HHAL MEDICAL NEWS OCTOBER 2011
Aspirin Lowers Risk for Hereditary Colon Cancer
Patients may be asking about news stories
that aspirin has a strong protective effect against colorectal cancer in patients with Lynch syndrome. Researchers reported
the results online in the Lancet. In a 2008 paper, they reported
no protective effect after a mean follow-up of about 2.5 years.
Using longer follow-up data, the researchers examined the incidence of
colorectal cancers in some 860 patients who had been randomized to take 600 mg of aspirin or placebo daily. After roughly
5 years' follow-up, per-protocol analysis among those who'd taken aspirin for at least 2 years showed a hazard ratio
of 0.41 for colorectal cancer, compared with placebo.
Editorialists consider the results compelling,
saying they "provide a strong rationale" for using aspirin routinely in Lynch syndrome and support more general
recommendations for its use in the prevention of sporadic cancers "in the context of individualized risk-benefit assessments."
Lancet article
NEJM 2008 paper
Annual Screening Chest X-Rays Don't
Lead to Increased Survival in Lung Cancer
Lung cancer mortality is not reduced among people who undergo
annual screening with chest x-rays, according to a report in JAMA.
Some 155,000 people aged 55 through 74 were randomized either to annual screening with chest radiographs
or to usual care for 4 years. After a median follow-up of 12 years, lung cancer mortality in the two groups was roughly the
same: 14.0 per 10,000 person-years in the x-ray group and 14.2 among controls.
An editorialist says that the results are valuable for
putting to rest the question of whether lung cancer screening with chest radiographs is effective.
JAMA article
JAMA editorial
U.S. Preventive Services Task Force Revisits Prostate Cancer Screening
In a preliminary draft, the USPSTF recommends against prostate-specific
antigen screening.
On October 11, 2011, the U.S. Preventive Services Task Force (USPSTF) posted a draft recommendation
statement on screening for prostate cancer. In its 2008 guideline on this topic, the USPSTF concluded that evidence was insufficient to make a recommendation
in men younger than 75, but it recommended against screening older men (age, 75). Now,
3 years later, the USPSTF recommends against prostate-specific antigen (PSA)-based screening for prostate cancer in all age
groups.
The impetus
for the USPSTF's revisiting of PSA screening is the recent publication of mortality results from two large randomized
screening trials. A U.S. trial showed no benefit from screening but was tainted by substantial
screening outside the trial in the control group. A
European trial showed a small statistically significant reduction in prostate cancer mortality in screened men; however, substantial
overtreatment occurred (i.e., a very small proportion of men who underwent surgery or radiation therapy ultimately benefited
from these interventions), and critics have voiced concerns about certain methodologic issues in this trial, too. In reaching
its decision, the USPSTF drew the following conclusions from its review of the evidence:
- The magnitude of harms from screening (e.g., falsely high
PSA levels, psychological effects, unnecessary biopsies, overdiagnosis of indolent tumors) is "at least small."
- The magnitude of treatment-associated harms
(i.e., adverse effects of surgery, radiation, and hormonal therapy) is "at least moderate" — particularly
because of overtreatment among men with low-grade disease.
- The 10-year mortality benefit of PSA-based prostate cancer screening is "small to
none."
- The
overall balance of benefits and harms results in "moderate certainty that PSA-based screening . . . has no
net benefit."
I agree with
this draft statement, which is a pre-release review and not the final recommendation. Public comment is invited through November 8, 2011, after which
a final statement will be published. Nevertheless, the expected firestorm has erupted already. Advocates of screening have
criticized the USPSTF analysis, and the American Urological
Association issued a press release stating that "the USPSTF — by disparaging the [PSA] test — is doing a great disservice to the men
worldwide who may benefit from the PSA test." Journal Watch will cover the final recommendation when it is published.
Vitamin
D Appears to Prevent Falls in Some High-Risk Subgroups
The benefit appeared limited to those
who received >800 IU of vitamin D daily.
Murad MH et al. J
Clin Endocrinol Metab 2011 Oct 96:2997
Obesity and Underweight
Related to Deletions and Duplications of Same Genetic Region
Severe obesity or underweight are associated
with depletion or duplication on chromosome 16p11.2, in both psychiatric and general populations.
Jacquemont
S et al. Nature 2011
Aug 31;
Prolonged Bottle Use
Is Associated with Increased Risk for Childhood Obesity
Bottle use at 24 months predicted body-mass
index 95th percentile at age 5.5 years.
Another Helping of Flaxseed for Breast
Cancer?
High levels of
serum enterolactone were associated with lower risk for death during follow-up in women with hormone receptor–negative
tumors.
Prehypertension and the Continuum of Stroke
Risk
Prehypertension,
especially in the higher range, is associated with incident stroke.
Xanthelasmata Signals Excess Risks for Ischemic Vascular
Disease and Death
No such association was found for arcus senilis corneae.
Christoffersen M et al. BMJ 2011 Sep 15; 343:d5497
Spironolactone plus Trimethoprim Induces
Hyperkalemia in Elders
Treatment with trimethoprim is associated
with risk for hospitalization in spironolactone-treated patients.
Antoniou
T et al. BMJ 2011
Sep 12; 343:d5228
α-Lipoic
Acid Is Ineffective for Diabetic Neuropathy
Objective improvement was borderline,
and symptom relief was nil.
Ziegler D et al. Diabetes
Care 2011 Sep 34:2054
Estradiol Vaginal Ring vs. Oral Oxybutynin
for Overactive Bladder
Both treatments were equally effective
at diminishing urinary frequency.
Nelken RS et al. Menopause 2011 Sep 18:962
Eckler K. Menopause 2011 Sep 18:941
Cialis Approved for Benign Prostatic Hyperplasia
The erectile dysfunction drug tadalafil (Cialis) has been approved to treat benign prostatic hyperplasia,
either alone or when it occurs along with erectile dysfunction, the FDA announcedon Thursday.
Approval was based on two trials in which men taking 5 mg daily of tadalafil
had significant improvements in BPH symptoms compared with those taking placebo. A third placebo-controlled trial showed that
the drug simultaneously improved symptoms of both BPH and erectile dysfunction.
FDA news release
Zen and the Art of IBS Management
In a randomized trial, mindfulness training was associated
with significant reduction in irritable bowel syndrome severity and improvement in psychological factors.
Each Lifestyle Factor Adds to Diabetes Risk
Unsurprisingly, the strongest predictor
was elevated body-mass index.
Reis JP et al. Ann
Intern Med 2011 Sep 6; 155:292
Treating
Lower Urinary Tract Symptoms with Saw Palmetto
Even at three times the usual dose, it was no better than
placebo.
Older men often use an extract of fruit from the saw palmetto tree as an
alternative treatment for lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia. Various hormonal, inflammatory,
and cellular mechanisms of action have been proposed. However, benefits found in earlier studies and meta-analyses have been
countered by negative findings in more recent trials. To assess the value of much-higher-than-usual saw palmetto doses, 369
men were randomized to daily placebo or saw palmetto (320 mg, with escalations to 640 mg at 24 weeks and to 960 mg at 48 weeks).
The men (age,
45; mean age, 61) had moderately impaired urinary flow and
a range of standardized LUTS scores.
In an intent-to-treat analysis of the 306 men who completed
the 72-week trial, both groups had similar small improvements in mean symptom scores, but saw palmetto conferred no benefit
over placebo on symptom scores or on any secondary outcomes. Adverse effects were similar in both groups, except that —
for unclear reasons — significantly more saw palmetto recipients than placebo recipients experienced physical injury
or trauma (24 vs. 10).
Barry MJ et al. Effect of increasing doses of saw palmetto extract
on lower urinary tract symptoms: A randomized trial. JAMA 2011
Sep 28; 306:1344. (http://dx.doi.org/10.1001/jama.2011.1364)
Original article
Medline abstract
Even Mild Preoperative Anemia
May Increase Risks After Major Noncardiac Surgery
Patients with even mild anemia before undergoing surgery
have increased morbidity and mortality at 30 days postoperatively, according to a retrospective study in the Lancet.
Researchers used an American College of Surgeons database
to gather information on some 225,000 patients who underwent major noncardiac surgery in 2008. Roughly one third had preoperative
anemia (defined as mild if the hematocrit was between 29% and 39% in men, and between 29% and 36% in women; considered moderate
to severe if 29% or lower in both sexes).
Compared with patients without preoperative anemia, those with anemia had a higher 30-day risk for
death (adjusted odds ratio, 1.42) and morbidity from cardiac, respiratory, urinary tract, venous thromboembolism, sepsis,
and wound complications (OR, 1.35). The increased risks were significant with both mild and moderate-to-severe anemia.
Lancet article
Hypertension and Restless legs syndrome(RLS)
Women with frequent symptoms of restless legs syndrome (RLS) are significantly more likely to have hypertension
than those without RLS, according to a cross-sectional study in Hypertension.
More than 65,000 women (average age, 50) participating in
the Nurses' Health Study II self-reported their RLS and hypertension status. Overall, 6% had RLS (defined as symptoms
at least 5 times per month). The more often women experienced RLS symptoms, the more likely they were to have hypertension.
In multivariable-adjusted analyses, women reporting RLS symptoms at least 15 times per month were 41% more likely to have
hypertension than those with no RLS symptoms.
Among the potential underlying mechanisms, the authors point out that most patients
with RLS have periodic limb movements during sleep, which cause elevations in both heart rate and blood pressure at night
and might lead to hypertension during the day.
Hypertension
Swimming Against the Current: Hormonal Forces Drive Excess Body Weight
Hormones that regulate hunger and energy storage make it hard for overweight people to lose weight.
Many of us were taught, and still believe, that being overweight
or obese results from lack of discipline about diet and exercise. However, during the past 20 years, a group of hormones produced
by adipose tissue and the gut have been shown to affect appetite and energy metabolism.
An
Australian team enrolled 50 overweight or obese participants without diabetes in a severe caloric-restriction program. The
program lasted 10 weeks and led to an average weight loss of 14%. Thereafter, participants were given individualized instructions
on caloric intake and exercise needed to maintain weight loss. At 62 weeks, participants had regained a mean of about half
their lost weight.
Caloric restriction and weight loss were associated with dramatic
increases in hormones (such as ghrelin), which increase appetite and energy storage, and with dramatic decreases in multiple
hormones that encourage satiety and promote energy expenditure (such as leptin). Even those participants who remained very
overweight after the weight-loss program experienced strong hormonal urges to eat more and to burn less energy.
Comment: Ubiquitous fast food and lack of exercise profoundly influence obesity. Although limited
by its relatively small size and high attrition rate, this study suggests that a biological component also might be present.
People who are overweight are constantly in a hormonal environment that makes them hungry and causes them to burn less energy
during exercise. Trying to lose weight through diet and exercise feels like swimming against the current.
Severe
Psoriasis Increases Risk for Cardiovascular Disease
Two newly published cohort studies have again
linked severe psoriasis to cardiovascular disease.
Mehta
and colleagues used data from the U.K. General Practice Research Database to identify 3603 patients with severe psoriasis
whose records included a code for psoriasis and use of systemic therapies, such as methotrexate, azathioprine, mycophenolate,
cyclosporine, acitretin, psoralen plus ultraviolet A (PUVA), or phototherapy. The investigators compared these patients with
5783 individuals without psoriasis for rates of myocardial infarction, cerebrovascular accidents, and death from cardiovascular
disease. Even after adjustments for other risk factors (smoking, diabetes, hypertension, hyperlipidemia, age, and sex), the
presence of severe psoriasis conferred a statisti cally significant risk for major adverse cardiovascular events (MACEs).
In addition, the researchers calculated that a 6.2% increase in MACE risk over a 10-year period was attributable to severe
psoriasis. They also pointed out that the use of methotrexate may have resulted in a MACE estimate that is lower than what
actually exists, because methotrexate therapy is associated with a lower risk for MACEs.
In
a Danish, population-based, cohort study, Ahlehoff and colleagues analyzed the risk for atrial fibrillation, ischemic stroke,
or both in patients with psoriasis (36,765 with mild psoriasis; 2793 with severe psoriasis), compared with the reference Danish
population. The definition of severe psoriasis was dependent upon in-hospital care or referral to a specialist. The researchers
found that the presence of psoriasis, whether mild or severe, conferred increased risks for atrial fibrillation and ischemic
stroke and that these risks were significantly higher in patients with severe psoriasis.
Relation Between Barrett's Esophagus and Adenocarcinoma Questioned
The risk that Barrett's esophagus will lead to esophageal
adenocarcinoma is about one quarter of previous estimates, according to a New England Journal
of Medicine study. The finding calls into question current surveillance approaches for patients
with the condition.
Using the Danish national pathology registry, researchers identified
some 11,000 patients who had Barrett's esophagus with or without dysplasia. They then looked for the later appearance
of those patients in the Danish cancer registry.
After a median follow-up of 5 years, the
incidence rate for esophageal adenocarcinoma in patients with Barrett's esophagus was 1.2 cases per 1000 person-years
(previous estimates hovered around 5.5). The relative risk for adenocarcinoma after a finding of Barrett's was some 11
times the risk in the general population — again, a several-fold decrease from previous estimates. Low-grade dysplasia
at initial biopsy was associated with higher risk.
The authors conclude that the risk "is
so minor that in the absence of dysplasia, routine surveillance ... is of doubtful value."
NEJM article
Leisure time physical activity in young adulthood,
benefits in maturity
Using a British birth cohort study, these authors examined how leisure time physical
activity impacts physical performance and strength in men and women during midlife. Results demonstrate that not only do the
benefits of physical activity accumulate across life, but promoting activity during early adulthood is the key to retaining
good physical performance later in life. American Journal of Preventive Medicine
Pedometers make a difference
When nursing home residents wear a pedometer, they have an increase
in steps per day, but once the pedometer is removed, the steps decline again. Benefits were also seen in improved time for
the Timed Up and Go, the 30-second leg lift and the 2-minute walking distance. Pedometers seemed to be a successful motivational
device. (Free abstract only.)Journal of the American Medical Directors Association
Obstructive sleep apnea: Another cardiac arrhythmia
clue?
This study reports that the prevalence of ventricular premature
complexes is increased in middle-aged persons with mainly mild or moderate obstructive sleep apnea, suggesting an association
between obstructive sleep apnea and ventricular arrhythmias even in mild disease.The American Journal of Cardiology
Researchers link insomnia to heart attack risk
People who routinely experience problems going to sleep had a 45% increased risk of
having a heart attack compared with those without sleep problems, according to a Norwegian study published in the journal
Circulation. Risk of heart attack was 30% higher among those who had problems staying asleep, researchers added. The results
were based on a 1995-1997 national health survey of nearly 53,000 men and women. More studies are needed to confirm the association
and identify reasons behind it, researchers said. U.S. News & World Report/HealthDay News
More about the obesity paradox: Stable weight is better?
This article reports that weight loss was related to higher mortality and weight
gain was related to lower mortality when compared with stable weight. The obesity paradox in this sample is explained in part
by a combination of nonvolitional weight loss related to occult disease and a protective effect of weight gain. The American Journal of Medicine
Study: Heart attack risk drops for men who get vigorous exercise
Vigorous physical activity such as running and playing basketball for three or more
hours weekly can reduce the risk of heart attack for men by 22%, Harvard University researchers reported. The study in the
journal Medicine & Science in Sports & Exercise found that people who reached that level of exercise had higher levels
of vitamin D and good cholesterol and lower levels of markers for diabetes. USA TODAY
Don't interrupt antiplatelet treatment
This study concluded that dental extractions may be safely performed in patients receiving single or dual antiplatelet therapy when appropriate local hemostatic
measures are taken, thereby averting the thrombotic risk of temporary antiplatelet discontinuation. The American Journal of Cardiology
Who's the winner in fighting diabetes?
In the fight to prevent diabetes, diet may win out. These
authors examined the combined and independent effects of dietary weight-loss and exercise. Authors found that women
who lost weight by cutting fat and calorie intake, with or without exercise, had significantly improved insulin resistance. American Journal of Preventive Medicine
Antioxidants may cut risk of breast cancer recurrence, study finds
In a study of 2,264 U.S. women diagnosed with early-stage breast cancer, those who
took supplements of vitamin C or vitamin E at least six days a week had a lower risk of cancer
recurrence. Researchers reported in the journal Cancer that breast cancer recurred in only 15% of the 540 women who took vitamin
C, compared with 19% of the 1,072 women
who did not take the vitamin. The differences in breast cancer outcomes were about the same for vitamin E. Reuters
Cardiovascular Risk Prediction
in Diabetic Men and Women Using Hemoglobin A1c vs Diabetes as a High-Risk Equivalent
Nina P. Paynter, PhD; Norman A. Mazer, MD,
PhD; Aruna D. Pradhan, MD; J. Michael
Gaziano, MD; Paul M. Ridker, MD; Nancy
R. Cook, ScD
Arch Intern Med. 2011;171(19):1712-1718.
doi:10.1001/archinternmed.2011.351
Background It is unclear whether models that include hemoglobin A1c (HbA1c)
levels only for diabetic patients improve the ability to predict cardiovascular disease (CVD) risk compared with the currently
recommended classification of diabetes as a cardiovascular risk equivalent.
Methods A total of 24 674
women (including 685 diabetic participants at baseline) and 11 280 men (including 563 diabetic participants at baseline)
were followed up prospectively for cardiovascular disease (CVD). One hundred twenty-five CVD events occurred in diabetic women
(666 in nondiabetic women), and 170 events occurred in diabetic men (1382 in nondiabetic men). Models for CVD risk were generated
separately for men and women using the traditional CVD risk factors with the addition of a term for HbA1c levels only for diabetic individuals. In diabetic participants, the resulting predicted risks were
compared with classification of diabetes as a cardiovascular risk equivalent (10-year CVD risk of at least 20%).
Results In women, the models
including HbA1c levels in diabetic participants improved the C statistic
by 0.177 (P < .001) over the risk equivalence model and showed improved reclassification (net reclassification
improvement [NRI] of 26.7% [P = .001]). In men, the improvements were more modest but still statistically
significant (C statistic change of 0.039 [P = .02]; NRI of 9.2% [P = .04]). Including
HbA1c levels also improved prediction over a dichotomous term for diabetes
in women (NRI of 11.8% [P = .03]) but not in men.
Conclusions In both women and men with diabetes at baseline, we observed
significant improvements in predictive ability of CVD risk using models incorporating HbA1c levels compared with classification of diabetes as a cardiovascular risk equivalent.
QT-Interval Duration and Mortality Rate
Results From the Third National Health and Nutrition Examination Survey
Yiyi Zhang, MHS; Wendy S. Post, MD, MS; Darshan Dalal, MD, PhD; Elena Blasco-Colmenares, MD,
PhD; Gordon F. Tomaselli, MD; Eliseo
Guallar, MD, DrPH
Arch Intern Med. 2011;171(19):1727-1733. doi:10.1001/archinternmed.2011.433
Background Extreme prolongation
or reduction of the QT interval predisposes patients to malignant ventricular arrhythmias and sudden cardiac death, but the
association of variations in the QT interval within a reference range with mortality end points in the general population
is unclear.
Methods We included 7828 men and women from the Third National Health and Nutrition Examination Survey. Baseline QT interval
was measured via standard 12-lead electrocardiographic readings. Mortality end points were assessed through December 31, 2006
(2291 deaths).
Results After an average follow-up of 13.7 years, the association between QT interval and mortality end points was U-shaped.
The multivariate-adjusted hazard ratios comparing participants at or above the 95th percentile of age-, sex-, race-, and R-R
interval–corrected QT interval ( 439 milliseconds) with participants in the middle quintile (401 to <410
milliseconds) were 2.03 (95% confidence interval, 1.46-2.81) for total mortality, 2.55 (1.59-4.09) for mortality due to cardiovascular
disease (CVD), 1.63 (0.96-2.75) for mortality due to coronary heart disease, and 1.65 (1.16-2.35) for non-CVD mortality. The
corresponding hazard ratios comparing participants with a corrected QT interval below the fifth percentile (<377 milliseconds)
with those in the middle quintile were 1.39 (95% confidence interval, 1.02-1.88) for total mortality, 1.35 (0.77-2.36) for
CVD mortality, 1.02 (0.44-2.38) for coronary heart disease mortality, and 1.42 (0.97-2.08) for non-CVD mortality. Increased
mortality also was observed with less extreme deviations of QT-interval duration. Similar, albeit weaker, associations also
were observed with Bazett-corrected QT intervals.
Conclusion Shortened and prolonged QT-interval durations, even
within a reference range, are associated with increased mortality risk in the general population.
Cell Phones Not Linked to Tumor Risk in Large Danish Study
Use of mobile phones does not increase the risk for brain tumors, a Danish national cohort study finds.
The results, reported in BMJ, update an earlier study that reported
findings until 2002, to which 5 years of follow-up data (to 2007) have now been added.
Researchers compared the incidence of brain tumors in nearly
360,000 subscribers to mobile phone services with the incidence in the rest of the population over a 17-year period. They
found that tumors of the central nervous system occurred at a similar rate in both groups.
Editorialists say that continued monitoring of such cohorts
is warranted, but new studies "are not needed." Earlier this year, WHO called cell phones "possibly carcinogenic."
BMJ article
Cholesterol Lowering By Statins May Be Affected By Gut Bacteria
http://www.medicalnewstoday.com/printerfriendlynews.php?newsid=235996
Diabetes Patients
Who Raise Their 'Good' Cholesterol Levels Reduce Their Risk Of Heart Attack And Stroke
http://mnt.to/l/42bs
Extra Calcium
During Pregnancy Has No Benefits, Except To Prevent Hypertension
http://mnt.to/l/428w
Eat Broccoli,
Not Supplements, For Health Benefits
http://mnt.to/l/42db
Ginger Root Supplement
Reduced Colon Inflammation Markers
http://mnt.to/l/42dx
Ginger Root May Protect From Colon
Cancer
http://mnt.to/l/42h5
Immune Defenses
Improved By Consumption Of Green Vegetables
http://mnt.to/l/42hV
Nourishing Protein
Slows Brain Disease
http://mnt.to/l/42mT
Caloric
Restriction Improves Insulin Action
http://www.medicalnewstoday.com/printerfriendlynews.php?newsid=235769
