HHAL MEDICAL
NEWS APRIL09
Vitamin D deficiency
in older men.
Most older people had low serum levels, and at least 25% of elders had frank vitamin D deficiency.
Researchers measured serum 25-hydroxyvitamin
D (25[OH]D) in 6000 community-dwelling men (age range, 65–99) who lived in various U.S.
regions. Average serum 25(OH)D level was 25 ng/mL; one quarter of subjects had levels lower than 20 ng/mL. In multivariable
analysis, lower 25(OH)D levels were associated with older age, obesity, black or Latino ethnicity, blood sampling in winter,
and residence at a northern latitude (e.g., Minneapolis, compared with San Diego). Use of vitamin D supplements and engaging
in outdoor activities were associated with higher vitamin D levels.
Dutch researchers examined relations between vitamin D levels
and bone metabolism in 1300 randomly selected older adults (age range, 65–88). Mean
serum 25(OH)D level was 21 ng/mL; half the participants had levels lower than 20 ng/mL. Findings included the following:
- Serum parathyroid hormone levels were inversely proportional to vitamin D
levels, without any plateau effect.
- Markers of bone turnover
(serum osteocalcin and urinary deoxypyridinoline) were inversely proportional to 25(OH)D levels until the latter
exceeded 20 ng/mL; above that point, bone turnover markers plateaued.
- Total hip bone-mineral density was directly proportional to 25(OH)D levels until the latter exceeded 20 ng/mL;
above that point, bone density plateaued.
CONCLUSIONS:
Vitamin D deficiency is common in older men and is especially prevalent in obese, sedentary men living at higher latitudes.
Use of vitamin D supplements at levels reported here did not result in adequate vitamin D nutrition. http://www.ncbi.nlm.nih.gov/pubmed/19158198?dopt=Abstract
http://www.ncbi.nlm.nih.gov/pubmed/19174492?dopt=Abstract
Low vitamin D levels in teens
linked to hypertension, hyperglycemia
Low serum levels of vitamin D were linked to increased blood pressure,
hyperglycemia, and obesity in an analysis of more than 3,500 American teenagers, a link previously seen in adults.
In addition, the prevalence
of vitamin D deficiency has increased among all Americans, based on data collected in a national survey during 1988-2006 and
presented in a separate report.
Independent
Effects of LDL Cholesterol and hsCRP Lowering in the JUPITER Trial
Greater
hsCRP reductions correlated with improved cardiovascular outcomes.
In the 2008 industry-supported JUPITER trial (JW Gen Med Nov 18 2008), healthy people with normal LDL cholesterol levels
(<130 mg/dL) and elevated levels of high-sensitivity C-reactive protein (hsCRP; 2 mg/L) who used rosuvastatin (20 mg daily) had significant reductions in adverse cardiovascular
endpoints during 2 years of follow-up. These results suggested that the anti-inflammatory properties of statins make them
useful for primary prevention in patients without hyperlipidemia.
Now, the JUPITER authors link declines in LDL cholesterol
and hsCRP to clinical outcomes. Among 15,548 patients (87% of the JUPITER cohort) whose LDL cholesterol and hsCRP values were
recorded after 1 year, rosuvastatin recipients had significant and largely independent reductions in both LDL cholesterol
and hsCRP. Compared with patients who took placebo, rosuvastatin recipients whose LDL cholesterol
levels remained >70 mg/dL had no significant reduction in adverse cardiovascular endpoints, whereas those who achieved
this LDL cholesterol target had 55% fewer endpoints. Rosuvastatin patients whose hsCRP levels fell below 2 mg/L had significantly
greater endpoint reductions than those whose hsCRP levels remained above this value (62% and 31% fewer than patients taking
placebo, respectively). Patients who achieved both targets had better outcomes than those who achieved either one alone.
http://www.ncbi.nlm.nih.gov/pubmed/19329177?dopt=Abstract
Spring, summer, winter, fall: Cholesterol
variations?
Previous studies have shown
seasonal variation in lipids. To understand whether this variation exists in patients with acute coronary syndromes receiving
statins, we examined data from the PROVE IT-TIMI 22 Study. At baseline, no significant difference in low-density lipoprotein
(LDL) cholesterol was observed when stratified by season. However, a statistically significant difference in high-density
lipoprotein cholesterol between winter (37 mg/dl) and summer (39 mg/dl) was observed (p <0.001) at baseline. On treatment, median LDL cholesterol was 102 mg/dl in winter versus 96 mg/dl in summer (p <0.001) for the pravastatin
group and 68 mg/dl in winter versus 62 mg/dl in summer (p <0.001) for the atorvastatin group. Median high-density lipoprotein
cholesterol was 43 mg/dl in summer versus 41 mg/dl in winter in the pravastatin group and 42 mg/dl in summer versus 39 mg/dl
in winter in the atorvastatin group (p <0.001). More patients achieved LDL cholesterol <100 mg/dl in summer at
56% versus 47% in winter in the pravastatin group (p <0.001) and 89% versus 87% in winter for the atorvastatin group (p
= 0.11). Achievement of LDL cholesterol <70 mg/dl was also higher in summer than winter.
This
was the first evidence of seasonal variability in cholesterol in patients with acute coronary syndromes
treated with statins. This variability affected achievement of National Cholesterol Education Program
goals and may affect management decisions based on season of collection.
http://www.ajconline.org/article/S0002-9149(09)00042-3/fulltext
Voglibose for prevention of type 2 diabetes
mellitus: a randomised, double-blind trial in Japanese individuals with impaired glucose tolerance
Interpretation
Voglibose, in addition to lifestyle modification, can reduce the development of type 2 diabetes in high-risk Japanese
individuals with impaired glucose tolerance.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60222-1/abstract
Review finds no link between statins, lower
risk of dementia
A review in the Cochrane Database of Systematic Reviews of two published
clinical trials shows no evidence that statins prevent Alzheimer's
disease or dementia despite previous studies linking the drugs to reduced rates of the condition. The finding suggests
that lipid-lowering drugs, such as Lipitor, Zocor and Crestor, should not be prescribed to prevent Alzheimer's,
U.K. researchers said.
http://news.yahoo.com/s/nm/20090420/hl_nm/us_statin_dementia;_ylt=AteTPH6ttOW5U.hccMh26TIQ.3QA
Studies mixed on charred meat's link
to cancers
Regularly eating very well-done, burned or charred red meat can raise a person's risk of pancreatic cancer by 60% to 70%, according to study results presented at an American Association
of Cancer Research conference. Another study presented at the conference found no link between eating charred meat and colon cancer.
http://www.reuters.com/article/healthNews/idUSTRE53K5QI20090421
What else can aspirin do?
Data suggest a small but not significant decrease in the risk of diabetes during five years of randomized
comparison of 325 mg of aspirin every other day. This trend was continued during 22 years of follow-up, indicating that self-selection
of any use of aspirin is associated with a significant, approximately 14% decrease in the risk of diabetes. Decreased risk
of Type 2 diabetes may be added to the list of the clinical benefits of aspirin.
http://www.amjmed.com/article/S0002-9343(08)01105-4/fulltext
Don't go looking for trouble in stroke prevention
This review concluded that the combination of aspirin and clopidogrel is associated with significantly
greater bleeding than either aspirin (≤325 mg/day) or clopidogrel alone. Aspirin plus extended-release dipyridamole has
a greater bleeding rate than clopidogrel but a lower rate than aspirin (≤325 mg/day) alone.
http://www.ajconline.org/article/S0002-9149(09)00033-2/fulltext
Preventing coronary heart disease: Whose guidelines work best?
Recommendations for statin use for primary prevention of coronary heart disease are based on estimation
of the 10-year CHD risk. Following the International Atherosclerosis Society and the US Adult Treatment Panel-III recommendations might prevent more
CHD deaths at the cost of higher numbers needed to treat compared to European Society of Cardiology guidelines.
http://www.ajconline.org/article/S0002-9149(09)00032-0/fulltext
Body-mass index is a strong
predictor of overall mortality
The
main associations of body-mass index (BMI) with overall and cause-specific mortality can best be assessed by long-term prospective
follow-up of large numbers of people. The Prospective Studies Collaboration aimed to investigate these associations by sharing
data from many studies.
March 28, 2009, edition of
The Lancet.
Blood pressure reduction from combining drugs from these four classes can be predicted
on the basis of additive effects. The extra blood pressure reduction from combining drugs from two different classes is approximately
five times greater than doubling the dose of one drug.
Conclusion
Blood
pressure reduction from combining drugs from these 4 classes can be predicted on the basis of additive effects. The extra
blood pressure reduction from combining drugs from 2 different classes is approximately 5 times greater than doubling the
dose of 1 drug.
Swine Influenza Reported in Two Children in Southern California
Patients may ask about
a widely reported notice of swine flu found in two children in neighboring counties in Southern California. The CDC alerted
healthcare providers on Tuesday in MMWR Dispatch.
Both cases involved swine influenza
A (H1N1) viruses that are genetically different from strains previously seen in humans and swine in the U.S. The viruses are resistant to amantadine and rimantadine.
The
children presented with febrile respiratory illness, received treatment (symptomatic treatment
in one case, amoxicillin/clavulanate potassium plus antihistamine in the other), and recovered "uneventfully." Neither
child appears to have had contact with swine.
The CDC advises clinicians to "consider animal as well
as seasonal influenza virus infections in their differential diagnosis"
of patients with febrile respiratory illness who:
- live
in San Diego or Imperial counties;
- have recently visited (or had contact with ill people from) these areas;
- have had recent exposure to swine.
A Skeptical Look at Tight Glycemic Control
Tight glycemic control in type 2 diabetes can overburden patients with complexity and
cost, giving "uncertain benefits in return," according to an Annals of Internal Medicine perspective published
online.
The authors reviewed recent trials that compared tight versus more relaxed glucose targets.
The results, "suggest that tight glycemic control may not reduce the risk for all-cause or cardiovascular mortality,
stroke, amputations, or even microvascular complications." They did find one clear message:
Tight control greatly increases the risk for hypoglycemia.
They
argue for "a change in emphasis" in diabetes care, away from "interventions that overwhelm the patients'
capacity to cope clinically, psychologically, and financially." And they say that clinical HbA1c targets should not be
the same as those used to measure quality of care. Quality measures set too low, they write, "invite clinicians to ignore
patient burden, context, and goals." Keeping levels between 7% and 7.5% "seems reasonable and feasible for many
patients."
Severe hypoglycemic episodes may cause dementia, according to study
Hypoglycemic episodes severe enough for hospital admission or emergency
department visits are associated with increased risk of dementia among older
patients with type 2 diabetes,
according to a new "provocative" study, with risk greatly increasing with each additional hypoglycemic episode.
Patients with 1 severe episode were 26% more likely to develop dementia, 2 episodes had 80% increased risk, and 3 had 94%
increased risk.
http://license.icopyright.net/user/viewFreeUse.act?fuid=MzI4NDgwNQ%3D%3D
Potent antiplatelet therapy prevents stroke in AF
Clopidogrel added to aspirin is superior to aspirin alone in preventing
stroke in preventing vascular events, especially stroke, in patients with nonvalvular atrial
fibrillation (AF) who are judged unsuitable for warfarin or are unwilling to
take it. These findings were presented at the recent American College
of Cardiology scientific meeting and an online Geriatrics article about the study has a link to other session highlights
http://license.icopyright.net/user/viewFreeUse.act?fuid=MzI4NDgyMQ%3D%3D
Vitamin C intake and the risk of gout in men: a prospective study.
During the 20 years of follow-up,
we documented 1317 confirmed incident cases of gout. Compared with men with vitamin C intake less than 250 mg/d, the multivariate
relative risk (RR) of gout was 0.83 (95% confidence interval [CI], 0.71-0.97) for total vitamin
C intake of 500 to 999 mg/d, 0.66 (0.52-0.86) for 1000 to 1499 mg/d, and 0.55 (0.38-0.80) for 1500 mg/d or greater (P <
.001 for trend). The multivariate RR per 500-mg increase in total daily vitamin C intake was 0.83 (95% CI, 0.77-0.90). Compared
with men who did not use supplemental vitamin C, the multivariate RR of gout was 0.66 (95% CI, 0.49-0.88) for supplemental
vitamin C intake of 1000 to 1499 mg/d and 0.55 (0.36-0.86) for 1500 mg/d or greater (P < .001 for trend).
CONCLUSIONS: Higher vitamin C intake is independently associated with
a lower risk of gout. Supplemental vitamin C intake may be beneficial in the prevention of gout.
http://archinte.ama-assn.org/cgi/content/abstract/169/5/502
An Angiotensin-Receptor Blocker Fails to Prevent Atrial Fibrillation
Recurrence
Conclusions
Treatment with valsartan was not associated with a reduction in the incidence of recurrent atrial fibrillation.
(ClinicalTrials.gov number, NCT00376272
Screening for Asymptomatic CAD
Does Not Reduce Cardiac Events in Patients with Diabetes
Patients with type 2 diabetes and no symptoms of coronary artery disease derive little
benefit from screening for inducible myocardial ischemia, JAMA reports.
Some
1100 patients aged 50 to 75 with type 2 diabetes and without CAD symptoms were randomized
to undergo stress myocardial perfusion imaging or to remain unscreened.
During
5 years' follow-up, the incidence of the primary endpoint — a composite of nonfatal myocardial
infarction and cardiac death — did not differ between the groups (about 3% in each). Among screened patients,
moderate or large perfusion defects were associated with greater risk for coronary events, but, the authors point out, only
12% of patients with such defects had an event (positive predictive value, 12%).
The
authors conclude that routine screening for CAD "cannot be advocated" for asymptomatic patients with type 2 diabetes.
USPSTF
Recommends Aspirin to Prevent MI in Men, Stroke in Women
The task force revised its 2002 recommendations,
primarily based on new data for women.
CONCLUSION: Aspirin reduces the risk for myocardial infarction in
men and strokes in women. Aspirin use increases the risk for serious bleeding events.
http://www.ncbi.nlm.nih.gov/pubmed/19293073?dopt=Abstract
Treadmill exercises improve walking distance in peripheral arterial disease
Regular exercise sessions on
a treadmill are thought to improve walking distance in people with intermittent claudication.
Most people with peripheral artery disease don’t have classic symptoms of claudication,
however, so researchers from the US designed a randomised trial in a more mixed population
of 156 adults with peripheral arterial disease. Three sessions of supervised treadmill training every week for six months
worked reasonably well, increasing the distance walked in six minutes by nearly 36 m (95% CI 15.3 to 56.5) compared with lifestyle
counselling alone. The training didn’t improve a validated measure of overall physical performance, but it did have
a positive effect on some physical aspects of quality of life, and on treadmill tests of walking
time. That is enough to recommend it to patients with and without claudication, say the researchers.
A third group
did resistance training instead of treadmill exercises. After six months, this group did no
better than controls at the six minute walking test (in a corridor) or the overall measure of physical performance. But they
were able to walk for 1.9 minutes (0.49 to 3.31) longer than controls on a treadmill.
Conclusions Supervised
treadmill training improved 6-minute walk performance, treadmill walking performance, brachial artery flow-mediated
dilation, and quality of life but did not improve the short physical performance battery scores of PAD participants
with and without intermittent claudication. Lower extremity resistance training improved functional performance
measured by treadmill walking, quality of life, and stair climbing ability.
http://jama.ama-assn.org/cgi/content/abstract/301/2/165
Poor sleep increases vulnerability to colds
Arch Intern Med 2009;169:62-7 [Arch Intern Med Abstract]
Sleeping badly makes you tired, but does it make you ill? To find
out, researchers recruited 153 healthy volunteers who agreed to be quarantined for five days and inoculated with the cold
virus RV-39. Most of them were infected (135/153; 88%), as defined by isolation of the virus from nasal
lavage or development of neutralising antibodies. Only 54 (35%) caught a cold with objective symptoms and signs, but
the researchers found a significant association between clinical illness and poor sleep in the two weeks before exposure.
People who slept less than seven hours a night were particularly susceptible (odds ratio 2.94,
95% CI 1.18 to 7.30, relative to those who slept eight hours or more). So were inefficient sleepers—people who spent
less than 92% of their time in bed actually asleep (5.5, 2.08 to 14.48 relative to more than 98% sleep efficiency). The link
between catching a cold and poor sleep efficiency was independent of more than a dozen possible confounders, including an
unhealthy lifestyle, obesity, and stress. The researchers conclude that poor sleep probably does make people more susceptible
to colds.
http://archinte.ama-assn.org/cgi/content/abstract/169/1/62
Viagra, Cialis
Do Not Interfere with Eye Health
Daily treatment with sildenafil
(Viagra) or tadalafil (Cialis) for 6 months appears to be safe for the eyes, according to an industry-supported study in Archives of Ophthalmology.
Nearly 250 men without
ophthalmologic abnormalities — and with mild or no erectile dysfunction — were randomized to receive tadalafil
(5 mg), sildenafil (50 mg), or placebo daily for 6 months. (Both drugs are phosphodiesterase type 5 inhibitors, which could
inhibit a retinal enzyme.)
The treatment and placebo groups did not differ in the primary electroretinographic
endpoint (dark-adapted, combined standard b-wave amplitude) or in visual function, intraocular pressure,
or ocular anatomy.
The authors point out that their findings may not be generalizable to men
with preexisting eye conditions or those with moderate or severe ED.
http://archopht.ama-assn.org/cgi/content/short/127/4/367
A Systematic Review of the Evidence Supporting a Causal
Link Between Dietary Factors and Coronary Heart Disease
Conclusions The evidence supports a valid association
of a limited number of dietary factors and dietary patterns with CHD. Future evaluation of dietary patterns,
including their nutrient and food components, in cohort studies and randomized trials is recommended.
http://archinte.ama-assn.org/cgi/content/abstract/169/7/659?ct
Vitamin B12 effective in treatment of recurrent aphthous stomatitis
CONCLUSION: Vitamin B(12) treatment, which is simple, inexpensive, and low-risk, seems
to be effective for patients suffering from RAS, regardless of the serum vitamin B(12) level.
http://www.ncbi.nlm.nih.gov/pubmed/19124628?dopt=Abstract
Prevalence of Carotid Stenosis and Silent Myocardial Ischemia in Asymptomatic Subjects With a Low Ankle-Brachial Index
CONCLUSION: Our results indicate that in high-risk asymptomatic subjects
>60 years of age, the presence of an ABI <0.9 identifies a subgroup of the population with an increased prevalence of
carotid stenosis and of silent myocardial ischemia and, as such, are candidates for closer follow-up.
http://www.ncbi.nlm.nih.gov/pubmed/18829225?dopt=Abstract
Single-Infusion Zoledronic Acid Treatment Non-Inferior to Daily Risedronate Tablets
A
single annual infusion of zoledronic acid is at least as effective as daily risedronate in preventing and treating glucocorticoid-induced
osteoporosis, according to a Lancet study.
The international
HORIZON trial investigators randomized some 800 patients in a placebo-controlled, double-dummy trial designed and conducted
by the manufacturer. Patients received either a single infusion of zoledronic acid or daily risedronate. Patients who had
been on glucocorticoids for more than 3 months were called the "treatment" subgroup; those on glucocorticoids less
than 3 months were called the "prevention" subgroup.
After 1 year, zoledronic
acid proved non-inferior to risedronate in both subgroups in increasing recipients' lumbar-spine bone
mineral density, the primary endpoint. Zoledronic acid also increased densities at the femoral neck, trochanter, and
total hip more than risedronate. Rates of new vertebral fractures at 1 year were low under
both treatments.
Calling the results "applicable to a wide range of individuals,"
commentators nonetheless call for additional studies addressing cost-effectiveness and safety.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60250-6/abstract
Dronedarone
— A New Option for Atrial Fibrillation?
A new drug
promises efficacy and safety for AF patients.
Currently available
antiarrhythmic drugs have suboptimal efficacy for patients with atrial
fibrillation (AF), and many also have potentially serious side effects. Dronedarone
is a new antiarrhythmic drug (not yet USFDA approved) that is similar to amiodarone but has
been engineered to reduce accumulation in tissues, which might ameliorate side effects. In an industry-sponsored trial, 4628
patients with AF and high-risk features were randomized to dronedarone or placebo.
After
a mean follow-up of 21 months, the incidence of the primary combined outcome of death or first hospitalization due to adverse
cardiovascular events was significantly lower in the dronedarone group than in the placebo group (31.9% vs. 39.4%). The rate
of cardiovascular-related death was also significantly lower. Dronedarone was associated with bradycardia,
QT-interval prolongation, nausea, diarrhea, rash, and elevated creatinine levels; thyroid- and pulmonary-related adverse events
did not differ significantly between groups. Discontinuation rates were similar (30.2% and 30.8%).
http://www.ncbi.nlm.nih.gov/pubmed/19213680?dopt=Abstract
