HHAL MEDICAL NEWS JANUARY 2011
New U.S. Dietary Guidelines Recommend Limiting Excess Salt,
Fat, Sugar
The U.S. Department of Health and Human Services and
the Department of Agriculture have
updated their 2005 nutritional guidelines, taking aim at sodium, refined sugars, fats, and refined grains.
Among the 23 recommendations:
·
Limit
daily sodium consumption to less than 2300 mg. High-risk groups (e.g., those who are
over 50, are black, or who have hypertension, diabetes, or chronic kidney diseases) should consume less than 1500 mg.
·
Restrict
the percentage of calories coming from saturated
fats to less than 10%.
·
Consume
less than 300 mg of dietary cholesterol daily.
·
Replace refined grains
with whole grains.
·
Restrict consumption of
solid fats and added sugars.
·
Limit alcohol to one drink
per day for women and two for men.
·
Eat a variety of fruits and vegetables and
more of them.
·
Replace some meat and
poultry with seafood.
The guidelines also offer specific recommendations for people ages 50 and
up and women who may become pregnant or who are pregnant or breast-feeding.
Executive summary with key recommendations (Full guidelines )
http://www.health.gov/dietaryguidelines/dga2010/DietaryGuidelines2010.pdf
Guidelines Discourage Routine Imaging for Low Back Pain
Routine
diagnostic imaging for low back pain doesn't improve outcomes and only increases complications and costs, warns a clinical
guideline from the American College of Physicians in the Annals
of Internal Medicine.
The authors revisit the guidelines issued by the ACP and
the American Pain Society in 2007 and add evidence from a meta-analysis of six clinical trials. Here are their principal recommendations:
·
Use an initial trial of
therapy rather than immediate imaging.
·
However, imaging is warranted
when the patient has major risk factors for cancer,
or shows severe or progressive neurologic deficits.
·
Risk
factors or signs of vertebral infection or the cauda
equina syndrome, although rare, also warrant more immediate imaging.
The authors state
that routine imaging "cannot be cost-effective." They conclude that "efforts to reduce use of imaging should
be multifocal and address clinician behaviors, patient expectations, and financial incentives."
Annals
of Internal Medicine article
Breast Cancer Risk Found to Vary According to Interval Between
Menopause and Starting Hormone Use
You
may get questions about a study that finds breast cancer risk increases among women who start hormone therapy around menopause. The study appears
in the Journal of the National Cancer Institute and was reported
over the weekend in the New York Times.
In
a follow-up to their 2003 report, researchers in the Million Women Study examined outcomes in some 1.1 million postmenopausal women in the U.K.
The
principal findings, from more than 4 million person-years of follow-up, include the following:
·
Both
current and past users were at significantly higher cancer risk than never users, and risk increased with duration of use;
·
The
risk was greater among current users if therapy started before or soon after menopause, compared with starting later;
·
The
greatest risk was among current users of estrogen-progestin formulations;
·
Risk
declined rapidly after stopping use, falling to that of never users within 3 years.
JNCI article
JNCI editorial
New
York Times story
C-Reactive Protein Levels Don't Predict
Response to Statins
Inflammation status,
as measured by high-sensitivity C-reactive protein levels, doesn't affect the relative benefits of statin therapy, according
to a Lancet study.
Heart Protection Study researchers investigated whether the benefits of
statin therapy were lessened in the face of low CRP
levels. To do so, they randomized some 20,000 high-risk patients to 40 mg/day of simvastatin or placebo. Patients were
stratified into risk groups based on their baseline CRP levels.
After 5 years'
therapy, all risk groups showed significant relative reduction in risk for cardiovascular events while taking statins —
all around 25%.
The authors conclude that their findings don't support the idea that
"the beneficial effects of statin therapy are affected by baseline CRP concentration or, more generally, by inflammation
status."
A commentator generally agrees, but notes that patients on statins "who
had low baseline CRP concentrations had the lowest rate of vascular events irrespective of their baseline LDL-cholesterol
values."
Lancet article
Treatment Approaches to Chronic Prostatitis/Chronic Pelvic Pain Syndrome
Alone or together, -blockers and
antibiotics might help — but, if so, the effect is modest.
Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is characterized by pelvic pain or discomfort and urinary
dysfunction, sexual dysfunction, or both for at least 3 of the prior 6 months; this
diagnosis usually is made after a wide range of structural and infectious causes have been excluded. Many treatments have
been suggested, but most treatment trials have been small and underpowered. In a meta-analysis of 262 randomized controlled
trials of various treatments for CP/CPPS, investigators indentified 23 — with a total enrollment of about 2300 patients
— that met inclusion criteria.
In pooled comparisons, either -blockers (i.e., tamsulosin,
doxazosin, or terazosin), antibiotics (mostly quinolones), or both in combination resulted in statistically significant but
clinically modest attenuation of symptoms (e.g., total symptoms, pain, voiding, quality of life).
http://www.ncbi.nlm.nih.gov/pubmed/21205969?dopt=Abstract
Transdermal DHT to Prevent Benign Prostatic Hypertrophy
Dihydrotestosterone treatment did not inhibit prostrate growth.
Idan A et al. Ann Intern
Med 2010 Nov 15; 153:621
Testosterone Supplementation in Older Men:
Mixed Messages
Higher testosterone levels might be associated with better physical
performance, but supplementation is recommended only for alleviation of sexual symptoms.
Androgen-Deprivation Therapy and
Risk for Colorectal Cancer
ADT was associated with excess risk for CRC among men who received this
treatment for prostate cancer.
Gillessen
S et al. J Natl Cancer Inst 2010
Dec 1; 102:1760
Lin JH and Giovanucci E. J
Natl Cancer Inst 2010 Dec 1; 102:1746
Does Androgen-Deprivation Therapy for Prostate Cancer Affect Physical
Function?
In
men with nonmetastatic prostate cancer, physical
function declined within 3 months of ADTinitiation.
Does Red Meat Consumption Raise Stroke
Risk?
Swedish women in the highest stratum of red
meat consumption were more likely to experience cerebral infarctions
than were those in the lowest stratum.
Findings about red meat consumption and stroke risk are sparse
and inconsistent. Investigators assessed self-reported red meat consumption in 34,670 participants in the Swedish Mammography
Cohort in relation to incidence of stroke (cerebral infarction, intracerebral or subarachnoid hemorrhage, or unspecified stroke) as reported in the Swedish Hospital Discharge Registry
during a mean follow-up of 10.4 years.
After multivariate adjustment, women
in the highest decile of red meat consumption (>102 g or >3.6 ounces daily) were at 42% higher risk for cerebral infarction
than were women in the lowest decile (<25 g or <0.9 ounces daily). Subgroup analysis showed that never-smokers without diabetes in
the highest decile of red meat consumption were at 68% higher risk for cerebral infarction than were similar women in the
lowest decile. For processed meat consumption, women in the highest quintile were at 24% higher
risk for cerebral infarction than were those in the lowest quintile. No significant association
was found between red or processed meat consumption and risk for intracerebral or subarachnoid hemorrhage.
Larsson
SC et al. Stroke 2010
Dec 16;
Are Probiotics a Panacea for Gastrointestinal
Complaints?
Add irritable
bowel syndrome to the list of diseases ameliorated by probiotics in
children.
Francavilla R et al. Pediatrics 2010 Dec 126:e1445
-Carotene Levels Are Associated with Mortality
Mortality was related to low levels of -carotene, but the significance
was unclear.
Li C et al. Arch
Intern Med 2010 Nov 22;
Another therapy in obesity
These authors report that alpha-lipoic
acid 1800 mg/d led to a modest weight loss in obese subjects. They conclude that alpha-lipoic acid may therefore be considered
as adjunctive therapy for obesity.
Conclusions
We showed that 1800 mg/d of oral
alpha-lipoic acid was effective in achieving significant weight loss in obese subjects. Although the therapeutic potency of
alpha-lipoic acid was modest, no serious side effects were observed. Differences in side effects from currently used anti-obesity
drugs suggest that alpha-lipoic acid may be effective as an adjunctive medication for obesity. Further studies are needed
to determine the adequate dosage of alpha-lipoic acid and its long-term safety and efficacy. Moreover, head-to-head comparisons
are needed to compare the safety and efficacy of alpha-lipoic acid with those of other anti-obesity drugs.
The American Journal of Medicine
10,000 steps a day may reduce diabetes risk, study says
A study of middle-age Australians estimated that
those who had a sedentary lifestyle could see a threefold improvement in insulin sensitivity and reduce their diabetes risk
by walking 10,000 steps each day, compared with those who walked just 3,000 steps. The researchers at Murdoch Children's
Research Institute wrote in the British Medical Journal that higher daily step counts also were associated with lower body
mass indexes and waist-to-hip ratios. HealthDay News
After stroke, try fluoxetine
In patients with ischemic stroke and moderate to severe motor deficit,
the early prescription of fluoxetine with physiotherapy enhanced motor recovery after three months. Modulation of spontaneous brain plasticity by drugs is a promising pathway for treatment of patients with ischemic
stroke and moderate to severe motor deficit. The Lancet Neurology
Vitamin D deficiency and peripheral arterial disease. Worse and
worse.
These authors conclude that vitamin
D deficiency is closely linked to increased adiposity, triglyceride, and glucose measurements. Vitamin D deficiency
was associated with an increased amputation risk in veterans with peripheral arterial disease and appears to mediate its effects
through traditional risk factors. (Free abstract only.) Journal of the American Medical Directors Association
Study: Prolonged screen time may raise risk of death, heart problems
Adults who spent at least
four hours a day on nonwork screen time such as watching TV or playing video games were 125% more likely to develop a heart
complication and 48% more likely to die from any cause compared with those who had less
than two hours of screen time, a study in the Journal of the American College of Cardiology found. The researchers plan to
investigate the connection between prolonged or "recreational sitting" and increased heart-related risks. Los Angeles Times/Booster Shots blog
Coronary artery calcium scoring. What's the diagnostic value?
This study concluded that coronary artery
calcium scoring appears to be an effective initial tool for risk stratification of low-intermediate risk patients with possible
acute coronary syndromes based on its high negative predictive value and additive diagnostic
value. The American Journal of Cardiology
Consistent exercise lowers colon cancer death risk
A U.S. study of more than 150,000 men and women
found that those who exercised consistently for at least 10 years had the lowest risk of dying from colon cancer. The study
in Cancer Epidemiology also showed that adults who were regularly physically active had a lower risk of death from colon cancer
patients than adults who were sedentary. United Press International
Statins for Patients with
Fatty Liver Disease and Mildly Elevated Transaminases
Benefits seem to outweigh
hepatotoxicity risk.
Patients
with hyperlipidemia often have elevated transaminase levels, usually caused by nonalcoholic fatty liver disease (NAFLD),
an independent predictor of mortality. Small studies have suggested that statins lower transaminase levels and improve
liver histology in patients with NAFLD, but many clinicians are reluctant to start or continue statins in such patients. In
two recent studies, investigators examined the effects of statins in patients with NAFLD who were enrolled in trials with
cardiovascular primary endpoints.
In a Greek study, researchers randomized 1600 patients with coronary heart disease and
hyperlipidemia to receive either structured care including atorvastatin (titrated to achieve LDL cholesterol level <100 mg/dL) or usual care by
their own physicians for an average of 3 years (Angiology 2003; 54:679). Of these patients, 437 had elevated transaminases ( 3 times the upper limit of normal) at baseline; most
had ultrasound findings consistent with NAFLD and no other apparent cause of transaminitis. In this subgroup, mean transaminases
declined significantly from baseline in patients assigned to statins and rose significantly from baseline in those assigned
to usual care. Patients with baseline transaminitis who were assigned to statins had 68% lower risk for cardiovascular events
than those receiving usual care; patients with normal baseline transaminases exhibited 39% relative risk reduction with statins. Fewer than
1% of patients assigned to statins in the original study had hepatotoxicity related to treatment.
In
a U.S. study, researchers randomized 1000 apparently healthy adults with elevated coronary calcium scores to receive a daily
combination of atorvastatin (20 mg), vitamin C (1 g), and vitamin E (1000 IU), or matching placebos for a mean of 3.6 years
(JW Cardiol Aug 12 2005). At baseline, all patients had LDL cholesterol levels between 90 and 174 mg/dL and
transaminases <1.5 times the upper limit of normal. Among the 455 patients who underwent baseline and follow-up abdominal
computed tomography (CT) scans, 80 met radiological criteria for NAFLD at baseline (defined as a ratio of liver to spleen
attenuation <1). Follow-up CT scans showed significantly fewer patients with NAFLD in the treatment group than in the placebo group (37% vs.
78% at 2 years). Three patients exhibited transient transaminase elevations during the study.
Comment: In patients with NAFLD and mildly elevated transaminase levels, the cardiovascular benefits of statins
seem to outweigh any risk for hepatotoxicity. Whether statins (with or without antioxidant vitamins) can interrupt the progression from NAFLD to advanced liver disease will require longer-term study. Also, randomized
trials of statins in patients with more-severe fatty liver disease are needed.
Echinacea for the Common Cold
The herb provided no significant benefit.
Barrett B et al. Ann Intern Med 2010 Dec 21; 153:769
Early Cigarette Smoking Associated with Breast Cancer
Young female patients who smoke may benefit from knowing that early smoking
is associated with a modest increase in breast cancer risk, according to an Archives
of Internal Medicinestudy.
Researchers analyzing
updated data from the Nurses' Health Study report that they have confirmed their 2002 finding of a slight elevation in
breast cancer risk associated with smoking. During some 3 million person-years of follow-up between 1976 and 2006, women who
smoked more than 25 cigarettes per day for more than 35 years and began smoking before age 18 had ahazard
ratio for invasive breast cancer of 1.25, compared with never-smokers.
The
effect was stronger when smoking began before the woman's first birth and before menopause. Postmenopausal smoking was
associated with a slightly decreased risk. There was no apparent increased risk from exposure to secondhand smoke.
Archives
of Internal Medicine article
Escitalopram Ameliorates Hot
Flashes
Escitalopram,
a selective serotonin reuptake inhibitor,
reduces the frequency and severity of hot flashes in menopausal women, according to a JAMA study.
Researchers
randomized 200 women to 8 weeks of treatment with either placebo or escitalopram. If by the fourth week hot flashes had not
been reduced sufficiently, escitalopram recipients received a doubled dose (20 mg/day) and placebo recipients received a matching
dummy pill.
By 8 weeks, the frequency of self-reported hot flashes had decreased by
roughly half in the escitalopram group and by about one third among placebo recipients. Similarly, severity scores also decreased
significantly more in the treatment group.
Three weeks after stopping therapy, symptoms recurred in the treatment group.
Asked to comment,
Dr. Andrew Kaunitz of Journal Watch Women's Health said
that the authors convincingly demonstrated escitalopram's greater efficacy. "However," he continued, "women
with bothersome symptoms who can safely take hormone
therapy should be counseled that SSRIs are, unfortunately, substantially
less effective than hormone therapy in achieving symptomatic relief."
JAMA article
Preventive Effects of Mindfulness in Recurrent Depression
A potentially valuable approach, especially for some patients
with remissions who wish to discontinue their medication after successful acute treatment.
Journal
Watch Psychiatry summary
Liver-Damage Caution over the Antiarrhythmic Dronedarone
The FDA has issued a safety alert on the antiarrhythmic
dronedarone (marketed as Multaq) because of cases of severe liver injury associated with the drug. Two cases required liver transplants.
The
agency says the complication is rare, but reminds clinicians to consider monitoring patients' liver enzymes, especially
during the first 6 months of treatment.
FDA MedWatch alert
Unique Cardiovascular Risks of Tricyclic Antidepressants
An epidemiologic study shows that use of this class of drugs increases the risk for cardiovascular disease.
Studies examining links between antidepressant use and risk for cardiovascular
disease (CVD) have produced conflicting results. Because most of these studies focused on a population already diagnosed with
CVD, the researchers could not determine whether CVD was driving depression and antidepressant use, and no study used a sample
representative of the general population. To prospectively study this link in such a population, researchers examined 8 years
of records of 14,784 participants without existing CVD from the Scottish Health Survey. The analysis compared CVD risk in
antidepressant users and nonusers and controlled for factors associated with antidepressant use and CVD risk.
Rates of use were 2.2% for tricyclic antidepressants (TCAs), 2.0% for selective serotonin reuptake inhibitors (SSRIs),
and 0.7% for other antidepressants. Multiple factors, including depression and anxiety symptoms, contributed significantly to CVD risk. After adjustments for these confounders,
only TCAs remained associated with a significant increase in rate of cardiovascular events
(hazard ratio, 1.35). Associations with specific coronary events were nonsignificant.
Comment: This excellent study shows that use of tricyclic antidepressants increases the risk for CVD. This effect is due neither
to coexisting depression or anxiety nor to reverse causality. These agents pose unique risks,
including prolonged QT
interval, hypertension, postural hypotension,
and effects on heart rate variability,
all of which could be contributing factors. The rate of TCA use in this population was relatively high, unlike in the U.S.,
where SSRIs have largely replaced TCAs. Still, TCAs are very effective for depression and some anxiety
disorders and remain an option in patients with disorders refractory
to other treatments. Clinicians should keep this long-term adverse effect in mind.
Herpes Zoster Vaccine
Found Effective in Community Setting
A
study conducted in a clinical practice setting confirms the effectiveness of herpes zoster vaccine, according to a report
in JAMA.
In a retrospective cohort study of health plan members,
researchers examined the incidence of herpes zoster among some 75,000 vaccinees aged 60 and older and 225,000 age-matched
controls who did not receive the vaccine. After a follow-up averaging about 2 years, the
incidence of herpes zoster was twice as high among controls as among vaccinees (13.0 vs. 6.4 per 1000 person-years).
The difference remained after adjustment for sex, race, presence of chronic disease, and health care utilization. There was
also a significant reduction in risk for ophthalmic herpes zoster.
The authors estimate
that one episode of herpes zoster would be prevented for every 71 patients vaccinated. They write that their results "support
recommendations to offer herpes zoster vaccine to eligible patients of all ages, including
the oldest population."
JAMA article
Tonsillectomy Guidelines
Issued
Evidence-based
guidelines on identifying children who should (and should not) undergo tonsillectomy appear in Otolaryngology — Head
and Neck Surgery.
The guidelines focus both on appropriate selection of patients
and their perioperative care.
Guidelines
include the following:
·
Tonsillectomy
may be appropriate for those with documented recurrent throat
infections(at least seven episodes in the past year, or at least five per year for the past 2 years, or at least three
per year for the past 3 years). Otherwise, the guidelines recommend watchful waiting.
·
Clinicians should ask
parents and caregivers of children with tonsil hypertrophy and sleep-disordered breathing about comorbid conditions —
e.g., growth retardation, poor performance in school, enuresis,
and behavioral problems — that might improve following tonsillectomy.
Otolaryngology
— Head and Neck Surgery article
Subclinical Thyroid Disease and Risk for
Hip Fracture
Risk was higher with either hyper- or hypothyroidism.
Lee JS
et al. Arch Intern Med 2010 Nov 22; 170:1876
Remarkable Reversal of Aging in Mice
Restoring telomerase function in mutant mice reversed signs of aging.
Jaskelioff M et al. Nature 2010 Nov 28;
Homocysteine-Lowering
Doesn't Offer Secondary Prevention After Myocardial Infarction
Homocysteine-lowering has no apparent effect on secondary prevention of cardiovascular
events after myocardial infarction, according
to a JAMA study that
confirms earlier findings.
Some 12,000 MI survivors were randomized to receive either
homocysteine-lowering vitamin supplements (2 mg of folic acid plus 1 mg of vitamin B12 daily) or matching placebo. Treatment
brought about a 28% lowering of homocysteine. After almost 7 years of follow-up, rates of vascular events — including
nonfatal MI, revascularization, death from coronary
disease, and fatal and nonfatal stroke — showed no significant differences between groups.
The
researchers conclude that homocysteine-lowering supplements "had no beneficial effects on major vascular events."
JAMA article
