HHAL MEDICAL NEWS OCTOBER 2009
Screening for Prostate and
Breast Cancers
Have the benefits been overstated?
Screening for prostate and breast cancers has
been promoted heavily in the U.S., and annual screening
costs are US$20 billion for just these two cancers. Lifetime diagnoses ofprostate cancer were made in 1 of 11 white men in 1980; in 2009, the risk is 1 in 6. For breast cancer, risks were 1 in 12 in 1980 and 1 in 8 in 2009.
Authors of a highly publicized review now challenge the value of such intensive screening.
If screening accurately identifies cancer at
an early treatable stage, the incidence of localized cancer should increase after screening is implemented, and the incidence
of metastatic cancer should decline. Because this pattern has occurred for neither breast nor prostate cancer, screening simply
might identify low-risk non–life-threatening cancers that then are treated inappropriately with aggressive therapy.
By comparison, screening for colon and cervical cancers has led to significantly fewer cases of advanced disease. The observed
decline in prostate cancer–related mortality
in the last 20 years probably is not attributable to screening but, rather, to aggressive new adjuvant therapies.
The costs associated with
screening are substantial. For breast cancer,
avoiding 1 cancer-related death requires annual screening of more than 800 women (age range, 50–70) for 6 years, which
generates hundreds of biopsies and overly aggressive treatment for many patients with low-grade cancers.
The authors recommend greater focus on identifying
new biomarkers that differentiate low- and high-risk cancers, minimalist approaches that are appropriate for treating patients
with low-risk cancers, better tools to guide physicians and patients in informed decision making, and a greater focus on prevention
and screening in high-risk patients rather than broad indiscriminate screening.
http://www.ncbi.nlm.nih.gov/pubmed/19843904?dopt=Abstract
To reduce weight, risk factors in the obese, try this
Liraglutide treatment over 20 weeks is well tolerated, induces weight loss, improves
certain obesity-related risk factors, and reduces prediabetes.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61375-1/abstract
What do higher C-peptide levels mean for nephropathy?
These authors demonstrate that higher C-peptide levels are associated
with metabolic syndrome in patients with Type 2 diabetes and in diabetes patients
who also had nephropathy and vascular disease. Masson/La Presse Medicale
http://www.em-consulte.com/article/227330
Medical exposure to radiation increased sixfold since 1980
The radiation exposure of U.S. patients from medical tests has increased sixfold since 1980, according
to a new report in Radiology. About 380 million diagnostic and interventional radiological tests were conducted in the U.S. in 2006, in addition to 18 million nuclear
medicine procedures.
http://health.usnews.com/articles/health/healthday/2009/10/27/radiation-from-medical-scans-soaring_print.htm
A postpartum diet that promotes weight loss?
Using a food-frequency
questionnaire and recording the weights of 430 women for nine months postpartum, researchers found that participants on a
high protein diet lost on average 316 grams more per month than those on a low protein diet.
The article asks whether this should become standard practice after childbirth.
Conclusion
A reported higher protein intake may improve moderate postpartum
body weight loss. Further studies should evaluate the long-term consequences of an HP diet postpartum.
http://www.nutritionjrnl.com/article/PIIS0899900709001269/fulltext
Phytoestrogens: A safe side-effect profile
Based on the available evidence, phytoestrogen
supplements have a safe side-effect profile for treatment of the climacteric syndrome with moderately elevated rates of gastrointestinal
side effects. Rates of vaginal bleeding, endometrial hyperplasia, endometrial cancer and breast cancer were not significantly
increased among phytoestrogen users in the investigated studies.
Conclusions
Based on the available evidence, phytoestrogen supplements
have a safe side-effect profile with moderately elevated rates of gastrointestinal side effects. Rates of vaginal bleeding,
endometrial hyperplasia, endometrial cancer, and breast cancer were not significantly increased among phytoestrogen users
in the investigated studies.
http://www.amjmed.com/article/S0002-9343(09)00542-7/fulltext
How bad for the heart is psychosocial stress? And how do you reduce it?
Psychosocial stress is
an independent risk factor for mortality in patients with coronary artery disease, and exercise training can effectively reduce
its prevalence. Exercise training reduces mortality in patients with coronary artery disease, and this effect seems to be
mediated in part because of the salutary effects of exercise on psychosocial stress.
Conclusion
Psychosocial
stress is an independent risk factor for mortality in patients with coronary artery disease, and exercise training can effectively
reduce its prevalence. Exercise training reduces mortality in patients with coronary artery disease, and this effect seems
to be mediated in part because of the salutary effects of exercise on psychosocial stress.
http://www.amjmed.com/article/S0002-9343(09)00439-2/fulltext
What's the relationship between moderate alcohol consumption and heart disease in
hypertensives?
Alcohol has diverse effects
on the cardiovascular system. Moderate drinking is associated with a reduced risk of cardiovascular disease, and yet increasing
amounts of alcohol consumption are known to elevate blood pressure. Data from this study demonstrated an inverse relationship
between moderate alcohol consumption and coronary heart disease in hypertensive men.
In conclusion, our data demonstrated an inverse
relation between moderate alcohol consumption and CHD in hypertensive men.
http://www.ajconline.org/article/S0002-9149(09)01103-5/fulltext
Research links diabetes with antioxidants
Antioxidants, the compounds in foods that can
prevent cell damage, might increase the risk of Type 2 diabetes, according to a study published in Cell Metabolism. Research
in mice indicated that the antioxidants remove a mechanism that can help the body use insulin
http://www.reuters.com/article/healthNews/idUSTRE5955Z620091006
Study: Depression less likely among those on Med diet
A study published in
the Archives of General Psychiatry followed more than 10,000 adults in Spain and found that those who were on a Mediterranean
diet were 42% to 51% less likely to suffer from depression. Although the diet, which is rich in fish, fruits, vegetables,
whole grains and nuts, might help prevent depression, researchers say it should not be used to treat people who have been
diagnosed with the condition.
http://healthday.com/Article.asp?AID=631618
Hormone replacement therapy and lung cancer deaths
Although treatment with
oestrogen plus progestin in postmenopausal women did not increase incidence of lung cancer, it increased the number of deaths
from lung cancer, in particular deaths from non-small-cell lung cancer. These findings should be incorporated into risk–benefit
discussions with women considering combined hormone therapy, especially those with a high risk of lung cancer.
Interpretation
Although treatment with oestrogen plus progestin in postmenopausal
women did not increase incidence of lung cancer, it increased the number of deaths from lung cancer, in particular deaths
from non-small-cell lung cancer. These findings should be incorporated into risk—benefit discussions with women considering
combined hormone therapy, especially those with a high risk of lung cancer.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61526-9/abstract
The benefits of chocolate: Only the beginning?
Evidence shows that chocolate
can lower blood pressure, reduce systemic inflammation, inhibit cavities, increase cerebral blood flow and stimulate the central
nervous system. This article details how some particular
qualities of cocoa remain unexplained.
http://www.nutritionjrnl.com/article/PIIS0899900709002342/fulltext
Diabetes raises atrial fibrillation risk for women
A Kaiser Permanente study
in Diabetes Care that compared 17,372 diabetic patients to nondiabetics found 3.6% of those
who had diabetes got atrial fibrillation, compared with 2.5% of nondiabetics. Researchers said men in both groups had
higher fibrillation rates than women but only among women did diabetes specifically increase the risk.
http://www.nytimes.com/2009/09/29/health/29risk.html?_r=2&ref=health&pagewanted=print
Midlife obesity raises health risks for women later
Obese middle-aged women
are 79% more likely to suffer from chronic health problems and impaired mental fitness, compared with their slimmer counterparts,
by the time they turn 70, a study in BMJ found. Every 2.2 pounds of extra weight lowered
the odds of healthy survival by 5%, researchers said.
http://healthday.com/Article.asp?AID=631452
Diabetes
Prevention Interventions Have Long-Lasting Effects
The benefits of lifestyle
intervention or metformin for preventing the development of diabetes in high-risk adults can persist for
10 years, according to a follow-up report from the Diabetes Prevention Program (DPP) trial published online in Lancet.
Researchers
examined longer-term follow-up data on some 2800 high-risk adults who had been randomized to intensive lifestyle intervention,
metformin, or placebo in the DPP trial. At the end of that period (roughly 3 years), both lifestyle intervention and metformin
had significantly lowered diabetes incidence relative to placebo (by 58% and 31%, respectively). Then, all participants were
offered lifestyle counseling; those originally assigned to lifestyle intervention received additional lifestyle support, while
the metformin group continued their treatment.
Over a median of 10 years' total follow-up, benefits of the interventions
persisted — overall diabetes incidence was reduced by 34% in the lifestyle group and by 18% in the metformin group,
relative to placebo.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61457-4/fulltext
Migraine with Aura Linked to Increased Stroke
Risk
Patients who suffer migraine with aura face twice the risk for ischemic stroke as those with migraine
without aura, according to an industry-funded meta-analysis in BMJ.
Researchers analyzed 25 studies
examining associations between migraine and cardiovascular risk. Among the findings:
Overall migraine was associated with increased risk for stroke; however, the association appeared limited to migraine
with aura.
Female migraineurs had greater overall stroke risk than males.
Stroke risk was further increased in migraineurs younger than 45, those who smoked, and those who used oral contraceptives.
Migraine
was not associated with risk for MI or cardiovascular death.
An editorialist notes: "The absolute
risk of stroke for most patients with migraine is low, so a doubling of risk is not cause for panic." She adds that while
some experts recommend against using oral contraceptives in women with migraine with aura, the benefits of treatment should
be weighed against the harms in women without additional stroke risk factors.
http://www.bmj.com/cgi/content/full/339/oct27_1/b3914
Midlife Overweight and Obesity
Predict Lower Chance for Healthy Survival After Age 70
For every unit of BMI >25 kg/m2 at midlife, odds for disease-free survival at
age 70 decreased by 12%.
Evidence strongly suggests that overweight (body-mass index,
25–30 kg/m2) and obesity (BMI, >30) are associated with risk for premature death. However, how adiposity affects health among those who actually survive to old age
is less clear. Using data from the prospective Nurses'
Health Study (NHS), investigators examined the associations between
healthy survival (i.e., free from major chronic diseases,
including myocardial infarction, cancer, and
stroke) in old age and adiposity in early adulthood or midlife.
More than 17,000 women who were healthy at NHS enrollment in 1976
(mean baseline age, 50) and who survived beyond age 70 were included in the study. About 1700 women were still healthy at
age 70. After adjustment for confounders, increasing BMI at baseline was associated inversely with odds for healthy survival
beyond age 70. For example, women who were obese at baseline had 79% lower odds for healthy survival than did lean women.
For every 1 unit of BMI >25, odds for healthy survival
decreased by 12%. Also, women who reported gaining
weight from age 18 to midlife had less chance for healthy survival
than did women whose weight was stable. For every 1 kg of weight gained since age 18, odds for healthy survival were reduced
by 5%. Unsurprisingly, healthy survival was lowest among women who were overweight at baseline and who gained
10 kg.
http://www.ncbi.nlm.nih.gov/pubmed/19789407?dopt=Abstract
Incremental Cardiovascular Benefits of Increased HDL
Raising HDL levels, by whichever
treatment, is associated with decreased risk for coronary events, according to an Archives of Internal Medicine study.
Researchers
examined public-domain data on some 450 patients — participants of the Framingham Offspring Study — who started lipid-lowering therapy between 1975 and 2003. (The analysis was
supported and partially conducted by a drug manufacturer.)
After an average follow-up of 8 years, the hazard
ratio for suffering a coronary event was lowest among those experiencing the greatest increase in HDL relative to baseline.
A 1% increase in HDL was associated with a 2% decrease in risk. The effect remained significant
after adjustment for pretreatment HDL levels, age, and sex.
Conclusions Raising HDL-C levels with commonly
used lipid medications appears to be an important determinant of the benefits associated with lipid therapy.
These results support the further evaluation of therapies to raise HDL-C levels to prevent CV events.
.http://archinte.ama-assn.org/cgi/content/abstract/169/19/1775
Abdominal
Aortic Aneurysm: Short-Term Outcomes After Endovascular vs. Open Repair
Endovascular repair of abdominal
aortic aneurysms carries a lower likelihood of perioperative death than open repair — a mortality advantage
that disappears by the 2-year mark — according to an interim report of a 9-year study in JAMA.
Researchers
randomized nearly 900 patients (aged 49 or older) from Veterans Affairs hospitals to either endovascular or open repair.
Mortality
during hospitalization or at 30 days was significantly lower with the endovascular approach; however, at the 2-year mark,
mortality did not differ significantly between the groups. In addition, the groups did not differ in self-reported measures
of health-related quality of life or in the incidence of erectile dysfunction at 2 years.
Conclusions As compared with
open repair, endovascular repair of abdominal
aortic aneurysm is associated with lower short-term rates
of death and complications. The survival advantage
is more durable among older patients. Late reinterventions related to abdominal aortic
aneurysm are more common after endovascular repair but are balanced by an increase in laparotomy-related reinterventions
and hospitalizations after open surgery.
http://content.nejm.org/cgi/content/short/358/5/464
Predicting Stroke in Patients
with Asymptomatic Carotid Stenosis?
Patients who already have CT evidence of silent embolic infarcts are most likely to benefit from surgery.
In randomized trials of
carotid endarterectomy for asymptomatic carotid stenosis,
surgery lowered stroke risks by only a few percentage points in men and not at all in women. Now, an international prospective observational study suggests one way
to select patients most likely to benefit from surgery.
The study involved 821 patients (40% women; median age, 71) with carotid stenosis 50%
and no history of ipsilateral stroke or transient ischemic
attack. All patients underwent computed tomography brain scanning; CT findings suggestive
of silent ischemic events were classified as "embolic" or "nonembolic," according to a published classification
scheme. During a mean follow-up of 45 months, 6% of patients experienced ipsilateral hemispheric strokes. In patients with
60% to 99% stenosis, annual stroke rates were significantly higher among those with silent embolic infarcts on baseline CT
than among those without such infarcts (3.6% vs. 1.0%).
Breast Tenderness After Starting Combination Hormone Therapy May Indicate
Higher Breast Cancer Risk
Postmenopausal women who experience new-onset breast tenderness after starting combination hormone
therapy may face increased risk for breast cancer, according to an Archives of Internal Medicine study.
Researchers
examined data on some 17,000 Women's Health Initiative participants who were randomized to receive estrogen-progestin
or placebo daily. In the hormone group, women with new-onset breast tenderness at 12 months were about 50% more likely to
be diagnosed with breast cancer during 5.6 years' follow-up, relative to those without tenderness. (There was no
such association among placebo recipients.)
The sensitivity and specificity of breast tenderness
for predicting cancer risk were 41% and 64%, respectively — which, the authors say, are similar to values for the Gail
model.
The authors note that hormone-induced elevations in serum estrone and estrone sulfate might
lead to increased breast tenderness and heightened cancer risk. They add that their findings "should be considered by
... prescribing physicians to inform decisions regarding continued combined hormone therapy."
Herpes Zoster Linked to Increased Risk
for Stroke
A patient's risk for stroke increases during the year after a herpes zoster attack, according to a retrospective
study published online in Stroke.
Using a national database, researchers in Taiwan examined the incidence of stroke in some 7800 adults who
had herpes zoster attacks and 23,000 matched controls. During 1 year of follow-up, stroke occurred in 1.7% of zoster patients
and 1.3% of controls (adjusted hazard ratio, 1.3). Patients with zoster and ophthalmic complications were at especially high
risk (adjusted HR, 4.3).
The association between zoster and stroke was limited to patients aged 45 and
older.
The authors write: "Although varicella zoster virus vasculopathy is a well-documented
complication ... it does not fully account for the unexpectedly high risk of stroke in these patients."
Conclusion—The risk for stroke increased after a zoster attack. Although varicella zoster virus vasculopathy
is a well-documented complication that may induce a stroke postherpes zoster attack, it does not fully account for
the unexpectedly high risk of stroke in these patients.
http://stroke.ahajournals.org/cgi/content/abstract/STROKEAHA.109.562017v1?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=kang&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT
A Third
of Patients with Chronic Back Pain Recover Within a Year
A third of patients may completely recover
from chronic lower back pain by 9 months, according to aBMJ study.
Researchers enrolled some
400 patients who presented to general practitioners, physiotherapists, or chiropractors soon after experiencing low
back pain and who had persistent pain at 3 months. The patients were followed for 1 year. By 9 months, some 35% had fully
recovered (i.e., they were pain-free, had no back-related disability, and had fully returned to work), and by 12 months, 41%
had.
The following groups were at increased risk for delayed recovery: those with previous sick leave related
to low back pain, high disability levels at enrollment, lower education levels, and a higher perceived risk for persistent
pain.
http://www.bmj.com/cgi/content/full/339/oct06_2/b3829
Vitamin
D Supplementation Linked to Decreased Risk for Falls
High doses of supplemental vitamin D may lower the
risk for falls in older adults, reports a BMJmeta-analysis.
Researchers examined data
from eight randomized controlled trials of supplemental vitamin D (vitamin D2 or D3) in roughly 2400 adults aged
65 or older. Among the findings:
Supplemental vitamin D at 700 to 1000 IU/day (but not lower doses) was associated with a significant, 19% reduction
in falls relative to no supplementation.
Serum vitamin D concentrations of
60 nmol/L or higher were associated with a 23% drop in falls (lower concentrations showed no significant association).
Researchers
also looked at two trials of some 600 older adults and active vitamin D, a metabolite that may be more readily available for
people with diminished kidney function. The reduction in falls was similar to that seen with supplemental vitamin D. However,
patients taking the active form were more likely to experience hypercalcemia than controls.
As a
potential underlying mechanism, the authors note that vitamin D has direct effects on muscle strength.
http://www.bmj.com/cgi/content/full/339/oct01_1/b3692
Is Clinical Breast Examination,
Added to Mammography, Worthwhile?
CBE was associated with 55 additional false-positives for each additional breast cancer detected.
Whether patients benefit when clinical breast examination (CBE) is added to screening mammography is unclear.
Canadian researchers addressed this issue in an analysis of data from the Ontario Breast Screening Program, a network of screening
centers. Two thirds of centers offer CBE (performed by specially trained nurses) plus mammography; one third offer mammography
only.
Nearly
300,000 women (age range, 50–69) were screened during 2 years. Mammography plus CBE resulted in slightly higher rates
of cancer detection, but also higher false-positive rates, than mammography alone. The authors calculate that, for every 10,000
screened women, 59 cancers were diagnosed with mammography alone, and 63 were diagnosed with CBE plus mammography. Thus, CBE detected 4 additional cancers per 10,000 women screened but also generated 219 additional false-positives
(women referred for further evaluation who ultimately did not have cancer) per 10,000 screened women.
CONCLUSIONS: Women
should be informed of the benefits and risks of having a CBE in addition to mammography for breast screening.
http://www.ncbi.nlm.nih.gov/pubmed/19720967?dopt=Abstract
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