HHAL MEDICAL NEWS DECEMBER2009

FDA Advisers Recommend Expanding Crestor to Patients Without High Cholesterol

An FDA advisory panel voted 12 to 4 on Tuesday to expand the use of rosuvastatin (Crestor) to patients with normal cholesterol levels and no history of cardiac disease, according to theAssociated Press.

The panel's recommendation was based on last year's JUPITER trial, in which rosuvastatin cut cardiovascular risk in patients with normal LDL cholesterol but high C-reactive protein levels.

The manufacturer said it "would focus on marketing the drug to patients with health issues that put them at increased risk of heart problems, such as a smoking habit or family history of hypertension," the AP reports.

The FDA is expected to make its decision in early 2010

http://www.google.com/hostednews/ap/article/ALeqM5jK6EmpbL8swxcfV5tmu4EL
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Does Exercise Lengthen Our Lives by Lengthening Our Cells' Lives?

Exercising was beneficial for preserving telomeres in both humans and mice.

Werner C et al. Circulation 2009 Dec 15; 120:2438

Acanthosis Nigricans Identifies Youth at Risk for Diabetes

Often seen in obese youth, this condition could signal the presence of insulin resistance or more-advanced disease.

More Evidence That Oxytocin Affects Human Behavior

A single base change in the gene for this 9-amino-acid peptide can affect empathy.

Rodrigues SM et al. Proc Natl Acad Sci U S A 2009 Dec 15; 106:21437

Pain Control in Newborn Infants

Skin-to-skin contact plus 25% oral dextrose is the most effective procedural pain control in newborns.

Chermont AG et al. Pediatrics 2009 Dec 124:e1101

Obstructive sleep apnea: A risk factor for Type II diabetes

This study found that sleep apnea increases the risk of developing diabetes, independent of other risk factors. Among patients with more severe sleep apnea, regular positive airway pressure use may attenuate this risk. The American Journal of Medicine

Conclusion

Sleep apnea increases the risk of developing diabetes, independent of other risk factors. Among patients with more severe sleep apnea, regular positive airway pressure use may attenuate this risk.

http://www.amjmed.com/article/S0002-9343(09)00679-2/fulltext

Lifestyle Intervention Can Prevent Diabetes Onset for at Least a Decade

Lifestyle changes slowed development of diabetes in a large cohort study.

Diabetes Prevention Program Research Group. Lancet 2009 Nov 14; 374:1677

BMI: The key driver for diabetes

Active men with normal and overweight BMIs had lower diabetes hazards than their inactive counterparts, but no difference by weekly activity was seen in obese men. Elevated BMI is a key driver of diabetes risk, with relatively modest attenuation by activity. The American Journal of Medicine

http://www.amjmed.com/article/S0002-9343(09)00143-0/fulltext

Oral Bisphosphonates and Osteonecrosis of the Jaw: A Case Series

The most common triggering events were tooth extractions and tooth implants.

Favia G et al. J Rheumatol 2009 Dec 36:2780

Atypical Fractures in Long-Term Bisphosphonate Users

A small subgroup of women might be susceptible.

Although bisphosphonates lower overall risk for fractures in women with osteoporosis, an unusual type of femoral fracture has been described in a few long-term bisphosphonate users. Two reports provide additional information.

In a case series, orthopedists at New York University describe seven women on long-term alendronate therapy (average duration, 9 years) who sustained sequential or simultaneous bilateral femoral "low-energy" fractures (i.e., resulting from falls from standing height or lower). All fractures were subtrochanteric or involved the femoral shaft, unlike typical femoral fractures that involve the intertrochanteric or femoral neck regions. These fractures each had a unique appearance, with a spike or beak configuration and cortical thickening at the fracture site.

In a case-control study from Cornell University, 41 postmenopausal women with low-energy subtrochanteric or femoral-shaft fractures were compared with 82 control women with classic intertrochanteric or femoral-neck fractures. Case patients were significantly more likely to be taking bisphosphonates than were controls (37% vs. 11%). Moreover, among case patients, the fracture pattern of "beaking with thick cortex" was highly correlated with prolonged bisphosphonate use (mean, 7 years).

Comment: These reports, and several others (e.g., suggest that a small subgroup of women could be susceptible to atypical femoral fractures after prolonged bisphosphonate use; suppression of bone turnover and accumulation of microdamage is a postulated mechanism. Prospective studies are needed to prove a causal relation; if causality is demonstrated, we'll need to determine whether the incidence of this complication is appreciable and whether at-risk patients can be identified.

http://us.mc812.mail.yahoo.com/mc/welcome?.partner=sbc&.gx=0&.tm=126290044
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Alcohol linked to breast cancer recurrence in older, heavier women

Women who were moderate to heavy drinkers had a 1.3-fold increase in breast cancer recurrence, compared with those who abstained or drank only minimally, according to a study presented Dec. 10 at the San Antonio Breast Cancer Symposium.

The highest risk was seen among the heaviest drinkers and overweight and/or post-menopausal survivors.

Researchers from Kaiser Permanente in Oakland, Calif. prospectively followed 1,897 women for 8 years following up.

Women's cholesterol spikes around final menstrual period

U.S. researchers said the critical time for adverse changes in lipid profiles in women is the year immediately around their final menstrual period, defined as 12 consecutive months without a period. The study, in the Journal of the American College of Cardiology, found sharp increases in total cholesterol, low-density-lipoprotein cholesterol and apolipoprotein B before and after that time period

http://www.medscape.com/viewarticle/713731

Kidney function, albuminuria and atrial fibrillation: What's the connection?
Among outpatients with coronary heart disease, cystatin C–based estimated glomerular filtration rate and higher albumin-to-creatinine ratio are each associated with prevalent atrial fibrillation, independent of one another. The American Journal of Cardiology

http://www.ajconline.org/article/S0002-9149(09)01392-7/fulltext

U.S. cancer diagnoses, mortality rates steadily decline

A report in the journal Cancer found cancer diagnosis rates for most all gender and ethnic groups in the U.S. dropped by an average of 1% per year from 1999 to 2006. Mortality rates also declined, mainly for common cancers such as lung, prostate and colorectal in men and breast and colorectal cancers in women.

http://www.cnn.com/2009/HEALTH/12/07/cancer.deaths.down/index.html

High stroke risk for people born in 7 Southern states

A report published in Neurology found a higher lifelong risk of dying from stroke among people born in North and South Carolina, Georgia, Tennessee, Arkansas, Mississippi and Alabama. Researchers said the risk, which continued even when people moved elsewhere, probably was not genetic but related instead to social factors such as diet and access to medical care

http://www.healthday.com/Article.asp?AID=633556

Predicting cardiovascular disease with physical activity

Physical activity was associated with cardiovascular disease, independent of the common cardiometabolic risk factors, in men and women. The association between PA and CVD risk was not mediated by the measured cardiometabolic risk factors. The American Journal of Cardiology

http://www.ajconline.org/article/S0002-9149(09)01389-7/fulltext

Waist circumference: Second only to age

This study concluded waist circumference is second only to age in the impact of the independent association with early-to-late (atrial) transmitral velocity (E/A) in a population sample with a high prevalence of excess adiposity. This effect was not accounted for by left ventricular hypertrophy or remodeling, 24-hour blood pressure, or arterial stiffness.The American Journal of Cardiology

http://www.ajconline.org/article/S0002-9149(09)01386-1/fulltext

Should Hypertensive Patients Take Their Aspirin at Night?

Data from a small, brief, randomized trial suggest yes, although significant effects on actual blood pressure levels were not found.

Snoep JD et al. Hypertension 2009 Nov 54:1136

Oral Diabetes Drugs and CVD Risk

An assessment of "real world" use of oral agents for type 2 diabetes shows significant risk differences among drug classes, BMJ reports.

Using a U.K. general practice database, researchers retrospectively examined prescribed drugs and subsequent outcomes among some 90,000 patients, who were followed a mean of 7 years. The outcomes examined included incident myocardial infarction, heart failure, and all-cause mortality.

Using metformin monotherapy as the reference group, the researchers noted:

· First- and second-generation sulfonylureas carried significantly higher mortality risks; second-generation drugs were more likely to cause heart failure.

· In some models, the sulfonylureas were associated with higher MI risk.

· Contrary to previous findings, no excess MI risk with rosiglitazone was found.

· Pioglitazone was associated with lower mortality (and had a more favorable risk profile than rosiglitazone).

The authors write that the sulfonylureas' unfavorable risk profile "is consistent with the recommendations of the American Diabetes Association ... that favor metformin as the initial treatment for type 2 diabetes."

Conclusions Our findings suggest a relatively unfavourable riskprofile of sulphonylureas compared with metformin for all outcomesexamined. Pioglitazone was associated with reduced all causemortality compared with metformin. Pioglitazone also had a favourablerisk profile compared with rosiglitazone; although this requiresreplication in other studies, it may have implications for prescribingwithin this class of drugs.

http://www.bmj.com/cgi/content/full/339/dec03_1/b4731

USPSTF Doesn't Recommend Using Nontraditional Risk Factors for CHD Risk

The task force finds the evidence to be insufficient to make a recommendation.

The U.S. Preventive Services Task Force (USPSTF) has issued a new guideline about the use of nontraditional markers for coronary heart disease risk to screen patients, particularly those at intermediate risk according to traditional risk factors (Framingham score). The task force evaluated nine nontraditional markers: high-sensitivity C-reactive protein (hs-CRP), ankle-brachial index (ABI), leukocyte count, fasting blood glucose level, periodontal disease, carotid intima–media thickness, coronary artery calcification score as determined by electron-beam computed tomography, homocysteine level, and lipoprotein(a) level.

The USPSTF concluded that evidence is insufficient to assess the balance of benefits and harms of using nontraditional risk factors to screen asymptomatic men and women with no histories of CHD to prevent subsequent CHD events. I statement (insufficient evidence; the grading system can be accessed on the USPSTF website.)

In the evidence review, researchers found that 11% of men with intermediate CHD risk would be reclassified as having high risk and 12% would have low risk by hs-CRP; 10% of women would be reclassified as having high risk by ABI. Data are insufficient for all other tests. The evidence is also insufficient to determine whether CHD events (and deaths) would be lessened following nontraditional risk factor screening. The USPSTF also cites possible harms of screening, such as adverse psychological consequences of overestimating CHD risk, expense of testing, and side effects of any preventive interventions (such as statins) that generally are safe but have known side effects that would be acceptable only if the interventions provide benefits.

http://www.ncbi.nlm.nih.gov/pubmed/19805770?dopt=Abstract

http://www.ncbi.nlm.nih.gov/pubmed/19805772?dopt=Abstract

Chronic Anticholinergic Use and Dementia Risk

A longitudinal study in community-dwelling elders suggests that chronic anticholinergic use may not only produce short-term cognitive effects but may also increase the risk for dementia.

Does chronic anticholinergic use, long recognized as causing cognitive impairment in older people, increase the long-term risk for dementia, particularly Alzheimer disease (AD)? And do patients who have discontinued anticholinergic medications have the same risk for dementia as chronic users?

To find out, researchers conducted an observational study in community-dwelling adults aged 65 and older. The study was partially funded by a manufacturer of anticholinergic drugs. Of the original 9077 dementia-free participants at study inception, data were available on 6912. Participants had follow-up examinations at 2 years and most also at 4 years (mean follow-up duration, 3.5 years). Cognitive measures included a word list generation task, Trail Making Tests A and B, and the Mini-Mental State Examination. A preliminary diagnosis of dementia according to DSM-IV criteria was validated by an independent panel. Anticholinergic use was assessed by means of drug-list interview for all prescription and over-the-counter medications and validated by direct inspection of prescriptions or medications whenever possible.

Of the 6912 participants, 86.4% did not report anticholinergic use at any time during the study, 2.5% reported use only at baseline (discontinuing group), and 4.6% reported use at baseline and at the 2-year follow-up or longer (continuous group). (Intermittent use was not considered.) Men and women in the continuous group had greater cognitive decline than the never-users, even after adjustments for comorbid factors (e.g., depression and Parkinson disease). Cognitive function did not differ significantly between the discontinuing group and never-users.

Among the 7123 participants included in the analysis for dementia, 221 had newly diagnosed dementia; 143 of these diagnoses were for AD. Continuous, but not discontinued, anticholinergic use was associated with increased dementia risk (hazard ratio, 1.65; P=0.05). The authors conclude that continuous anticholinergic medication use in elders may place them at increased risk for dementia or AD.

Comment: The acute risk of anticholinergic medication use in elders with or without preexisting dementia is well known. The Beers List of "potentially inappropriate medications" particularly highlights anticholinergic medications (Arch Intern Med 2003; 163:2716), which produce not only delirium and other cognitive effects but also adverse effects particularly troubling to older individuals, such as constipation and bladder retention. Despite the potential for these adverse effects, anticholinergic medications continue to be prescribed to older individuals with surprising frequency. In the present study, 14.6% of these community-dwelling participants received prescription or over-the-counter anticholinergic medications at some time during a 4-year period.

The authors raise an important concern as to whether chronic use of anticholinergic medications can increase the risk for dementia or AD, in addition to the known acute effects. They acknowledge that misdiagnosis of dementia may occur in patients taking chronic anticholinergic medication. However, chronic anticholinergic exposure may genuinely increase the long-term risk for dementia, perhaps through an effect on trophic factors or cholinergic system regulation. If so, anticholinergic medications may join late-life hormone therapy in women as iatrogenic factors that may contribute to dementia.

Carrière I et al. Arch Intern Med 2009 Jul 27; 169:1317

Bad Bugs and Nursing Homes

Cultures of samples obtained from nursing-home residents and from environmental surfaces yielded MRSA and multidrug-resistant gram-negative bacteria.

O'Fallon E et al. Infect Control Hosp Epidemiol 2009 Dec 30:1172

Low vitamin D levels are associated with impaired cognition.

Annweiler C et al. Neurology 2009 Sep 30;

Intravenous Bisphosphonate Therapy for Postmenopausal Women with Low Bone Mass

IV zoledronic acid prevented bone loss.

McClung M et al. Obstet Gynecol 2009 Nov 114:999

Angiotensin-Receptor Blockers in Heart Failure: What Difference Does a Dose Make?

In a randomized trial, high-dose losartan was associated with small but significant improvements in clinical outcomes, compared with a lower dose.

Konstam MA et al. Lancet 2009 Nov 17;

Krum H. Lancet 2009 Nov 17;

Should Patients with Heart Failure "Pump" Iron?

In a randomized trial, intravenous iron improved symptoms, even in patients without anemia.

Anker SD et al. N Engl J Med 2009 Nov 17;

Dec GW. N Engl J Med 2009 Nov 17;

Multifocal Glasses and Risk for Falling

Ground-level obstacles can be precarious with these glasses.

Menant JC et al. J Am Geriatr Soc 2009 Oct 57:1833

Commentary Urges 'Expanding the Diagnostic Paradigm of Pharyngitis' in Young People

An Annals of Internal Medicine commentator urges that clinicians change their approach to treating pharyngitis in adolescents and young adults. He argues that Fusobacterium necrophorum is more likely to cause severe complications than group A beta-hemolytic strep is to cause rheumatic fever.

Using available data, the commentator, Dr. Robert Centor, estimates that both organisms are equally likely to cause pharyngitis in young people between the ages of 15 and 24. Of greatest concern is the association between fusobacterium infection and Lemierre syndrome, which has amortality rate of nearly 5%.

When physicians treat pharyngitis empirically in young people, he argues, macrolides should no longer be used, since they are ineffective against fusobacterium. Instead, penicillins or cephalosporins should be used until a better way of diagnosing fusobacterium infections is found

http://www.annals.org/content/151/11/812.abstract