HHAL MEDICAL NEWS JUNE 2011

Olive Oil Use Associated with Lower Stroke Risk

Regular use of olive oil confers a lower risk for ischemic stroke, according to a French cohort study reported in Neurology.

Olive oil use was gauged by dietary recall at baseline in some 7600 subjects followed for a median of 5 years. All participants were aged 65 or older; a subgroup of 1200 underwent baseline measurement of plasma fatty acids.

Compared with nonusers, there was a 41% lower risk for stroke among intensive users of olive oil — i.e., using the oil in dressings as well as for cooking. Similarly, plasma oleic acid levels among the tested subgroup roughly paralleled olive oil intake and an accompanying lower stroke risk.

Editorialists agree with the authors that oleic acid is only an indirect — and as yet unvalidated — measure of olive oil use.

Aspirin and NSAIDs Might Raise Risk for Diverticulitis and Diverticular Bleeding

Moderately elevated risk was noted in an observational study.

Observational studies (with various limitations) have suggested that regular use of aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) raises risk for complications of colonic diverticulosis. This association is explored in an analysis from the observational Health Professionals Follow-Up Study.

Among 47,000 male participants, 14,000 used aspirin regularly, and 2500 used nonaspirin NSAIDs regularly (i.e., at least twice weekly). During 22 years of follow-up, 939 men reported diverticulitis, and 256 reported diverticular bleeding. In a multivariate analysis, regular aspirin use was associated with significantly elevated risks for diverticulitis (hazard ratio, 1.25) and diverticular bleeding (HR, 1.70); the same was true for regular NSAID use (HRs, 1.72 and 1.74, respectively). For both aspirin and NSAID use, these findings represent roughly one additional case of diverticular complications per 1000 person-years.

Strate LL et al. Use of aspirin or nonsteroidal anti-inflammatory drugs increases risk for diverticulitis and diverticular bleeding. Gastroenterology 2011 May; 140:1427.

Medline abstract (Free)

Neurology article (Free abstract)

Predicting Alzheimer Disease with Magnetic Resonance Imaging

Thinner cortex in specific brain regions was associated with deterioration from normal cognition to Alzheimer disease in two separate cohorts of elders.

Dickerson BC et al. Neurology 2011 Apr 19; 76:1395

Screening for Orientation to Time as an Indicator of Cognitive Dysfunction

Disorientation to month or year in patients aged 65 and older predicted dementia or delirium.

O'Keeffe E et al. J Neurol Neurosurg Psychiatry 2011 May 82:500

Fecal Occult Blood Tests Can Do More Harm Than Good in the Elderly

Among elderly men, 87% with the worst life expectancy and 65% with the best life expectancy experienced more burden than benefit from fecal occult blood testing.

Kistler CE et al. Arch Intern Med 2011 May 9;

β-Blockers in COPD Patients

Four-year mortality was lower among patients with chronic obstructive pulmonary disease who received β-blockers.

Short PM et al. BMJ 2011 May 10; 342:d2549

PPIs Might Decrease the Effectiveness of Alendronate to Prevent Fractures

Concurrent use of proton-pump inhibitors blunted the efficacy of the bisphosphonate in reducing risk for hip fractures in patients aged 70 and older.

Abrahamsen B et al. Arch Intern Med 2011 Jun 13; 171:998

PPIs Seem to Interfere with Aspirin's Antiplatelet Effects

Cardiovascular risk was higher in Danish MI patients who received proton-pump inhibitors along with aspirin than in those not getting a PPI. However, if the study's sicker patients were more likely to receive a PPI, then that confounder could explain the results

CT Angiography for Diagnosing Cerebral Aneurysms

Computed tomographic angiography is a highly accurate technique for diagnosing cerebral aneurysms in symptomatic patients, according to a meta-analysis of CTA studies.

http://neurology.jwatch.org/cgi/content/full/2011/531/1?q=topic_stroke

Exercise the Arms, Benefit the Legs

Supervised arm exercises improved walking distance in patients with vascular claudication.

Saxton JM et al. J Vasc Surg 2011 May 53:1265

Can We Delay Conversion from Mild Cognitive Impairment to Alzheimer Disease?

Control of vascular risk factors may lower the conversion rate.

Li J et al. Neurology 2011 Apr 26; 76:1485

Surgery vs. Observation for Early-Stage Prostate Cancer Free!

During median follow-up of 12.8 years, fewer deaths occurred among men who underwent radical prostatectomy than among those assigned to watchful waiting.

Bill-Axelson A et al. N Engl J Med 2011 May 5; 364:1708

Smith MR. N Engl J Med 2011 May 5; 364:1770

Screening Does Not Reduce Ovarian Cancer Mortality

Screening with transvaginal ultrasound and CA-125 measurement does not reduce ovarian cancer mortality, according to results from the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial published in JAMA.

Some 78,000 women aged 55 to 74 without histories of ovarian cancer were randomized to usual care, or to screening with annual transvaginal ultrasound for 4 years and annual CA-125 blood testing for up to 6 years. During roughly 12 years' follow-up, the primary endpoint — ovarian cancer mortality — did not differ between the groups.

Roughly 3000 women had false-positive results on screening, one third of whom had surgery (e.g., oophorectomy) as part of the diagnostic evaluation. Among these, the rate of major surgical complications was 21 per 100 procedures.

JAMA article (Free)

Be Vigilant for New-Onset Diabetes with High-Dose Statins, Meta-Analysis Suggests

Compared with moderate-dose regimens, high-dose statins are associated with increased diabetes risk, according to a JAMA meta-analysis.

Researchers studied outcomes from five trials comparing high- versus moderate-dose statins in some 33,000 patients free of diabetes at baseline. During a mean follow-up of almost 5 years, the risk for new-onset diabetes was higher in the high-dose group (odds ratio, 1.12). The risk for cardiovascular events was, conversely, lower in the high-dose group (OR, 0.84). The authors estimate that 498 patients per year would need to take high-dose statins to cause one additional case of diabetes. To prevent one cardiovascular event, 155 patients would need to be treated.

Although the authors have not identified a mechanism for this effect, they "suggest that clinicians should be vigilant for the development of diabetes in patients receiving intensive statin therapy."

JAMA article

 Dietary Fiber Intake and Mortality in the NIH-AARP Diet and Health Study

Arch Intern Med. 2011;171(12):1061-1068. doi:10.1001/archinternmed.2011.18

Background  Dietary fiber has been hypothesized to lower the risk of coronary heart disease, diabetes, and some cancers. However, little is known of the effect of dietary fiber intake on total death and cause-specific deaths.

Methods  We examined dietary fiber intake in relation to total mortality and death from specific causes in the NIH (National Institutes of Health)-AARP Diet and Health Study, a prospective cohort study. Diet was assessed using a food-frequency questionnaire at baseline. Cause of death was identified using the National Death Index Plus. Cox proportional hazard models were used to estimate relative risks and 2-sided 95% confidence intervals (CIs).

Results  During an average of 9 years of follow-up, we identified 20 126 deaths in men and 11 330 deaths in women. Dietary fiber intake was associated with a significantly lowered risk of total death in both men and women (multivariate relative risk comparing the highest with the lowest quintile, 0.78 [95% CI, 0.73-0.82; P for trend, <.001] in men and 0.78 [95% CI, 0.73-0.85; P for trend, <.001] in women). Dietary fiber intake also lowered the risk of death from cardiovascular,infectious, and respiratory diseases by 24% to 56% in men and by 34% to 59% in women. Inverse association between dietary fiber intake and cancer death was observed in men but not in women. Dietary fiber from grains, but not from other sources, was significantly inversely related to total and cause-specific death in both men and women.

Conclusions  Dietary fiber may reduce the risk of death from cardiovascular, infectious, and respiratory diseases. Making fiber-rich food choices more often may provide significant health benefits.

Arch Intern Med. 2011;171(12):1061-1068. doi:10.1001/archinternmed.2011.18

Predicting Fracture Risk in Patients with Type 2 Diabetes

At similar bone-mineral densities, fracture risk was higher for diabetic patients.

Type 2 diabetes mellitus is associated with both higher bone-mineral density (BMD) and, paradoxically, higher fracture risk. Normative values for BMD, or other standardized risk assessments, such as the WHO Fracture Risk Algorithm (FRAX) score, might not perform well in diabetic patients. Data from three national prospective cohort studies were combined to assess fracture risk in 9449 older women (median follow-up, 12.6 years) and 7436 older men (median follow-up, 7.5 years). Among 770 diabetic women, 262 suffered nonspine fractures; among 1199 diabetic men, 133 suffered nonspine fractures. About one quarter of reported fractures we re hip fractures.

Age- and sex-adjusted BMD (T-score) predicted fracture risk similarly for participants with or without diabetes. However, at any given T-score, diabetic patients were at higher risk than nondiabetic participants: Diabetic women with T-scores that were 0.59 units higher (i.e., less negative) than nondiabetic women of the same age had similar hip fracture risk; the corresponding value for men was 0.38 units. Similar relations were noted for FRAX scores.

Schwartz AV et al. Association of BMD and FRAX score with risk of fracture in older adults with type 2 diabetes. JAMA 2011 Jun 1; 305:2184.

Medline abstract 

Evaluation, Treatment, and Prevention of Vitamin D Deficiency

A new practice guideline recommends against routinely measuring serum vitamin D levels in adults.

The Endocrine Society has published a new practice guideline on vitamin D deficiency. This summary covers portions of the guideline that are relevant to adult medicine (the pediatric portion is covered elsewhere; JW Gen Med Jun 23 2011). Key points follow:

·                     Population-wide screening for vitamin D deficiency is not recommended because evidence to support this practice is lacking. However, screening is recommended in adults who are at high risk for deficiency, including those with osteoporosis, obesity, or history of falls.

·                     Vitamin D deficiency is defined as serum 25-hydroxyvitamin D (25[OH]D) level <20 ng/mL (50 nmol/L); however, serum assays are notoriously variable.

·                     Recommended dietary intake for adults is at least 600 IU daily (800 IU for those aged >70); however, some at-risk adults might require  1500 IU. Few foods contain substantial vitamin D naturally, and many adults eat little vitamin D–fortified food and do not get enough sun exposure to maintain vitamin D sufficiency. Blacks and other dark-skinned people are at higher risk for deficiency than whites.

·                     Both vitamin D₂ (ergocalciferol) and D₃ (cholecalciferol) are acceptable as supplements.

·                     Treatment of vitamin D deficiency is indicated mainly for skeletal reasons; evidence also suggests that treatment lowers the incidence of falls in older adults. In contrast, evidence that treatment prevents cardiovascular disease, lowers mortality, or generally improves quality of life is lacking.

Comment: Because many clinicians routinely check vitamin D levels these days, the guideline's rejection of population-wide screening is perhaps the key point for clinicians. Unfortunately, for average-risk adults, the guideline doesn't explicitly say whether clinicians should recommend daily supplements (600–800 IU) universally or should evaluate, case-by-case, whether a given person's sun exposure and dietary intake likely ensure sufficient vitamin D.

Holick MF et al. Evaluation, treatment, and prevention of vitamin D deficiency: An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2011 Jun 6; [e-pub ahead of print](http://dx.doi.org/10.1210/jc.2011-0385)

Triglycerides and Cardiovascular Disease: The Experts Speak

Experts redefine an optimal triglyceride level and stress that lifestyle changes are required to reach it.

While debate continues about whether hypertriglyceridemia independently predicts coronary artery disease, mean triglyceride levels in the U.S. are rising, along with rates of obesity and diabetes. In a new scientific statement, the American Heart Association (AHA) outlines the scope of the problem and offers treatment recommendations. Triglyceride levels directly influence high- and low-density lipoprotein metabolism, and hypertriglyceridemia can be mediated genetically or acquired (e.g., in patients with hypothyroidism, diabetes, or renal disease).

The authors propose a "practical algorithm" for initial screening with nonfasting triglyceride measurement. If levels are <200 mg/dL (corresponding to <150 mg/dL on a fasting sample), they suggest that patients continue with healthy diet and activity levels. At levels  200 mg/dL, fasting lipoprotein measurement is advised, and suggested targets are provided for weight loss and intake of dietary carbohydrates, sugars, and fats. Increased physical activity and intake of  -3 fatty acids also are advocated for their profound effects on elevated triglycerides levels. At the highest triglyceride levels or in symptomatic patients, pharmacologic therapy can be useful (e.g., to lower risk for pancreatitis in patients with triglycerides >500 mg/dL). At all triglyceride levels, the AHA recommends avoiding consumption of trans fats, which raise triglyceride levels and atherogenic l ipid particles. Finally, the guidelines set <100 mg/dL as an optimal triglyceride level.

This statement summarizes what we know about triglycerides and their relation to disease and provides a framework for treating the many patients with suboptimal triglyceride levels. Patients should be advised that lifestyle changes in diet, weight loss, and exercise are basic to treating most cases of hypertriglyceridemia, although tightening the definition of an optimal triglyceride level inadvertently could invite additional prescribing.

Miller M et al. Triglycerides and cardiovascular disease: A scientific statement from the American Heart Association. Circulation 2011 May 24 ; 123:2292. (http://dx.doi.org/10.1161/CIR.0b013e3182160726)

Medline abstract (Free)

Simvastatin plus Ezetimibe Improves Cardiovascular Outcomes in Patients with Chronic Kidney Disease

But would a statin alone have produced similar results?

Two previous trials failed to demonstrate the effectiveness of statins for preventing adverse cardiovascular events in patients on dialysis (JW Cardiol Aug 19 2005 and Mar 30 2009). In SHARP, a randomized trial, investigators compared simvastatin plus ezetimibe with placebo. Of the 9270 patients (age,  40; mean age, 62; 63% men) with chronic kidney disease and no histories of acute myocardial infarction (AMI) or coronary revascularization, about one third were on dialysis. The study was funded by the drug combination's manufacturer, who participated in the study design.

Patients had creatinine levels of at least 1.7 mg/dL in men or 1.5 mg/dL in women. Nonadherent participants were excluded after a 6-week, single-blind, run-in placebo course. The primary endpoint was first major atherosclerotic event. At baseline, mean total cholesterol level was 189 mg/dL, and mean LDL cholesterol level was 108 mg/dL.

At study midpoint, the mean LDL cholesterol level was 33 mg/dL lower in the treatment group than in the placebo group. During a median follow-up of 4.9 years, a primary endpoint occurred in 11.3% of patients in the treatment group and 13.4% of those in the placebo group (relative risk, 0.83; 95% confidence interval, 0.74–0.94; P=0.002). Although the rate of nonfatal AMI or death from coronary heart disease did not differ significantly between groups, the rates of nonhemorrhagic stroke and revascularization (coronary, carotid, aortic, or leg) were significantly lower in the treatment group, whereas all-cause mortality was nonsignificantly higher (24.6%, vs. 24.1% with placebo). The study was underpowered for comparison by dialysis status; the rate of the primary endpoint in patients on hemodialysis was 15.2% in the treatment group and 15.9% in the placebo group.

Lung Function After Tiotropium in Patients with Severe Asthma

As an add-on therapy, tiotropium improved lung function at 8 weeks.

A recent trial that involved patients whose asthma was not controlled by low-dose inhaled corticosteroids (ICS) showed that tiotropium was more effective than a double dose of ICS and was equivalent to a long-acting β₂-agonist (LABA) for improving lung function and easing asthma symptoms. (JW Gen Med Oct 7 2010). Investigators now examine the effectiveness of triple therapy — addition of tiotropium (Spiriva) in patients who already are receiving ICS/LABA combination therapy.

In a double-blind crossover study with three 8-week treatment periods, 107 adults whose severe asthma was not controlled by high-dose ICS/LABA combinations were treated with each of two doses of tiotropium and placebo in random order. The 5-µg and 10-µg doses of tiotropium were equally effective and were both superior to placebo in improving forced expiratory volume in 1 second (FEV₁; mean improvements with low and high doses, 139 mL and 170 mL). No differences were noted in asthma symptom scores during any treatment period.

Annual Screening with Low-Dose CT Reduces Lung Cancer Mortality

Results from the National Lung Screening Trial — which was stopped in late 2010 after it found a 20% reduction in lung cancer mortality with annual low-dose CT — have been published in theNew England Journal of Medicine.

The randomized trial compared low-dose CT with chest radiography (3 annual screens in each group) in some 53,000 high-risk patients. Overall, the lung cancer mortality rate was 247 per 100,000 person-years in the CT group versus 309 per 100,000 person-years in the radiography group.

An editorialist acknowledges the large effect observed, but cautions that "primary care physicians should ... know the number of patients needed to screen to avoid one lung-cancer death [calculated to be 320], the limited amount of information that can be gained from one screening test, the potential for overdiagnosis and other harms, and the reduction in the risk of lung cancer after smoking cessation."

NEJM article (Free)

High-Selenium Yeast Supplements Improve Plasma Lipid Levels

But the effects of this treatment in individuals with normal or high baseline selenium concentrations remain unproven, as do clinical outcomes.

Rayman MP et al. Ann Intern Med 2011 May 17; 154:656

 Smoking Increases Risk for Prostate Cancer Recurrence and Mortality

The risks for biochemical recurrence and disease-specific mortality were significantly higher for men who were smokers at the time of diagnosis than for those who had never smoked

Dexamethasone Shortens Hospitalization in Uncomplicated Community-Acquired Pneumonia

But this Dutch study should not alter routine practice in the U.S.

Meijvis SCA et al. Lancet 2011 Jun 11; 377:2023

Even Short-Term NSAID Use Associated with Cardiovascular Events

Registry data show adverse effects of both selective cyclooxygenase-2 inhibitors and nonselective agents within the first week of treatment.

Schjerning Olsen A-M et al. Circulation 2011 May 24; 123:2226

 Dogs Can Smell Cancer

A specially trained Labrador Retriever detected colorectal cancer well, which could lead to screening tests based on specific volatile organic compounds in breath and feces of patients.

More sleep leads to less stress
Among teens, more hours of sleep predicted a steeper decline in cortisol levels during waking hours, and greater waking cortisol levels predicted more hours of sleep the following day. Journal of Adolescent Health 

White-Coat Effect Accounts for One Third of Resistant Hypertension Cases

Ambulatory blood pressure monitoring reveals the prevalence and characteristics of true versus white-coat resistant hypertension.

de la Sierra A et al. Hypertension 2011 May 57:898

CT for Suspected Acute Appendicitis

Multidetector computed tomography is highly accurate.

Use of computed tomography (CT) for diagnosing suspected acute appendicitis rose from approximately 20% in 2000 to >90% in 2006. However, few researchers have examined the diagnostic performance of multidetector CT (MDCT) for this purpose. To assess diagnostic performance, researchers enrolled more than 2800 consecutive adults from a single academic institution in Wisconsin who were referred for MDCT (from 2000 through 2009) to evaluate suspected acute appendicitis. Surgical pathology and intraoperative findings were used to determine whether patients had acute appendicitis; patients were followed for a minimum of 12 months to determine the presence of acute appendicitis in those who did not undergo surgery.

The overall prevalence of acute appendicitis was 23%. MDCT was positive in 708 patients and negative in 2163 patients. In 10 patients, CT results were false-negative; in 43 patients, CT results were false-positive. The sensitivity of MDCT for acute appendicitis was 98.5%, specificity was 98.0%, and negative and positive predictive values were 99.5% and 93.9%.

Medline abstract

In Chronic Kidney Disease, Ambulatory BP Measurements Give Best Prognostic Value

In chronic kidney disease, ambulatory blood pressure measurements — particularly measurements taken at night — are better prognostic indicators of cardiorenal risk than those taken in the clinic, according to an Archives of Internal Medicine study.

Researchers followed roughly 440 patients not requiring dialysis. During a median 4 years' follow-up, BP was measured both in the clinic and at home.

Daytime systolic ambulatory readings at or above 136 mm Hg predicted greater risk for fatal and nonfatal cardiovascular events requiring hospitalization as well as greater risk for renal death. Nighttime systolic recordings at or above 125 mm Hg were also predictive of higher risk. Office measurements were not. The prognostic value of ambulatory measurements was independent of other risk factors, such as proteinuria and glomerular filtration rate.

Praising the study, commentators write, "It is now harder to defend reliance on clinic BP measurement alone if we nephrologists are serious about targeted BP intervention."

Archives of Internal Medicine article (Free abstract)

In Determining Blood Pressure, More Measurements Improve Accuracy

A single measurement doesn't correctly classify a patient's hypertensive status, according to anAnnals of Internal Medicine study.

Department of Veterans Affairs researchers followed some 450 patients with hypertension. Over 18 months, systolic pressures were determined from home recordings, routine clinical visits, and scheduled research-associated visits. When examined by method of measurement, 28% of patients were within BP control limits according to routine clinical measurements, 47% according to home measurements, and 68% according to research-visit measurements.

When examined by frequency of measurement, within-patient variances (usually about 10%) decreased dramatically when two or more measurements were made, although there was little benefit beyond five or six measurements. The advantage of repetition held across all methods of measurement.

The authors call for use of averaged home readings to ensure high-quality care. Editorialists, citing the widespread prevalence of sloppy technique, review the proper method and also advocate use of BP measurement as a performance metric.

Annals of Internal Medicine article (Free PDF)

Varenicline Might Pose a Risk for Patients with Cardiovascular Disease, FDA Warns

Varenicline, the smoking-cessation drug marketed as Chantix, might increase the risk for myocardial infarction and other cardiovascular events in patients with existing cardiovascular disease, the FDA cautioned on Thursday.

The warning follows the review of a clinical trial in which 700 smokers with documented cardiovascular disease were randomized to varenicline or placebo. Those treated with varenicline were more likely to have an adverse cardiovascular event, such as nonfatal MI, angina pectoris, or peripheral vascular disease diagnosis, than those on placebo.

The FDA has asked the manufacturer to conduct a meta-analysis of data from existing varenicline studies. In the meantime, safety information will be added to the drug's prescribing label.

FDA MedWatch alert (Free)

FDA Warns of Possible Bladder Cancer Risk from Pioglitazone

The label for the diabetes drug pioglitazone (Actos) will now warn patients about a potential increased risk for bladder cancer when taken for 1 year or more, the FDA announced on Wednesday. Last week, France decided to pull pioglitazone off the shelves over similar concerns, and Germany recommends that new patients not start using the drug.

The FDA says it based its decision on 5-year interim data showing an increased risk for bladder cancer among those who took pioglitazone the longest and at the highest doses.

The agency is warning clinicians not to use the drug in patients with active bladder cancer and says they should use it cautiously in patients with prior bladder cancer.

FDA MedWatch alert 

Tiotropium Concerns: Increased All-Cause Mortality with Use of Mist Inhaler

Inhaled tiotropium mist is associated with increased all-cause mortality, a BMJ meta-analysis finds. (The mist product, Respimat, is approved in Europe but not the U.S., where only the powdered formulation, Spiriva HandiHaler, is approved for use in patients with chronic obstructive pulmonary disease.)

Researchers gathered data from five randomized trials that compared mortality rates after use of tiotropium mist or placebo for at least 30 days in some 6500 patients with COPD. The tiotropium group showed a 46% relative increase in risk for all-cause mortality (2.6% vs. 1.8% per year).

The authors cite studies showing higher peak concentrations of the anticholinergic with the mist inhaler than with the powdered formulation. And an editorialist concludes that, pending the results of a head-to-head comparison of mist versus powder, the powdered formulation is the "safer bet."

BMJ article (Free)

Hypertension? Coronary artery disease? Watch out for NSAIDs
Among hypertensive patients with coronary artery disease, chronic self-reported use of nonsteroidal anti-inflammatory drugs (NSAIDs) was associated with an increased risk of adverse events during long-term follow-up. The American Journal of Medicine 

Aspirin works
According to this article, primary prevention with aspirin decreased the risk for total cardiovascular (CV) events and nonfatal myocardial infarction (MI), but there were no significant differences in the incidences of stroke, CV mortality, all-cause mortality and total coronary heart disease. The American Journal of Cardiology

For diabetes plus hypertension, lower may not always be better
The investigators selected 15 pertinent reports from a Medline search regarding aggressive blood glucose and blood pressure control (BP) in patients with diabetes mellitus (DM) and hypertension. This review of the findings suggests less aggressive control of glucose and BP and that "the lower the better" goal may not be defensible at present, until new data become available. The American Journal of Cardiology 

What can the neutrophil count do in infarction stratification?
According to this article, the neutrophil count does not improve the early diagnosis of acute myocardial infarction (AMI) in patients presenting with chest pain but does identify patients at increased risk of death. The American Journal of Medicine

Nurse study OKs coffee for people with heart disease or stroke
Data on 11,697 female nurses with a history of heart disease or stroke show no difference in risk of death between those who consume coffee regularly and those who never drink the beverage. The finding warrants further investigation in other populations, said the lead researcher of the study, which was published in the American Journal of Clinical Nutrition.Reuters 

What reverses overanticoagulation in the elderly?
In elderly inpatients with INR above or equal to 5.0, both vitamin K antagonist dose omission and vitamin K1 administration according to recommendations were effective in reversing overanticoagulation, allowing most INRs to return to the 1.8-3.2 range without excessive overcorrection. These authors conclude that the American College of Chest Physicians recommendations may be applied to elderly inpatients.The American Journal of Medicine 

Statin compliance means less costs, fewer hospitalizations
This study concluded that statin adherence is associated with reductions in subsequent total health care costs and cardiovascular disease-related hospitalizations. The American Journal of Cardiology 

Study: Not following heart failure guidelines costs lives
A study in the American Heart Journal found that about 70,000 Americans die each year because they don't receive optimal heart failure treatments as called for by medical guidelines. University of California, Los Angeles, researchers reviewed six evidence-based treatments for heart failure and found that more than 2 million patients who were eligible for them did not receive them. Los Angeles Times/Booster Shots blog 

Depressed teens at risk for cardiovascular disease
This study reports that adolescent depression was found to be a significant predictor of arterial stiffness in adolescents. (Full-text access is time-limited) Journal of Adolescent Health 

Post-traumatic stress disorder, coronary atherosclerosis and mortality
This study concluded that post-traumatic stress disorder is associated with the presence and severity of coronary atherosclerosis and predicts mortality independent of the age, gender and conventional risk factors.The American Journal of Cardiology 

Acid-Suppressive Medication in Noncritical Patients

Bleeding risk was reduced slightly, but the absolute benefit was very small.

Acid-suppressive medication helps to prevent stress-related gastrointestinal (GI) bleeding in critically ill patients, but the practice has spread to noncritical patients despite no good evidence of benefit. Various studies have shown that up to 70% of all inpatients receive acid-suppressive medication. Boston investigators sought to supplement the results of smaller randomized trials with a retrospective cohort study of about 79,000 adults admitted for diagnoses other than GI bleeding; about 46,000 (59%) of them received acid-suppressive medications.

The rate of nosocomial GI bleeding (i.e., bleeding occurring more than 24 hours after admission) was 0.29%. In adjusted analyses that compared patients treated and not treated with acid-suppressive medication, the rate of GI bleeding was lower by roughly 37% in those taking medication.

Comment: These results, while retrospective and uncontrolled, further support the recommendation against use of acid-suppressive medication in noncritical

Herzig SJ et al. Acid-suppressive medication use and the risk for nosocomial gastrointestinal tract bleeding. Arch Intern Med 2011 Jun 13; 171:991.

Medline abstract (Free)

U.S. Foodborne Salmonella Infections Up; European E. coli Source Elusive

Salmonella infection was the most common foodborne illness in the U.S. in 2010, showing no improvement compared with its incidence in 1996–1998, according to an analysis from the Foodborne Diseases Active Surveillance Network published in MMWR.

The network surveys about 15% of the U.S. population for laboratory-confirmed infections with nine foodborne pathogens. Among other findings:

·                         Compared with 2006–2008, Salmonella incidence in 2010 increased by 10%.

·                         The incidences of Campylobacter, Listeria, Escherichia coli O157, Shigella, and Yersiniainfections decreased from 1996–1998 to 2010.

·                         In general, children younger than 5 years were most often infected, while adults aged 60 and older were most likely to be hospitalized or die from infection.

And in other foodborne illness news, the source of the E. coli outbreak that has sickened over 2300 people in Germany (and over 100 in other countries) continues to elude public health officials. To date, the outbreak is responsible for 24 deaths in Germany, the Associated Press reports.

MMWR article (Free)

Associated Press story on E. coli outbreak (Free)