according to background information. Previous research has shown that radiotherapy and chemotherapy after surgery can reduce the risk of recurrence. However, radiotherapy is costly and can cause long-term complications such as impaired bowel function, incontinence and sexual dysfunction.

The study involved 1,350 rectal cancer patients in the United Kingdom, Canada, South Africa and New Zealand. Professor Robert Steele, of Ninewells Hospital in Dundee, Scotland, and his colleagues randomly assigned the participants to receive five daily treatments of radiotherapy followed by surgery, or to have surgery followed by 25 treatments of chemo-radiotherapy.

Three years after treatment, 4.4 percent of those who had received radiotherapy before surgery had a local recurrence of the cancer, compared with 10.6 percent of those who had received radiotherapy after surgery. The disease-free survival rate after three years was 77.5 percent for people who had received pre-surgery radiotherapy and 72 percent for those who had gotten post-surgery radiotherapy. There was no significant difference in overall survival -- 157 deaths in the pre-surgery radiotherapy group and 173 deaths in the post-surgery group.

The findings were published in this week's issue of The Lancet.

Another study in the same issue of the journal found that recent improvements in surgical techniques have improved rectal cancer patient outcomes. Professor Phil Quirke, of the University of Leeds, in the United Kingdom, and his colleagues assessed how circumferential resection margin and the plane of surgery (the amount of tissue removed around the tumor) affected cancer recurrence risk in 1,156 people.

Of that group, 128 (11 percent) had involvement of the circumferential resection margin -- the presence of a tumor within 1 millimeter of the circumferential margin, which is associated with a high risk of local recurrence and poor survival. The plane of surgery was good (mesorectal) in 604 patients (52 percent), intermediate (intramesorectal) in 398 (34 percent) and poor (muscularis propria plane) in 154 (13 percent).

Three years after surgery, cancer had recurred locally in 6 percent of those with a negative circumferential margin and in 17 percent who had a positive circumferential margin. Local recurrence occurred in 4 percent of people in the mesorectal group, 7 percent in the intramesorectal group and 13 percent in the muscularis propria plane group.

For any plane of surgery achieved, short-course radiotherapy before surgery reduced local recurrence by about half, the study found.

"At present, only 50 percent of rectal cancer surgery is done in the mesorectal plane, suggesting that a further decrease in local recurrence rates might be obtained by improving the plane of surgery achieved," the researchers concluded. "[This could] be achieved through education and surgical tuition."

The findings of these studies show that "perioperative radiation can mitigate but not eliminate the adverse effects of imperfect surgery," Dr. Robert Madoff, of the University of Minnesota, wrote in an accompanying comment in the journal. "The best outcomes occurred when preoperative radiation was followed by optimum surgery. … The next challenge is to understand which patient needs what therapy to maximize his or her chances for a cure."

Warning: Don't wear medication patches during MRI

By LAURAN NEERGAARD

WASHINGTON, 06 mar 2009– Need an MRI scan? Tell the doctor if you use a nicotine patch or any other medication patch — or you'll risk a burn during the MRI.

Patches that ooze medication slowly through the skin are becoming more popular, from over-the-counter nicotine patches to prescription patches that deliver estrogen, pain medication, Alzheimer's or Parkinson's drugs, even an anti-nausea drug for chemotherapy recipients.

But the Food and Drug Administration just discovered that some are missing a key safety warning about MRI compatibility.

More than a quarter of the 60 different drug patches sold contain traces of aluminum or other metals in their backing, the part that makes them stick to the skin, estimated Dr. Sandra Kweder, the FDA's deputy drug director.

You can't see the metal; the patch even may appear completely clear. But affected patches contain just enough metal to conduct electricity, meaning a patch worn during an MRI scan can overheat and cause a skin burn similar to a bad sunburn.

The FDA recently learned of a few patients who suffered patch burns, none severe. In January, tracking the source of one burn, officials found that Teva Pharmaceuticals' fentanyl painkiller patch lacked the MRI warning. The FDA then found a variety of other drug patches also lacked the warning.

On Thursday, the FDA issued a public health advisory: Tell your doctor about any medication patches, so the professional can decide which should be removed before an MRI, how soon before the scan, and when it can be reapplied.

"If there's any uncertainty, just don't wear it in the machine," Kweder said. "It's just the smart thing to do."

As for patch makers, FDA is reviewing every product's label to be sure ones that are supposed to carry the safety warning do. Some may be missing because a patch was reformulated to add metal after its label was written; other times FDA acknowledged it just didn't ensure the warning was present in the first place.

Now the agency is considering having an MRI warning somehow be put on the individual patch, not just the box it comes in.

"We have to look at the different configurations of these patches and what's going to be practical to allow for this," Kweder said.

Mortality risk greater for elderly women who nap daily

Older women who reported taking daily naps had a significantly greater risk of dying

San Francisco, Calif.05 mar 2009– A new study appearing in Journal of the American Geriatrics Society has found that older women who reported taking daily naps had a significantly greater risk of dying. The results of the study are in contrast to a number of prior studies which have indicated that daily napping improves health.

Four communities consisting of 8,101 Caucasian women aged 69 and older were studied over a 7-year period. Women who reported napping daily were 44 percent more likely to die from any cause, 58 percent more likely to die from cardiovascular causes and 59 percent more likely to die from non-cardiovascular, non-cancer causes. This relationship remained significant among relatively healthy women.

The findings also showed that older women who reported sleeping between 9-10 hours per 24-hour period also had a greater risk of mortality compared to those who slept between 8-9 hours. The association was strongest for cardiovascular-related mortality.

The results of this study should not be interpreted to mean that napping causes poor health outcomes, and it is not recommended that older adults avoid napping. Napping and long sleep duration may be caused by sleepiness due to underlying sleep disorders or other medical conditions. "Since excessive sleep suggests that night time sleep is disrupted, interventions to treat sleep disorders and improve sleep quality in older women may reduce mortality risk," says Katie L. Stone, co-author of the study. Additional studies are needed to explain why napping is linked with increased risk of death.

Noted in the study, however, was that elderly women who napped less than 3 hours per week were not at increased risk of mortality compared to women who did not nap at all. "Shorter and less frequent naps do not appear to be related to any increase in risk of death," says Stone.

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This study is published in Journal of the American Geriatrics Society. Media wishing to receive a PDF of this article may contact medicalnews@bos.blackwellpublishing.net

Innappropriate drug prescriptions wasting millions, raising health risks

CORVALLIS, Ore., 05 mar 2009– A recent study in Oregon suggests that drugs designed for treating the most severe mental illnesses are often prescribed at inappropriately low doses and at considerable expense, for use in conditions where their benefit has not been established.

In this case, prescription drugs that might cost as much as $20 to $25 a day were being widely used to treat problems for which they were not FDA-approved. Some of those problems could have been addressed with generic medications costing $1 a day, with better results and less risk of serious side effects.

This is a reflection of widespread use of medications for "off-label" uses that have not been carefully considered or approved by the Food and Drug Administration, researchers said, some of which are unnecessarily raising medical costs and reducing the effectiveness of health care.

The research was done by scientists in the College of Pharmacy at Oregon State University, the Department of Psychiatry at Columbia University, and Oregon Health and Science University. It was published in the Journal of Clinical Psychiatry, and funded by the National Institutes of Health.

"It's legal for a physician to prescribe a medication for something other than its FDA-approved uses, and based on good studies or clinical judgment it may be justified," said Daniel Hartung, an assistant professor of pharmacy practice at OSU. "However, the approved uses are usually a pretty good proxy for real, proven effectiveness. And if in fact drugs are being used inappropriately, it not only can be very expensive but also pose an unnecessary health risk."

Both of those problems were found in this study.

In this case, the health conditions of 830 Oregon Medicaid patients were examined – all of whom had been given one of the newer antipsychotic medications approved only for some of the most severe forms of mental illness, such as schizophrenia or bipolar disorder. However, the researchers found that the vast majority of the people receiving one of these drugs did not have schizophrenia or bipolar disorder, the underlying mental health conditions for which the drugs had been approved.

Most people who received these "atypical antipsychotic" drugs, which are very powerful and have potentially severe side effects, had less serious mental health concerns such as depression, anxiety, post-traumatic stress disorder – or no psychiatric disorder other than insomnia.

The newer antipsychotic drugs can cause side effects such as neuromuscular rigidity, increased risk of stroke, heart arrhythmias, moderate-to-severe weight gain, and worsening glucose control that leads to increased risk of diabetes. The drugs may be necessary for patients with major mental health problems such as schizophrenia, Hartung said, but have not been demonstrated to be effective for most of their off-label uses, such as depression or agitation in persons suffering from dementia.

The prescriptions, he said, were also often given at lower doses and for shorter time periods than anything that has been shown to be therapeutic.

And the concerns involve many types of practitioners, the study found – the medications were prescribed by primary care physicians and nurse practitioners and, to a lesser extent, psychiatrists and psychiatric nurse practitioners.

"Some drug companies have been accused of encouraging and expanding the off-label use of drugs, and that may be where part of this misinformation is coming from," Hartung said. "That is an illegal practice, and some companies have been successfully sued on that basis. Regardless of what's causing this, it's a serious concern, both for ensuring resources are used judiciously and protecting health care quality."

These issues should be more carefully explored, the researchers said in their study. They are particularly relevant to Medicaid programs, in which use of antipsychotic medications is surging. In 2002 these drugs constituted more than 7 percent of the expenditures for all Medicaid programs nationally. In Oregon, the medications represented nearly 30 percent of all outpatient fee-for-service drug expenditures in 2006.

During 2006, the study found, the Oregon Medicaid program spent about $2.5 million for chronic, subtherapeutic use of a single antipsychotic drug in adult patients.

Based on this, the researchers concluded that "a statewide initiative to provide guidance regarding the administration of antipsychotic medication could be beneficial."

The study was done in Oregon, Hartung said, but is probably a reflection of trends across the nation.

The researchers wrote in their report that "states wishing to reduce costs and improve the quality of use for atypical antipsychotic medications should examine prescribing patterns to ensure that these drugs are prescribed within acceptable practice limits, and are not used for off-label uses when other approaches may be more appropriate and less expensive."

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About the OSU College of Pharmacy: The College of Pharmacy prepares students of today to be the pharmacy practitioners and pharmaceutical sciences researchers of tomorrow by contributing to improved health, advancing patient care and the discovery and understanding of medicines.

Is one diet as good as another? U of I study says no and tells you why

Any diet will do? Not if you want to lose fat instead of muscle. Not if you want to lower your triglyceride levels so you'll be less likely to develop diabetes and heart disease. Not if you want to avoid cravings that tempt you to cheat on your diet. And not if you want to keep the weight off long-term.

05 mar 2009--"Our latest study shows you have a better chance of achieving all these goals if you follow a diet that is moderately high in protein," said Donald Layman, a University of Illinois professor emeritus of nutrition. The research was published in the March Journal of Nutrition.

Layman's new study followed the weight-loss efforts of 130 persons at two sites, the U of I and Penn State University, during 4 months of active weight loss and 8 months of maintenance.

Two previous studies had looked at short-term weight loss; this one was designed to look at long-term effects, he said.

Although both plans were equal in calories, half the group followed a moderate-protein diet (40% carbohydrates, 30% protein, 30% fat) while the other followed a diet based on USDA's food-guide pyramid (55% carbohydrates, 15% protein, 15% fat).

"Persons in the first group ate twice the amount of protein as the second group," said Layman.

And the difference in protein made all the difference in improved body composition and body lipids, he said.

Although the amount of weight lost in both groups was similar, at 4 months participants in the protein group had lost 22 percent more body fat than members of the food-pyramid group. At 12 months, the moderate-protein dieters had lost 38 percent more body fat.

"The additional protein helped dieters preserve muscle. That's important for long-term weight loss because muscle burns calories—if you lose muscle, and you used to be able to consume 2,000 calories without gaining weight, you'll find that now you can only eat, say, 1,800 calories without weight gain," he said.

What were the effects on lipids? Although at 4 months the food-guide pyramid appeared to be more effective in lowering LDL and total cholesterol levels, at 12 months LDL levels came back up until both diets were equally effective, Layman said.

"This is the first study to show that short-term changes in LDL cholesterol are not maintained with long-term weight loss. Most scientists believe that high cholesterol is more a factor of genetics than of diet," he said.

But the moderate-protein diet had by far the bigger effect on lowering triglycerides, and that lasted as long as individuals remained on the diet, he said.

"Of the two types of lipid problems, high triglycerides pose a greater risk for heart disease. Approximately twice as many people have high triglycerides, and people with this condition are approximately four times more likely to die from heart disease," the scientist said.

To ensure compliance, participants met every week for weigh-ins and nutrition instruction. "We taught participants how to follow their diet, how to grocery shop, and how to prepare the meals. They also measured everything they ate three days a week," he said.

"Studies that report there is no difference among diets also report that subjects were not carefully following the diets," said Layman. "It's very important to realize the difference between diet compliance and diet effectiveness."

The protein diet was easier to follow and maintain long-term, with 64 percent of the moderate-protein dieters completing the study compared to 45 percent of dieters using the high-carbohydrate diet, Layman said.

"Subjects on the moderate-protein diet reported that they weren't as interested in snacks or desserts, and they didn't have food cravings. When you eat protein, you feel full longer," he said.

Average weight loss for the protein group was 23 percent higher than the food-pyramid group, with 31 percent of "completers" in the protein group losing more of than 10 percent of their initial body weight versus 21 percent of the food-pyramid group.

Stem cells could halt osteoporosis, promote bone growth

MUHC team describes a new pathway that controls bone remodelling

Montreal, 05 mar 2009– While interferon gamma sounds like an outer space weapon, it's actually a hormone produced by our own bodies, and it holds great promise to repair bones affected by osteoporosis. In a new study published in the journal Stem Cells, researchers from the Research Institute of the McGill University Health Centre explain that tweaking a certain group of multipotent stem cells (called mesenchymal stem cells) with interferon (IFN) gamma may promote bone growth.

"We have identified a new pathway, centered on IFN gamma, that controls the bone remodelling process both in-vivo and in-vitro," explains Dr. Kremer, the study's lead author and co-director of the Musculoskeletal Axis of the McGill University Health Centre. "More studies are required to describe it more precisely, but we are hopeful that it could lead to a better understanding of the underlying causes of osteoporosis, as well as to innovative treatments."

From cell culture to animal model

"First, we stimulated cultured mesenchymal stem cells to turn into bone cells (osteoblasts) in-vitro," says Dr Richard Kremer, a Professor with the McGill's Faculty of medicine. "We realised that this differentiation process involved IFN gamma-related genes, but also that these bone cells precursors could both be stimulated by IFN gamma and produced IFN gamma."

The next step was to move to an animal model where IFN gamma effect is blocked by inactivating its receptor, a model called IFN gamma receptor knock-out. Bone density tests, comparable to those used to diagnose people with osteoporosis, were conducted. The results revealed that these animals have significantly lower bone mass than their healthy counterparts In addition, their mesenchymal stem cells have a decreased ability to make bone. "These findings confirm that IFN gamma is an integral factor for mesenchymal stem cells' differentiation into osteoblasts also in-vivo," says Dr. Kremer.

New biological pathway, now hope for treatments

Both in-vitro and in-vivo results proved that IFN gamma is key to the differentiation of mesenchymal cells into bone cells, and to growth process of the bone. The exact pathway by which IFN acts on bone cells' formation will require more research to be described, but the strict correlation highlighted in this study leaves no doubt on its importance.

Until now, IFN gamma has been mostly used as an agent to prevent infections and to reinforce the immune system from illnesses such as cancer. These findings provide hope that IFN gamma itself, or another molecule involved in its pathway, could soon also become an efficient drug-target for an antidote for osteoporosis.

'Pre-diabetics' face heightened risk of heart disease

Routine glucose testing and preventive therapies could reduce risk

The study, published in the Journal of Clinical Endocrinology & Metabolism, was led by Jill P. Crandall, M.D., associate professor of clinical medicine and director of the Diabetes Clinical Trials Unit at Einstein.

05 mar 2009--Diabetes becomes increasingly common with age. An estimated 37 million Americans over the age of 65 have diabetes, almost one-quarter of that population. Another 20 to 30 percent of seniors, an estimated 7.5 to 11.1 million, are not clinically diabetic but have impaired glucose tolerance, which is considered a form of "pre-diabetes."

"In most cases, this mild form of high blood glucose causes no symptoms and is often overlooked by both doctors and patients, but studies have shown that it may be associated with increased risk of heart disease," says Dr. Crandall. "The purpose of this study was to explore the cardiovascular risk profile of older adults with pre-diabetes."

The study looked at 58 older adults with an average age of 71, half with normal glucose tolerance and half with post-challenge hyperglycemia (PCH). PCH is characterized by a temporary spike in blood glucose levels that occurs immediately after a meal. Various measures were taken before and after study participants consumed a standard high carbohydrate meal.

The researchers found that the adults with PCH not only had higher glucose and insulin levels after the meal, but also higher levels of triglycerides (a type of blood fat considered an independent risk factor for cardiovascular disease). They also had higher levels of a protein that promotes blood clotting, and more inflammation of blood vessels, compared to controls. In addition, a test of blood vessel function after the meal showed impairment only in the PCH group. Studies show that increases in each of these measures raise one's risk for heart disease.

Routine glucose screening of the elderly, using the standard oral glucose tolerance test (OGTT), could be used to identify these high-risk individuals, the researchers note. The OGTT measures the body's ability to use glucose, the body's main source of energy. The test begins with a measure of one's fasting blood glucose level, providing a baseline for comparing other glucose values. The patient then drinks a sweet liquid containing a specific amount of glucose. Blood samples are collected at several intervals over the next two or three hours.

Despite the results of this study, it has not been established whether treatment aimed at reducing mild hyperglycemia will lower their risk for heart disease. "Consequently, other interventions designed to reduce the risk of cardiovascular disease, including the use of statins and aspirin, should be strongly considered for older adults with PCH," says Dr. Crandall.

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Dr. Crandall's co-authors, all based at Einstein, include Harry Shamoon, M.D., professor of medicine and associate dean for clinical research; Hillel W. Cohen, Ph.D., associate professor of epidemiology & population health; Migdalia Reid, R.N., M.P.H.; Srikanth Gajavelli, M.D.; Gilda Trandafirescu, M.D.; Vafa Tabatabaie, M.D.; and Nir Barzilai, M.D., professor of medicine and of genetics.

The study, "Post-challenge Hyperglycemia in Older Adults is Associated with Increased Cardiovascular Risk Profile," was published in the February 10 online version of the Journal of Clinical Endocrinology & Metabolism.

New 'smart' homes for dementia sufferers

Within five years innovative 'smart' sensing systems that will help the UK's 700,000 dementia sufferers live independently at home could be available commercially.

04 mar 2009--Once installed, the systems are designed to closely monitor people's movements and actions around the home. As well as providing voice-prompts (e.g. reminders to turn off a tap or cooker), they can also directly switch lights or appliances on and off in order to eliminate potential dangers.

Developed at the University of Bath with funding from the Engineering and Physical Sciences Research Council (EPSRC), the systems incorporate specially developed, cutting-edge sensor, electronics and IT capabilities.

Two trial systems installed in care homes in London and the West Country have now been operating successfully for over a year.

They are providing clear evidence that, if installed in domestic properties, systems like this could help people with dementia live safely and with more control over their lives. They could be particularly useful where sufferers live on their own.

As well as boosting quality of life for those with dementia, the systems could help reduce the burden on the families of people with the condition, as well as on professional carers and healthcare budgets.

A mocked-up living environment with working examples of these 'smart' technologies will be on show at EPSRC's 'Pioneers 09' showcase event, to be held on Wednesday 4th March at London's Olympia Conference Centre.

Professor Roger Orpwood, the lead scientist behind the systems' development, says: "The driver really has been to arrive at a creative engineering solution that addresses real problems faced by real people with real needs. The key is to focus on enabling people, not on taking decisions away from them."

It is envisaged that systems installed in domestic properties would function on a simple 'plug in and use' basis, with minimal visibility or intrusiveness.

The key will be to tailor them to individual requirements and ensure that they act as much like a live-in carer as possible. For example, voice-prompts can utilise the voices of relatives or friends to deliver reassuring messages, as well as to influence behaviour.

The systems are also designed to be monitored remotely via computer by healthcare professionals.

Professor Orpwood says: "The next step is to make sure the systems can be managed by non-technical local authority carers and healthcare staff. If manufacturers can be brought on board, we could see systems in people's houses within five years or so."

Evaluation of the two trial systems is currently being funded by two medical charities.

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Notes for Editors

'Pioneers 09' aims to bring together forward-thinking researchers and business people. It is being organised by EPSRC and supported by the Confederation of British Industry.

Venue directions for Olympia Conference Centre, Kensington, London:

The nearest underground and overground station is Kensington (Olympia). Turn left out of the exit of the station and walk to the end of Olympia Way. Turn right onto Hammersmith Road. The entrance to Olympia Two is a short distance along on the right-hand side. Olympia Conference Centre is further along on the right-hand side.

For detailed directions and a map, please visit http://www.eco.co.uk/visitors/travel/

It is estimated that there are currently 700,000 people in the UK living with dementia. As the proportion of older people within the population grows, this number could double over the next 30 years.

The Engineering and Physical Sciences Research Council (EPSRC) is the UK's main agency for funding research in engineering and the physical sciences. EPSRC invests around £740 million a year in research and postgraduate training, to help the nation handle the next generation of technological change. The areas covered range from information technology to structural engineering, and mathematics to materials science. This research forms the basis for future economic development in the UK and improvements for everyone's health, lifestyle and culture. EPSRC also actively promotes public awareness of science and engineering. EPSRC works alongside other Research Councils with responsibility for other areas of research. The Research Councils work collectively on issues of common concern via Research Councils UK. Website address for more information on EPSRC: www.epsrc.ac.uk/

For more information, contact:

Professor Roger Orpwood, University of Bath, tel: 01225 824103, e-mail: r.d.orpwood@bath.ac.uk

Patients 'Connected' to a Specific Physician More Likely to Receive Recommended Care

04 mar 2009--Patients who use a single primary care physician are more likely to receive guideline-consistent care, reports Annals of Internal Medicine.

Researchers assessed whether some 156,000 adults seen at 13 practices in a primary care network were considered "connected" to a particular physician, and then examined whether connectedness was associated with quality of care. (Connectedness was determined using an algorithm that predicted the likelihood that a physician would identify a patient as "my patient.")

In adjusted analyses, patients who were connected to a specific physician were significantly more likely to receive guideline-recommended cancer screenings and chronic disease management, compared with those connected to only a practice.

An editorialist says the findings "make a strong case" that a personal physician improves quality — which has important implications for promoting a "patient-centered medical home" approach to primary care.

LINK(S):

Annals of Internal Medicine article (Free abstract; full text requires subscription)

Annals of Internal Medicine editorial (Subscription required)

Using PPIs with Clopidogrel Associated with Adverse Outcomes After ACS

04 mar 2009--After acute coronary syndrome, use of a proton pump inhibitor (PPI) alongside clopidogrel is associated with more frequent rehospitalization or mortality compared with clopidogrel alone, according to an observational study in JAMA.

Veterans Affairs researchers examined outcomes in some 8200 patients prescribed clopidogrel at discharge after ACS. Nearly two thirds of the patients also received a PPI either at discharge or during a median 1.5-year follow-up. The primary endpoint, a combination of rehospitalization for ACS or death from any cause, occurred more often among those taking clopidogrel with a PPI than among those taking clopidogrel alone.

The authors note that previous studies have shown that PPIs attenuate clopidogrel's antiplatelet effects.

In Journal Watch Cardiology, JoAnne Foody concludes: "Although [the current] results bear the limitations of all observational studies ... clinicians should consider this potential interaction when they weigh the pros and cons of prescribing a PPI with clopidogrel for ACS patients."

LINK(S):

JAMA article (Free)

Moderate alcohol intake associated with bone protection

Epidemiological study examines effects of beer, wine and liquor on BMD

BOSTON , 04 mar 2009-- In an epidemiological study of men and post-menopausal women primarily over 60 years of age, regular moderate alcohol intake was associated with greater bone mineral density (BMD). Researchers at the Jean Mayer USDA Human Nutrition Research Center on Aging (USDA HNRCA) at Tufts University found associations were strongest for beer and wine and, importantly, BMD was significantly lower in men drinking more than two servings of liquor per day. The results suggest that regular moderate consumption of beer or wine may have protective effects on bone, but that heavy drinking may contribute to bone loss.

"Previous research suggests that moderate alcohol consumption in older men and post-menopausal women may protect against BMD loss, a major risk factor for osteoporosis," said Katherine L. Tucker, PhD, corresponding author and director of the Dietary Assessment and Epidemiology Research Program at the USDA HNRCA. The 2005 Dietary Guidelines issued by the federal government defines moderate alcohol consumption as one drink per day for women and two drinks per day for men.

"Our study also looks at the possible effects of the three alcohol classes, beer, wine and liquor on BMD," Tucker continued. "We saw stronger associations between higher BMD and beer drinkers, who were mostly men, and wine drinkers, who were mostly women, compared to liquor drinkers." The results were published online February 25 by the American Journal of Clinical Nutrition.

Tucker, who is also a professor at the Friedman School of Nutrition Science and Policy at Tufts, and colleagues analyzed BMD measurements taken at three hip sites and the lumbar spine in 1,182 men, 1,289 post-menopausal women, and 248 pre-menopausal women whose parents or in-laws participated in the original Framingham Heart Study. There was not enough data to determine the effects of more than two servings of alcohol per day in post-menopausal women or the effects of daily alcohol consumption on BMD in pre-menopausal women. Participants self-reported their alcohol intake on dietary questionnaires. One serving of beer equaled a glass, bottle or can (356 mL), one serving of wine equaled a 4-oz. glass (118 mL), and one serving of liquor equaled one mixed drink or shot (42 mL).

After adjusting for several other factors that may have accounted for the higher BMD, such as silicon intake, calcium intake and smoking history, the authors still saw an association between higher BMD and moderate alcohol consumption. One of the strongest associations was seen in men who reported consuming one or two servings of total alcohol (a combination of beer, wine and liquor) or one or two servings of beer per day. Hip BMD in this group was significantly greater compared to non-drinkers.

In contrast, the authors observed significantly lower BMD at the hip and spine in men who consumed more than two servings of liquor per day compared to men who consumed one or two servings of liquor per day. "There is a body of research showing alcoholism is devastating to bones," Tucker said. "It's a major risk factor for osteoporosis. No one should depend solely on alcohol to maintain bone health."

The authors hypothesize that the silicon found in beer is contributing to the higher BMD scores in the men who reported consuming one or two servings of total alcohol or beer per day, citing previous studies finding silicon has greater bioavailability as a liquid. It is less clear why liquor and wine might protect BMD.

"We cannot say definitively what component of these alcoholic drinks might be beneficial to bone health because our findings are from an observational study, as opposed to a clinical trial," Tucker said. "Future studies might dig deeper into patterns of alcohol consumption, as we relied on a self-reported dietary questionnaire. Another component of data worthy of exploration is whether the antioxidants found in wine, such as revesterol or polyphenols, have a protective effect on bone in addition to other health benefits."

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The study was supported by a USDA contract and grants from the National Institutes of Health (NIH). Co-authors Ravin Jugdaohsingh and Jonathan J. Powell, at the Rayne Institute, St. Thomas' Hospital, London, UK, have an active grant from the charitable foundation of the Institute of Brewing and Distilling. Co-author Supannee Sripanyakorn is sponsored by a studentship from the Government of Thailand and Jugdaohsingh is sponsored by a fellowship from The Frances and Augustus Newman Foundation.

Is esomeprazole the best choice for reflux esophagitis patients?

04 mar 2009--In patients with gastroesophageal reflux disease (GERD), esomeprazole, has demonstrated pharmacological and clinical benefits beyond those seen with the other proton pump inhibitors( PPIs ). However it has not hitherto been fully determined whether differences in the onset of antisecreatary activity may affect the speed of symptom relief with different PPI.

Dr. Ri-Nan Zheng from China addresses this question. He investigated whether there is any difference in the symptom relief in patients with reflux esophagitis following the administration of four PPIs (omeprazole, lansoprazole, pantoprazole, esomeprazole). This will be published on February 28, 2009 in the World Journal of Gastroenterology.

In this study, two hundred and seventy-four patients with erosive reflux esophagitis were randomized to receive 8 wk of 20 mg omeprazole (n = 68), 30 mg of lansoprazole (n = 69), 40 mg of pantoprazole (n = 69), 40 mg of esomeprazole (n = 68) once a day in the morning. Daily changes in heartburn and acid reflux symptoms in the first 7 d of administration were assessed using a six-point scale (0: none; 1: mild; 2: mild-moderate; 3: moderate; 4: moderate-severe; 5: severe).

He found that the mean heartburn score in patients treated with esomeprazole more rapidly decreased than those receiving other PPI. Complete resolution of heartburn was also more rapid in patients treated with esomeprazole for 5 d compared with omeprazole (P = 0.0018, P = 0.0098, P = 0.0027, P = 0.0137, P = 0.0069, respectively), lansoprazole (P = 0.0020, P = 0.0046, P = 0.0037, P = 0.0016, P = 0.0076, respectively), and pantoprazole (P = 0.0006, P = 0.0005, P = 0.0009, P = 0.0031, P = 0.0119, respectively). There were no significant differences between the four groups in the rate of endoscopic healing of reflux esophagitis at week 8.

The results indicated that esomeprazole may be more effective than omeprazole, lansoprazole, and pantoprazole for the rapid relief of heartburn symptoms and acid reflux symptoms in patients with reflux esophagitis.

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Reference: Zheng RN. Comparative study of omeprazole, lansoprazole, pantoprazole and esomeprazole for symptom relief in patients with reflux esophagitis. World J Gastroenterol 2009; 15(8): 990-995 http://www.wjgnet.com/1007-9327/15/990.asp

Correspondence to: Sun-Mi Choi, OMD, PhD, Department of Medical Research, Korea Institute of Oriental Medicine, 483 Exporo, Yuseong-gu, Daejeon 305-811, South Korea. smchoi@kiom.re.kr

In Elderly Women, Hip Fractures Often Follow Arm Breaks

03 mar 2009-- Elderly women who suffer a broken upper arm are five times more likely than normal to break a hip within a year after the arm fracture, a finding from a new study that might help in efforts to prevent both types of fractures.

"There have been studies in the past showing a relationship between upper arm fractures and hip fractures, but we wanted to determine when that risk is greatest," Dr. Jeremiah Clinton, an orthopedic surgeon and associate professor of orthopedics at the University of Washington in Seattle, said in an American Academy of Orthopaedic Surgeons news release. "By recognizing when that period of increased risk occurs, physicians have a window of opportunity to take steps that may possibly prevent a subsequent fracture."

The study was published in the March issue of The Journal of Bone & Joint Surgery.

The exact relationship between arm and hip fractures isn't clear, but "there is evidence to support that both fractures stem from similar reactions to a fall," Clinton said. "When patients age, their reflexes slow down, and they may not have the time or ability to correctly position themselves as they fall. Rather than trying to catch themselves as a younger person would do, studies show that elderly people have a tendency to simply tuck and roll, which causes greater force on the shoulder and hip."

Causes of falls among elderly people include: effects of medications, neurological disorders, loss of an ability to maintain balance and decreased reaction time.

"One of the first steps a patient should take following a fall is to talk with their orthopedist and other physicians to determine the cause," Clinton said. "Once the cause is more clearly understood, the proper steps can be taken to decrease a patient's risk of having another fall and potentially future fractures."

Wine May Be Protective Against Esophageal Cancer

03 mar 2009-- Drinking a glass of wine a day may lower the risk of Barrett's esophagus, a condition that precedes esophageal cancer.

Barrett's esophagus, which affects about 5 percent of the population, occurs when heartburn or acid reflux permanently damages the lining of the esophagus. People with this condition are 30 to 40 times more likely to develop a type of esophageal cancer called esophageal adenocarcinoma. In the last 30 years, the incidence of esophageal cancer in the United States has increased 500 percent.

In this Kaiser Permanente study, researchers looked at 953 men and women in Northern California and found that those who drank one or more glasses of red or white wine a day were 56 percent less likely to develop Barrett's esophagus. Beer or liquor did not lower the risk, and the protective effect of wine didn't increased with higher consumption.

"The rate of esophageal adenocarcinoma in this country is skyrocketing, yet very little is known about its precursor, Barrett's esophagus. We are trying to figure out how to prevent changes that may lead to esophageal cancer," principal investigator Dr. Douglas A. Corley, said in a Kaiser Permanente news release.

The study was published in the March issue of Gastroenterology. Two other studies in the same issue of the journal reported similar findings. An Australian study found that people who drink wine were less likely to develop adenocarcinoma, and Irish researchers reported that drinking wine reduces the risk of esophagitis, an irritation of the esophagus that follows chronic heartburn and often precedes Barrett's esophagus and cancer.

It's not clear why wine may lower the risk of Barrett's esophagus. Researchers suggest it may be because antioxidants in wine neutralize the damage done by gastroesophageal reflux disease. Or it may be because wine drinkers typically have food with their wine, thereby reducing the potentially damaging effects that drinking alcohol alone can have on esophageal tissue.

The wine study is part of a larger Kaiser Permanente study led by Corley looking at the link between Barrett's esophagus and abdominal obesity and consumption of dietary antioxidants, fruits and vegetables. That study found that eating eight servings of fruit and vegetables a day and maintaining normal body weight can reduce the risk of Barrett's esophagus.

"My advice to people trying to prevent Barrett's esophagus is: Keep a normal body weight and follow a diet high in antioxidants and high in fruits and vegetables," Corley said. "We already knew that red wine was good for the heart, so perhaps here is another added benefit of a healthy lifestyle and a single glass of wine a day."

Alcohol types and socioeconomic status are associated with Barrett's esophagus risk

Additional study suggests drinking alcohol in early adulthood may increase reflux esophagitis risk

Bethesda, MD, 03 mar 2009– Although the relationship between alcohol and esophageal squamous cell carcinoma is well established, studies investigating the association between alcohol intake and reflux esophagitis (RE), Barrett's esophagus (BE) and esophageal adenocarcinoma (EAC) have reported inconsistent findings. Furthermore, little is known regarding the effect of alcohol on BE, especially related to alcohol types.

Two recent studies published in Gastroenterology further our understanding of these illnesses. Gastroenterology is the official journal of the American Gastroenterological Association (AGA) Institute.

Education Status Is Significantly Inversely Associated with BE Risk

A new diagnosis of BE is associated with alcohol types, and the effects are modified by the presence of vitamin supplement use, according to a new study in Gastroenterology. The observed associations are independent of demographic and life-style factors that are related to choice of alcoholic beverages, including vitamin supplement use. In addition, higher education level is inversely related to the risk.

People with BE have a 30 to 125 fold increased risk of developing EAC compared to the general population. The incidence of EAC has increased by more than 500 percent in the last three decades, more rapidly than any other malignancy in the U.S. The rate of increase is most predominant among Caucasian males, suggesting that environmental or lifestyle factors may play important roles in the change in incidence.

"The identification of risk factors for BE may provide information on early events in the carcinogenic pathway for EAC that could lead to effective intervention strategies," said Ai Kubo, PhD, of Kaiser Permanente and lead author of the study.

This study is the first community or population-based study in the U.S. to evaluate alcohol and socio-demographic factors as risk factors for BE. Using a case-control study within the Kaiser Permanente Northern California membership, patients with a new diagnosis of BE (n=320) between 2002 and 2005 were matched to persons with gastroesophageal reflux disease (GERD; n=316) and to population controls (n=317). Information was collected using validated questionnaires during direct in-person interviews; analyses used multivariate unconditional logistic regression.

Total alcohol use was not significantly associated with the risk of BE, although stratification by beverage type showed an inverse association for wine drinkers compared to nondrinkers (seven+ drinks wine/week versus none: OR=0.44, 95 percent CI (0.20-0.99); multivariate analysis). Among population controls, those who preferred wine were more likely to have college degrees and regularly take vitamin supplements than those who preferred beer or liquor. Adjustment for these factors or GERD symptoms did not eliminate the inverse association between wine consumption and BE. Education status was significantly inversely associated with the risk of BE.

"Future studies examining the interaction between vitamin supplement and alcohol types and how socioeconomic status may affect GERD and BE are needed," added Dr. Kubo.

Total Alcohol Consumption at 21 Is Significantly Associated with RE

Alcohol consumption in early adulthood may lead to the development of reflux esophagitis (RE), according to a new study in Gastroenterology. However, more recent alcohol consumption does not appear to confer any increased risk of RE, BE or EAC. In fact, wine consumption may reduce the risk of these esophageal disorders.

Gastroesophageal reflux (GER) symptoms are common in Western societies with 10 to 20 percent of adults experiencing at least weekly symptoms. GER is the main predisposing risk factor for erosive RE, BE and EAC; alcohol may increase GER by causing relaxation of the lower esophageal sphincter.

Using data collected as part of an all-Ireland case-control study, the FINBAR (Factors INfluencing the Barrett's Adenocarcinoma Relationship) study, information relating to alcohol consumption (at age 21 and five years before the interview date) was collected from 230 RE, 224 BE and 227 EAC patients and 260 frequency-matched population controls. Logistic regression analyses were used to compare alcohol consumption in the three case groups to controls with adjustment for potential confounders. The FINBAR study is one of the largest case-control studies to date to investigate the association between alcohol consumption and RE, BE and EAC using the same control group.

Population controls reporting GER symptoms were less likely than controls without symptoms to drink alcohol five years before the interview date (OR 0.44, 95 percent CI 0.20-0.99). No associations were observed between total alcohol consumption five years before the interview date and RE, BE or EAC (ORs, 95 percent CI: 1.26, 0.78-2.05, 0.72, 0.43-1.21 and 0.75, 0.46-1.22, respectively). Wine was inversely associated with RE (OR 0.45, 95 percent CI 0.27-0.75). Total alcohol consumption at age 21 was significantly associated with RE (OR 2.24, 95 percent CI 1.35-3.74), but not with BE or EAC (ORs, 95 percent CI: 1.06, 0.63-1.79 and 1.27, 0.77-2.10, respectively).

These preliminary findings warrant further research. Future studies should consider the influence of reflux symptoms and the temporality of the association carefully when interpreting the association between alcohol and RE, BE and EAC.

Chantix side effects no worse with depression history

Group Health studies over 1,000 smokers in COMPASS trial

03 mar 2009--People with a likely history of depression who take varenicline (Chantix®) do not report more severe mood symptoms, medication side effects, or less success quitting smoking compared to people with no history of depression taking this drug.

The findings by Group Health, Free & Clear, and SRI International researchers are reported in a Journal of General Internal Medicine article published online (http://www.springerlink.com/content/77207452k3822r3v/). The National Cancer Institute (NCI)-funded, randomized COMPASS trial tracked more than 1,100 Group Health patients receiving behavioral treatment and varenicline to quit smoking. It's the first "real-world" examination of varenicline use since the original Food and Drug Administration (FDA) studies that the manufacturer funded.

"People tend to feel more depressed or irritable while quitting smoking, especially if they have had depression before," said lead author Jennifer McClure, PhD, Group Health Center for Health Studies' associate director for research. "And concerns have been raised that varenicline may increase neuropsychiatric symptoms including depressed mood in people with prior depression." Yet she and colleagues found using varenicline didn't worsen mood symptoms such as depression, anxiety, or irritability in people with a likely history of depression compared to others. "Still," she added, "it's prudent for clinicians to follow the FDA's advice of closely monitoring patients on this drug."

Varenicline is the latest drug the FDA has approved to help tobacco users quit. It seems more effective than other cessation medications, McClure explained, but post-marketing surveillance and case reports have raised concerns about its side effects. These include depression, agitation, and suicidal thoughts and actions, especially in people with a history of psychiatric problems. This has led to several FDA advisories.

COMPASS confirmed previous findings that varenicline side effects, especially nausea, are relatively common. At 3 weeks and 3 months after their target quit date, people with a likely history of depression tended to report these side effects slightly more often—although with no more intensity—than did people without a history of depression.

Feelings of stress and depression tended to decline in both groups—with and without a probable history of depression, said McClure. The trial detected only one serious psychiatric event involving suicidal thoughts and requiring hospitalization. It was in a person who had a previously undisclosed history of bipolar disorder.

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Group Health Center for Health Studies

Founded in 1947, Group Health Cooperative is a Seattle-based, consumer-governed, nonprofit health care system that coordinates care and coverage. Group Health Cooperative is ranked "Highest in Member Satisfaction among Commercial Health Plans in the Northwest Region" by J.D. Power and Associates. For 25 years, the Group Health Center for Health Studies has conducted research on preventing, diagnosing, and treating major health problems. Government and private research grants provide the main funding for this non-proprietary, public-interest research institute.

Sex is in the brain, says new research from Stanford

STANFORD, Calif., 03 mar 2009 — More than 40 percent of women ages 18-59 experience sexual dysfunction, with lack of sexual interest — hypoactive sexual desire disorder, or HSDD — being the most commonly reported complaint, according to medical researchers. While some question the validity of this diagnosis, a multidisciplinary team from the Stanford University School of Medicine is devoted to objective investigation of such problems.

Here is a quick briefing on new research on this problem from Bruce Arnow, PhD, professor of psychiatry and behavioral sciences, and Leah Millheiser, MD, clinical assistant professor of obstetrics and gynecology and director of the Female Sexual Medicine Program at Stanford Hospital & Clinics.

The question: What role does the brain play in some women's lack of sexual desire?

Background: Studies of factors affecting sexual performance have largely focused on men, and on physiology of the body rather than the brain. But the brain, rather than peripheral organs, may play the key role in female sexual dysfunction.

The study: The trial is the first to compare brain-activation patterns of females who have HSDD with those who don't. Sixteen women diagnosed with HSDD, along with 20 normal control subjects, took part in the study. All subjects identified themselves as heterosexual.

The experiment: Subjects were shown erotic video segments interspersed among footage of female sporting events. These segments were separated by intervening tranquil sequences of such subjects as flowers, mountains or ocean waves to bring the women's brains to a resting state between more-active segments. Their brain activity was monitored by functional magnetic-resonance imaging, which allows the activity of different brain regions to be assessed in real time. The women also reported their subjective levels of sexual arousal throughout the viewing. Meanwhile, the researchers also collected objective measurements of the women's level of genital arousal.

The findings: Activity patterns throughout most of the brain were more or less identical among the HSDD and normal groups, but with a few notable exceptions. There was a bigger jump in relative activity in three brain areas of HSDD women — the medial frontal gyrus, right inferior frontal gyrus and bilateral putamen — compared with the control subjects when shown the erotic clips. In another brain area — the bilateral entorhinal cortex — the opposite effect occurred. This finding establishes specific locations in the brain where activity in women with HSDD is altered in comparison with women not reporting this problem.

Discussion: Two of the brain areas where the HSDD women had increased activity (the medial frontal gyrus and right inferior frontal gyrus) have been previously associated with, respectively, heightened attention to one's own and others' mental states, and suppression of one's emotional response. The research suggests that increased attention to one's own responses to erotic stimuli plays some part in the sexual dysfunction. The increased activation in the entorhinal cortex observed in the control subjects may correlate with an improved ability among women with no sexual dysfunction, compared with HSDD women, to lay down emotional memories related to sexual events.

Caveats: Correlation is not cause and effect. The study could be showing how paying too much attention causes inhibition of sexual desire — or how the lack of desire in a sexually charged situation causes heightened self-consciousness.

Bottom line: "The results of this study provide yet another valuable tool for understanding the complexity of female sexual function as it relates to desire," Millheiser said. "The next step is to translate this information into the clinical realm, specifically as it relates to cognitive and pharmacotherapeutic approaches."

Published: The results appeared in the Jan. 23 issue of the journal Neuroscience.

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Stanford University Medical Center integrates research, medical education and patient care at its three institutions — Stanford University School of Medicine, Stanford Hospital & Clinics and Lucile Packard Children's Hospital at Stanford. For more information, please visit the Web site of the medical center's Office of Communication & Public Affairs at http://mednews.stanford.edu.

Many middle-aged and older Americans not getting adequate nutrition

New study published in the Journal of the American Dietetic Association evaluates supplement intake

St. Louis, MO, 02 mar 2009 – Micronutrients such as calcium, magnesium, potassium and vitamin C play essential roles in maintaining health. As older adults tend to reduce their food intake as they age, there is concern that deficits in these micronutrients lead to medical problems. In a study published in the March 2009 issue of the Journal of the American Dietetic Association, researchers examined how well different ethnic groups met the recommended daily allowances (RDAs) through food intake and supplement consumption. The study determined that many middle-aged and older Americans are not getting adequate nutrition.

Using data drawn from the Multi-Ethnic Study of Atherosclerosis (MESA), a prospective cohort study designed to investigate the prevalence, correlates and progression of subclinical cardiovascular disease, researchers examined over 6200 participants from 4 ethnic groups, Caucasian, African American, Hispanic and Chinese. Dietary intakes were determined from food frequency questionnaires and respondents were asked to provide amounts and frequencies of micronutrient consumption using label information from their supplements. These data were used to calculate whether the RDAs or Adequate Intake (AI) levels were being met. The large sample size and multiple ethnic groups in this population gave investigators enough power to examine interactions between supplementation and ethnicity.

Over half of the population took supplements, and supplement users were more likely to be older, women, Caucasian and college-educated. Calcium and vitamin C supplements were most common. Although dietary intake of calcium, magnesium, potassium and vitamin C was similar between supplement users and non-users for both men and women, there were differences in median dietary intake levels between the different ethnic groups. Chinese Americans tended to have the lowest dietary intakes, particularly in calcium where both Chinese and African Americans had significantly lower dietary intakes of calcium than Caucasians and Hispanics.

The study also evaluated differences between multivitamins and high-dose supplements. While high-dose calcium was associated with meeting RDA/AIs for all ethnic groups, some high-dose supplements could also cause users to exceed their Tolerable Upper Intake Levels (ULs). For calcium, 15.0% of high-dose users exceeded the UL compared to 1.9% of multivitamin users and 2.1% of non-users. For magnesium, 35.3% of high-dose supplement users exceeded the UL compared to 0% of both multivitamin users and non-users. In addition, 6.6% high-dose vitamin C users exceeded the UL compared to 0% of both multivitamin users and non-users.

The study also found that potassium intake was very much below the RDA whether supplements were taken or not. This could point to a need to reformulate supplements to deliver higher potassium doses.

Writing in the article, Pamela J. Schreiner, MS, PhD, Professor and Director of Graduate Studies, Division of Epidemiology and Community Health, University of Minnesota, states, "The present study indicates a clear association between meeting RDA/AIs and supplement use for calcium, magnesium and vitamin C. However, even with the assistance of dietary supplements many middle-aged and older Americans are not getting adequate nutrition, and there was no association between supplement use and meeting the AI for potassium. In addition, those taking high-dose vitamin supplements were more likely to exceed the UL for that nutrient. Future studies should explore dietary supplementation along with other methods to improve nutrition in middle-aged and older Americans."

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The article is "Supplement use contributes to meeting recommended dietary intakes for calcium, magnesium and vitamin C in four ethnicities of middle-aged and older Americans

Anger Induces Heart Instability and Arrhythmias

Possible link between stress and sudden death

02 mar 2009-- Anger-induced T-wave alternans, a marker of repolarization instability, predicts ventricular arrhythmias in patients with implantable cardioverter-defibrillators (ICDs), providing a link between stress and sudden death, according to a report in the Mar. 3 issue of the Journal of the American College of Cardiology.

Rachel Lampert, M.D., from Yale University School of Medicine in New Haven, Conn., and colleagues determined whether T-wave alternans induced during a mental stress protocol could predict ventricular arrhythmias in 62 patients with ICDs.

During a follow-up of at least one year, the researchers found that the 10 patients with ICD-terminated arrhythmias had significantly higher anger-induced T-wave alternans (13.2 versus 9.3 microvolts). Arrhythmias were more common in patients in the highest quartile of anger-induced T-wave alternans (greater than 11.9 microvolts) on extended follow-up (40 versus 9 percent), the investigators report. After controlling for confounding factors, anger-induced T-wave alternans was an independent predictor of ICD-terminated arrhythmia, with patients in the highest quartile having a 10.8-fold higher risk of arrhythmia, the authors write.

"The investigators provide the first evidence that patients with higher levels of anger-induced T-wave alternans during provocative testing are at greater risk for ventricular arrhythmias detected by ICDs during follow-up," Eric J. Rashba, M.D., from Stony Brook University Medical Center in Stony Brook, N.Y., writes in an accompanying editorial.

PinMed Inc. provided the repolarization analysis software used in the study, and two of the study authors are employees of the company and one has a significant ownership stake. Authors of the study and editorial report relationships with device companies.

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Study Supports Halt of PSA Testing in Some Older Men

Those 75 to 80 with prostate specific antigen less than 3 ng/mL unlikely to develop high-risk prostate cancer

02 mar 2009-- Men who are 75 to 80 years old and have a prostate specific antigen (PSA) less than 3 ng/mL are not likely to have life-threatening prostate cancer during the remainder of their lives, according to research released online in advance of publication in the April issue of the Journal of Urology.

Edward M. Schaeffer, M.D., Ph.D., of the Johns Hopkins University School of Medicine in Baltimore, and colleagues analyzed data from 122 men with prostate cancer and 727 without the disease in the Baltimore Longitudinal Study of Aging cohort. The primary outcome was death from prostate cancer or development of aggressive prostate cancer.

None of the men between the ages of 75 and 80 who had PSA less than 3 ng/mL died of prostate cancer, the researchers report. However, men of all ages who had PSA of 3 ng/mL or greater had a continually increasing chance of death from the disease, the investigators found.

"The optimal approach to prostate cancer screening remains controversial. To date there is limited evidence with which to inform the decision of when to discontinue prostate cancer screening," the authors write. "Our findings suggest that men 75 to 80 years old who have a PSA less than 3 ng/mL are unlikely to be diagnosed with high-risk prostate cancer during life. Therefore, these men may represent an ideal target group for discontinuation of PSA testing, which could dramatically reduce the costs associated with screening, as well as the potential morbidity of additional evaluations and/or treatment in a population unlikely to experience benefit."

Schaeffer disclosed a relationship with Covidien.

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Procedure Significantly Improves Urinary Incontinence

Incontinence, overactive bladder symptoms improved by transobturator tape procedure

02 mar2009-- A transobturator tape procedure resulted in nearly an 80 percent improvement in urge urinary incontinence, according to research published in the March issue of Obstetrics & Gynecology.

Samina Tahseen, of the Luton and Dunstable Hospital in Bedfordshire, United Kingdom, and a colleague conducted follow-up interviews, at a median of 13 months, on 58 women who had undergone a transobturator tape procedure. Based on diagnosis, women were categorized into three groups, either having stress incontinence only, mixed incontinence with predominant stress leakage, or mixed incontinence with predominant urge leakage.

Overall, urge urinary incontinence was cured in 43 percent and improved in 36 percent, the researchers report. In the group of women with stress predominant leakage, incontinence was cured and improved in an equal proportion of patients (43.5 percent each). In women with urge predominant leakage, incontinence was cured in 43 percent and improved in 28.5 percent of patients, the investigators found. Stress incontinence was completely resolved in 77 percent and was improved in an additional 19 percent. No cases of de novo urge incontinence were reported, the authors note.

"The transobturator midurethral sling has been shown in this study to improve urge urinary incontinence and overactive bladder symptoms significantly in mixed urinary incontinence and to provide high postoperative patient satisfaction," the authors conclude.

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Calcium tied to lower cancer risk in older people

By Lindsey Tanner

CHICAGO, 02 mar 2009 --A study in nearly half a million older men and women bolsters evidence that diets rich in calcium may help protect against some cancers. The benefits were mostly associated with foods high in calcium, rather than calcium tablets.

Previous studies have produced conflicting results. The new research involved food questionnaires from participants and a follow-up check of records for cancer cases during the subsequent seven years. This research method is less rigorous than some previous but smaller studies.

But because of its huge size -- 492,810 people and more than 50,000 cancers -- the new study presents powerful evidence favoring the idea that calcium may somehow keep cells from becoming cancerous, said University of North Carolina nutrition expert John Anderson, who was not involved in the study.

The study was run jointly by the National Institutes of Health and AARP. The results appear in Monday's Archives of Internal Medicine.

National Cancer Institute researcher Yikyung Park, the study's lead author, called the results strong but said more studies are needed to confirm the findings.

Duke University nutrition researcher Denise Snyder said the results support the idea that food rather than supplements is the best source for nutrients.

Participants were AARP members aged 50 to 71 who began the study in the mid-1990s. A total of 36,965 men and 16,605 women were later diagnosed with cancer. There were more than 10 different kinds of cancer, the most common being prostate, breast, lung and colorectal.

Compared with people who got little calcium, those who consumed the most had the lowest chances of getting colon cancer. Those in that highest category got on average 1,530 milligrams a day among men and 1,881 milligrams daily among women. The recommended amount for older people is 1,200 milligrams, and getting much more than that didn't result in any greater protection. Adults can get that amount from four cups of milk or calcium-fortified orange juice.

Men who got the most calcium from food were about 30 percent less likely to get cancer of the esophagus, about 20 percent less likely to get head and neck cancer and 16 percent less likely to get colon cancer, when compared to men who got low amounts of calcium.

Among women, those who got the most food-based calcium were 28 percent less likely to get colon cancer than low-calcium women.

In men, calcium supplements only seemed to help protect against colon cancer; for women, supplements meant a lower risk for liver cancer, which is rare.

Some previous studies have linked diets high in calcium with prostate cancer but the current study found no such risk.

Adults who ate the most calcium also tended to be healthier overall than the others.

Daytime sleepiness provides red flag for cardiovascular disease

Clinicians should be alert to patients reporting "excessive" day time sleepiness (EDS), says the European Society of Cardiology, after a French study found healthy elderly people who regularly report feeling sleepy during the day have a significantly higher risk of dying from cardiovascular disease.

01 mar 2009--The Three City study, published in Stroke, by the American Heart Association (Thursday, February 26), found that elderly people who reported excessive day time sleepiness have a 49 % relative risk increase of cardiovascular death (from cerebrovascular disease, myocardial infarction and heart failure) , compared to those who do not report sleepiness.

"Based on this study asking patients the simple question of whether they feel sleepy during the day, is a useful way of identifying a subgroup of elderly patients at higher risk of cardiovascular disease who require a more thorough follow up," said Professor Guy DeBacker, from the Division of Cardiology at the University of Gent, Belgium, and former chair of the European Society of Cardiology Joint Prevention Committee.

Professor Torben Jorgensen, from the Research Centre for Prevention and Health, Glostrup, Denmark, commented: "The study offers the opportunity to practice prevention by investigating the underlying causes of patient's sleep problems, and then introducing lifestyle changes with the intention of preventing later cardiovascular complications."

The Three City study represents the largest yet investigation exploring the prospective association between EDS and mortality in the community dwelling elderly, and the only study yet to have been conducted in Europe – all the other studies were undertaken in North America. Criticisms of the study include a low responder rate (37%) that could introduce an element of bias, and the fact that it lacked objective measures of day time sleepiness (such as polysomnography readings), instead using self reported patient responses.

"The subjects with EDS were less educated and had a lower income so there were differences between the two groups in "socioeconomic status", which was not accounted for in the multivariate analysis. SES is a strong independent predictive factor for total and for cause specific mortality, and it might be that the difference between the two groups is just the effect of socioeconomic differences," said DeBacker.

Both DeBacker and Jorgensen say the results are "hypothesis generating", and that the data needs to be confirmed in other large scale studies in different populations before any changes should be made to existing guidelines.

"Overall the study population had a particularly low number of cardiovascular deaths, suggesting that the French paradox may be in operation. We need to be asking identical questions to different populations to see if we still get the same effect," said DeBacker.

Jorgensen added that he would like to see future trials where EDS patients were randomised to receive sleep interventions or not, to see if cardiovascular complications might be prevented.

Three-City Study

The Three-City Study led by Jean-Philippe Empana from Inserm, (the French Public Institute on Health and Medical Research) and colleagues followed 9,294 community dwelling people aged over 65 (who did not live in nursing homes or other care facilities). In face to face interview, participants were asked if they had never, rarely, regularly or frequently experienced excessive sleepiness during the day. People diagnosed with dementia at baseline were excluded, providing an overall study population of 8,269 people.

Investigators found even after adjusting for other risk factors,(such as age, gender, body mass index and previous cardiovascular disease), people who experienced excessive day time sleepiness had a 49 % increase in relative risk of cardiovascular death, and a 33 % increase in the relative risk of overall death.

Earlier studies have suggested that atherosclerosis might mediate the association between EDS and cardiovascular death, and that EDS might be associated with sympathetic tone activation.

However, when investigators undertook ultrasound examination of the carotid artery in two-thirds of participants, they found no difference in carotid plaque burden between people with and without EDS. Additionally resting heart rate, a simple marker of increased sympathetic tone activation, was no different among people with or without EDS.

Such data, say the authors, leaves them unclear as to whether sleep complaints are a symptom of underlying cardiovascular disease or whether sleepiness triggers or worsens disease.

"These data may have clinical implications adding to the body evidence that EDS is not a benign but rather an important risk marker for midterm mortality in community dwelling elderly," they conclude, adding that simple questionnaires incorporating questions on sleeping patterns should become part of routine examinations in the elderly.

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REFERENCE:

Excessive Daytime Sleepiness is an independent Risk Indicator for Cardiovascular Mortality in Community Dwelling Elderly. The Three Cities Study. JP Empana, Y Dauviliers, JF Dartigues et al. Stroke 2009: 40:00-00. 1-6

Older women find health benefits through volunteer program

01 mar 2009--A new article in The Journal of Gerontology: Social Sciences reveals that African American women aged 60 and older who volunteer in elementary schools are not only more physically active than their non-volunteering counterparts, but seem to sustain this physical activity over time. Specifically, those who volunteered burned twice as many calories as those who did not.

This study, led by Erwin Tan, PhD, of the Johns Hopkins University, suggests that the country's investment in national and community service programs can simultaneously be an investment in public health.

"For our volunteers," Tan said, "volunteering with children may be as good for their health as a gym membership. For our children, the wisdom that our older adults have is priceless." He added that, due to their enjoyment of working with children, the volunteers may be more willing to keep up with this approach in the long term, compared with traditional exercise programs.

Tan also explained that the focus on African American women was due to their prevalence in the two community groups from which the study participants were recruited, but he said the results are likely the same for all older people.

The data was gathered from participants in the Experience Corps (EC) program, a community-based initiative that places older adults as volunteers in public elementary schools. This information was then compared to surveys of non-volunteers enrolled in the Baltimore Women's Health and Aging Studies.

Tan's research builds on the results of a 2006 study of the EC program, which showed that 15 hours of volunteer work per week at an elementary school nearly doubled a sedentary older adult's activity level. The new study demonstrates that the increased activity can remain high for at least three years.

Another Johns Hopkins-based investigation of the EC program was published in the December 2008 issue of The Gerontologist. A research team led by Michelle Carlson, PhD, reported similar findings about EC's potential cognitive benefits for participants.

She and her colleagues found that EC volunteers showed greater improvements in memory and executive function than those who did not participate in the program. In fact, the older adults with the lowest baseline performance in these areas — those most at risk for health disparities — demonstrated the most significant gains.

Both studies highlighted above show that everyday activity interventions (e.g., EC) can appeal to older adults' desires to remain socially engaged and productive in their post-retirement years. Simultaneously, these activities provide measurable physical and cognitive health benefits.

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The Journal of Gerontology: Social Sciences and The Gerontologist are refereed publications of The Gerontological Society of America (GSA), the nation's oldest and largest interdisciplinary organization devoted to research, education, and practice in the field of aging. The principal mission of the Society — and its 5,000+ members — is to advance the study of aging and disseminate information among scientists, decision makers, and the general public. GSA's structure also includes a policy institute, the National Academy on an Aging Society, and an educational branch, the Association of Gerontology in Higher Education.

How yeast is helping us to understand Parkinson's Disease

Teams of scientists from Australia and the United States have used yeast and mammalian cells to discover a connection between genetic and environmental causes of Parkinson's disease.

01 mar 2009--Yeasts are single cell organisms, used widely in biological research because their structure resembles that of cells found in animals and humans. Yeasts share many genes, or their functional equivalents, with humans and offer the ability to screen or test thousands of genes and analysing their effects.

Two genes (alpha-synuclein and PARK9) had separately been associated with forms of Parkinson's disease, while manganese poisoning can cause PD-like symptoms in miners and welders exposed to high manganese levels. Findings connecting alpha-synuclein, PARK9 and sensitivity to manganese, made possible by yeast research, have been published online in the February issue of the prestigious international journal, Nature Genetics.

"This is the first time that we've been able to connect three pieces of the Parkinson's disease jigsaw puzzle and it tells us we're on the right track to understanding what goes wrong in this disease" said Dr Antony Cooper from Sydney's Garvan Institute of Medical Research and head of the project group in Australia.

Parkinson's disease involves the degeneration of neurons that produce the neurotransmitter dopamine. Autopsies show an abundance of the small protein alpha-synuclein in affected regions of the brain, so scientists have known for some time that over-expression of the protein is toxic.

When a European group discovered PARK9's involvement in an inherited form of Parkinson's disease they examined some of the surviving neurons from patients who had 'sporadic' Parkinson's, as opposed to inherited forms of the disease, and found they contained ten times the levels of PARK9 when compared with similar parts of the brain in patients without the disease.

"Its possible that the surviving neurons remained functional, unlike the degenerated neurons surrounding them, because high levels of PARK9 protected them in some way," said Cooper.

"Little was known of PARK9's function but as yeast contains an equivalent gene, we were able to analyse its function."

"We found that high levels of the PARK9 in a cell diminish the toxic effects of alpha-synuclein. We also found that it appears to be a manganese pump, capable in theory of removing excess levels of the metal from cells."

"We need to know what is happening at the critical early stages of the disease, so that we can stop it, but we only get to examine human brains after death, when the damage has been done. Using yeast allows us to examine the early damaging stages."

A key, and perplexing, question for researchers in the field has been whether or not there is a single cause, or related group of genetic determinants, that result in dopaminergic neuron loss, or 'Parkinson's disease'.

"We would love to be able to link all the genes that we know have something to do with Parkinson's disease," said Cooper. "If you discover there's a central pathway involved, it provides much better potential for finding a successful treatment"

"So far, we've linked PARK9, alpha-synuclein and manganese toxicity. These linkages are not coincidental. They're likely to be affecting a pathway and we suspect it's a central pathway. To confirm that would be very exciting indeed."

Dr Cooper has been collaborating for several years with Dr Susan Lindquist, from the Whitehead Institute for Biomedical Research and Dr Aaron Gitler, from the University of Pennsylvania School of Medicine, to find how alpha-synuclein can damage cells.

To confirm that their results were not specific to yeast alone, Gitler, Cooper and Lindquist collaborated with Associate Professor Guy Caldwell, from the University of Alabama, and Associate Professor Jean-Christophe Rochet from the University of Purdue in Indiana, who verified their results in other Parkinson model systems.

"We wanted to check our findings were relevant in other Parkinson's models, because the more models it fits into, the more you believe it's real," said Cooper.

Long-term outlook good for rotator cuff repairs

Relief from pain continues long after surgery has been conducted

LAS VEGAS, NV, 01 mar 2009 - Patients who underwent a rotator cuff repair surgery experienced pain relief and improved shoulder function, even after a tear recurrence, according to a new study presented at the 2009 American Orthopaedic Society of Sports Medicine Specialty Day in Las Vegas. Rotator cuff tears can be caused by a traumatic event to the shoulder, such as a fall, or over a period of time due to wear and tear, which is more common in athletic individuals. The study evaluated a group of 15 patients approximately eight years after they received rotator cuff repair.

"We initially tested the patients at three years after their surgery and found that those with a recurrence of a tear were doing well," explains lead author, Christopher Dodson, MD, of the Hospital for Special Surgery in New York City where 839 rotator cuff repairs were preformed last year. "The study analyzed whether having the original surgery produced any long-term benefits for the patient."

At an average of eight years after surgery, 15 patients completed four assessment surveys. Of those 15, 11 were reexamined with ultrasound testing. The test results indicated that those who with recurrent rotator cuff defects were still better off in terms of pain, function, and strength than they were before the rotator cuff was originally repaired. The study also found that the recurrent tears grew in size, but remained painless and did not affect function. None of the patients had needed further treatment or surgery, and none experienced any persistent shoulder pain.

"Our obvious concern for patients who have a recurrent rotator cuff defect after surgical repair is that symptoms may recur over time. Our study concluded that the patient will experience long-term benefit from surgery and remain asymptomatic, even if a recurrent defect is present. This is encouraging for both the surgeon and the patient undergoing rotator cuff repair."

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The American Orthopaedic Society for Sports Medicine (AOSSM) is a world leader in sports medicine education, research, communication and fellowship, and includes national and international orthopaedic sports medicine leaders. The Society works closely with many other sports medicine specialists, including athletic trainers, physical therapists, family physicians, and others to improve the identification, prevention, treatment, and rehabilitation of sports injuries.

Statins lower stroke severity, improve recovery

ROCHESTER, Minn., 01 mar 2009 — Mayo Clinic researchers have shown that patients who were taking statins before a stroke experienced better outcomes and recovery than patients who weren't on the drug — even when their cholesterol levels were ideal. The finding is reported in the current issue of the Journal of Stroke and Cerebrovascular Diseases.

"We were trying to determine if the daily use of statins had more of an impact on stroke patients than simply lowering their "bad" (low-density lipid) cholesterol," explains lead researcher Latha Stead, M.D. "We already knew statin use improved outcomes in general, so we focused on the patients who had optimal LDL levels and found it still had quite significant value."

Statins or reductase inhibitors are enzymes that are widely used to improve cardiovascular health and, more recently, for certain vascular conditions in the brain. One use has been to lower the level of LDL which can contribute to arterial blockages.

Significance of the Research

Previous researchers had shown a lower death rate and improved function in strokes when people had used statins. The Mayo team found that statin used in this cohort also decreased the severity of the strokes and significantly improved overall outcomes. The researchers say this shows benefits far beyond lowering lipid levels. Researchers think the specific benefits may include plaque stabilization and improved cell function in vascular walls, as well as anti-inflammatory and antioxidant factors. More research is needed to pinpoint the specific benefits.

How it was done

Researchers identified 508 patients who were diagnosed with acute ischemic stroke in the emergency department during the 22 months from March 2004 to December 2005. Among that number, 207 had their lipid levels measured within 15 days either side of the stroke incident — and had LDL levels at or below 100 mg/dL, which is considered optimal for healthy individuals. Roughly half the cohort of 207 had been taking statins. Researchers also adjusted for age, gender and stroke severity.

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Others on the research team were Lekshmi Vaidyanathan, M.B.B.S.; Gautam Kumar, M.B.B.S.; M. Fernanda Bellolio, M.D.; Robert Brown, Jr., M.D.; Smitha Suravaram, M.B.B.S.; Sailaja Enduri, M.B.B.S.; Rachel Gilmore, M.B.B.Ch.; and Wyatt Decker, M.D., all of Mayo Clinic.