1.Handwashing with soap and water is the most appropriate way to prevent infection by an influenza virus.
2.Touching of eyes or nose before washing hands should be avoided.
3.Personal items should not be shared with another person during an influenza outbreak.
4.Chemoprophylaxis is a less desirable alternative and is only effective against influenza A virus.
5.Influenza vaccination in targeted high-risk populations is the best means of preventing severe disease caused by influenza virus.
Guidelines regarding the prevention and control of influenza have been established by the Advisory Committee on Immunization Practices.
Vaccines made using inactivated influenza virus provide 60-90% protection against influenza when the vaccine matches the epidemic strain.
The antigenic composition is reviewed annually so that the current vaccine contains the most recently circulating strains, usually one or more subtypes of influenza A virus and a subtype of influenza B virus.
Vaccine efficacy for preventing infection in elderly persons is 30-40%. Efficacy in preventing hospitalization for pneumonia and influenza is 50-60% in elderly persons living in nursing homes and 30-70% in elderly persons living outside of nursing homes. Efficacy in preventing death in elderly patients who live in nursing homes is 80%.
Indications for influenza vaccine include the following:
1.Persons aged 65 years and older (and recommended for those aged 50-64 y)
2.Residents of nursing homes and other long-term–care facilities
3.Patients with chronic pulmonary (eg, asthma) or cardiac disorders (except hypertension)
4.Patients with chronic metabolic disease (eg, diabetes), renal dysfunction, hemoglobinopathies, or immunosuppression (eg, human immunodeficiency virus [HIV])
5.Children and teenagers (6 mo to 18 y) with long-term use of aspirin
6.Persons who have any condition (eg, cognitive dysfunction, spinal cord injuries, seizure disorders, or other neuromuscular disorders) that may compromise respiratory function or the handling of respiratory secretions or that can increase the risk for aspiration
7.Pregnant women who will be in their second or third trimester during influenza season
8.Physicians, nurses, and other health care providers
9.Employees of nursing homes and long-term care facilities
10.Providers of home care to persons at high risk
11.Household members (eg, children aged <5 years) of persons at high risk
12.Providers of essential community services (eg, police, fire)
13.International travelers
14.Students and dormitory residents
15.Anyone wishing to reduce risk of influenza
The CDC recommends that the following groups receive priority for inactivated influenza vaccine:
1.Persons aged 50 years and older
2.Residents of long-term–care facilities
3.Persons aged 2-64 years with comorbid conditions
4.Children aged 6 months to 4 years (59 months)7,6
5.Women who will be pregnant during the influenza season
6.Health care providers who provide direct patient care
7.Household contacts and out-of-home caregivers of children younger than 6 months
Administration of influenza vaccine includes the following:
For adults and older children, the recommended site of vaccination is the deltoid muscle.
The preferred site for infants and young children is the anterolateral aspect of the thigh.
Influenza vaccine should be administered during the autumn season.
Vaccination is recommended in children aged 6 months or older.
Two doses administered at least 1 month apart are recommended in children 6 months to 8 years who are receiving influenza vaccine for the first time.
Other children or adults may be vaccinated with one shot.
Annual immunization is recommended because of declining immunity during the year after immunization and because, in most years, at least one of the antigens is changed in the vaccine to increase the antigenic similarity between the vaccine and circulating strains. The optimal time for influenza vaccination is usually between October and November.
Influenza vaccine should not be administered to persons known to have severe anaphylactic hypersensitivity to egg protein or to other components of the influenza vaccine.
The presence of minor illnesses with or without fever is not a contraindication to the use of influenza vaccine.
Influenza vaccine may be administered with pneumococcal vaccine and with other routine vaccinations of childhood.
Influenza vaccine is also available as a nasal spray (FluMist) for healthy children aged 2 years or older, adolescents, and adults aged 49 years or younger. Children aged 2-8 years who have not previously received influenza vaccine as a nasal spray require 2 doses at least 1 month apart. Those who only received 1 dose in their first year of vaccination should receive 2 doses in the following year.
Children who take aspirin, have asthma, or have had a wheezing episode in the preceding 12 months should not receive the FluMist vaccine.
Complications
Primary influenza viral pneumonia
Secondary bacterial pneumonia
Croup
Exacerbation of chronic pulmonary disease
Myositis
Myocarditis
Toxic shock syndrome
Guillain-Barré syndrome
Reye syndrome
Prognosis
The prognosis for recovery is excellent, although full return to normal levels of activity and freedom from cough usually requires weeks rather than days.
Patient Education
For excellent patient education resources, visit eMedicine's Cold and Flu Center. Also, see eMedicine's patient education article Flu in Children.
Miscellaneous
Special Concerns
In children younger than 16 years who have symptoms of influenza or colds, aspirin is not recommended because of an association with Reye syndrome.
source: Influenza: Follow-up
http://emedicine.medscape.com/article/972269-followup
Author: Hakan Leblebicioglu, MD, Chairman, Professor, Department of Infectious Diseases and Clinical Microbiology, Ondokuz Mayis University Medical School, Turkey
Coauthor(s): Itzhak Brook, MD, MSc, Professor, Department of Pediatrics, Georgetown University School of Medicine
Updated: Apr 27, 2009
Thursday, April 30, 2009
Tamiflu - Oseltamivir
Note to my patients: Tamiflu is an antiviral drug, not a vaccine against flu
This article from emedicine will help you.
Tamiflu
Inhibitor of neuraminidase, which is a glycoprotein on the surface of the influenza virus that destroys the infected cell's receptor for viral hemagglutinin. By inhibiting viral neuraminidase, release of viruses from infected cells and viral spread are decreased.
Effective against influenza virus types A and B.
Available as capsule and an Per Oral suspension.
Oseltamivir (Tamiflu) resistance has emerged in the United States during the 2008-2009 influenza season.
The CDC has issued revised interim recommendations for antiviral treatment and prophylaxis of influenza.
Preliminary data from a limited number of states indicate the prevalence of influenza A (H1N1) virus strains resistant to oseltamivir (Tamiflu) is high.
Because of this, zanamivir (Relenza) is recommended as the initial choice for antiviral prophylaxis or treatment when influenza A infection or exposure is suspected. A second-line alternative is a combination of oseltamivir plus rimantadine, rather than oseltamivir alone.
Local influenza surveillance data and laboratory testing can assist the physician regarding antiviral agent choice.
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in renal impairment (decrease dose if CrCl <30 mL/min), chronic cardiac or respiratory disease, and breastfeeding; may cause nausea or vomiting
Contraindication
Documented hypersensitivity
This article from emedicine will help you.
Tamiflu
Inhibitor of neuraminidase, which is a glycoprotein on the surface of the influenza virus that destroys the infected cell's receptor for viral hemagglutinin. By inhibiting viral neuraminidase, release of viruses from infected cells and viral spread are decreased.
Effective against influenza virus types A and B.
Available as capsule and an Per Oral suspension.
Oseltamivir (Tamiflu) resistance has emerged in the United States during the 2008-2009 influenza season.
The CDC has issued revised interim recommendations for antiviral treatment and prophylaxis of influenza.
Preliminary data from a limited number of states indicate the prevalence of influenza A (H1N1) virus strains resistant to oseltamivir (Tamiflu) is high.
Because of this, zanamivir (Relenza) is recommended as the initial choice for antiviral prophylaxis or treatment when influenza A infection or exposure is suspected. A second-line alternative is a combination of oseltamivir plus rimantadine, rather than oseltamivir alone.
Local influenza surveillance data and laboratory testing can assist the physician regarding antiviral agent choice.
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in renal impairment (decrease dose if CrCl <30 mL/min), chronic cardiac or respiratory disease, and breastfeeding; may cause nausea or vomiting
Contraindication
Documented hypersensitivity
Swine Flu
A client of mine was asking about swine flu and tamiflu.
This article for doctors might be useful for you at this worrisome time.
Swine Flu: Guidance and Resources for Clinicians
Susan B. Yox, RN, EdD
Published: 04/28/2009
Swine influenza is a highly contagious respiratory disease of pigs caused by one of several swine influenza A viruses. Outbreaks are common in pigs year-round, but infection in humans historically is a result of close contact with infected animals. This current virus is a novel influenza A virus, more properly termed a new subtype of influenza A (H1N1) that was not previously detected in swine or humans. More important is that this new strain appears to be spread by human-to-human transmission.
It is likely that most people, particularly those who do not have regular contact with pigs, do not have any immunity to swine influenza viruses. Thus the concern is that if efficient human-to-human transmission is established, a pandemic is possible.
Government and public health officials are monitoring this situation worldwide to assess the threat from swine flu and to provide guidance to healthcare professionals and the public. Because the situation is changing rapidly, it is important to check regularly for changes in recommendations as new information becomes available.
This article is based on guidance and resources available from both the United States Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO); they have been summarized here with the objective of offering practicing clinicians a one-stop resource for clinical practice concerns related to swine flu.
What Is the Clinical Presentation of Swine Flu?
Persons infected with swine flu may appear similar to those with seasonal influenza, presenting with symptoms of acute respiratory illness. Symptoms include at least 2 of the following:
Rhinorrhea or nasal congestion;
Sore throat;
Cough; and
Fever.
In addition, persons with swine flu may have other typical symptoms of influenza, including body aches, headache, chills, fatigue, and possibly diarrhea and vomiting.
Who Is Most at Risk for Swine Flu?
The CDC recommends that clinicians particularly consider the possibility of swine influenza A (H1N1) virus infection in patients with fevers and respiratory symptoms who:
1.Live in areas in the United States with confirmed human cases of swine influenza A (H1N1) virus infection. (To find the most up-to-date information on areas with confirmed swine influenza cases, go to http://www.cdc.gov/swineflu/index.htm)
2.Traveled recently to Mexico or were in contact with persons who had febrile respiratory illness and were in areas of the United States with confirmed swine influenza cases or Mexico in the 7 days preceding illness onset.
3.In addition, a person with an acute respiratory illness who has a recent history of contact with an animal with confirmed swine influenza should also be suspected (http://www.cdc.gov/swineflu/recommendations.htm).
What Is the Range of Illness Severity Seen With Swine Flu?
Many cases of swine flu may be mild or even asymptomatic. In the past, cases were identified by chance as part of regular seasonal influenza surveillance. Most of the recent cases seen in the United States thus far have been mild as well.
However, in Mexico, many patients' illnesses have been much more severe, have presented in young adults, and have included pneumonia, respiratory failure, and acute respiratory distress syndrome. Illness-related fatalities have been recorded in Mexico. At this time, it is not clear why such differences in illness severity have been seen. Early in epidemics it is difficult to gauge severity because the overall denominator of people infected is unknown.
How Should Swine Flu Be Diagnosed?
Preferred specimens. If swine flu is suspected, clinicians should obtain a respiratory specimen for analysis. In an ideal situation, the best method is via nasal pharyngeal aspirate or nasal wash aspirate into viral culture media; however, some experts are recommending the use of Dacron nasal swabs to decrease aerosolization of the virus. If these specimens cannot be collected, a combined nasal swab with an oropharyngeal swab is also acceptable and will be feasible in most settings. (Ideally, swab specimens should be collected using swabs with a synthetic tip and an aluminum or plastic shaft. Swabs with cotton tips and wooden shafts are not recommended. Specimens collected with swabs made of calcium alginate are not acceptable.)
The specimen should be placed in a 4°C refrigerator (not a freezer) or immediately placed on ice or cold packs for transport to the laboratory. Once collected, make contact with the state or local health department to facilitate transport and timely diagnosis at a state public health laboratory.
Recommended tests. The CDC currently recommends "real-time RT-PCR for influenza A, B, H1, H3 conducted at a State Health Department Laboratory. Currently, swine influenza A (H1N1) virus will test positive for influenza A and negative for H1 and H3 by real-time RT-PCR. If reactivity of real-time RT-PCR for influenza A is strong (e.g., Ct ≤ 30) it is more suggestive of a novel influenza A virus." Confirmation as swine influenza A (H1N1) virus is now performed at the CDC but may be available in state public health laboratories soon.
Rapid influenza testing. Rapid testing for swine flu likely is similar to that for seasonal flu, meaning that sensitivities range between 50% and 70% of cases (no better than using fever and cough as a marker in a patient during influenza season), depending on the manufacturer. Therefore, negative rapid tests should not indicate a lack of influenza. (For general guidance on rapid influenza testing, see http://www.cdc.gov/flu/professionals/diagnosis/rapidlab.htm)
Rapid tests can distinguish between influenza A and B viruses. A patient with a positive rapid test for influenza A may meet criteria for a probable case of swine flu, but again, a negative rapid test could be a false negative and should not be assumed a final diagnostic test for swine influenza infection.
Other tests. Immunofluorescence (DFA or IFA) tests can distinguish between influenza A and B viruses. A patient who is positive for influenza A by immunofluorescence may meet criteria for a probable case of swine influenza. However, a negative immunofluorescence could be a false negative and should not be assumed a final diagnostic test for swine influenza infection.
Isolation of swine influenza A (H1N1) virus by viral culture is also diagnostic of infection but may not yield timely results for clinical management. A negative viral culture does not exclude infection with swine influenza A (H1N1) virus.
To stay up-to-date on the latest recommendations for testing, check regularly at: http://www.cdc.gov/swineflu/specimencollection.htm
How Can Swine Flu Be Treated?
According to the CDC, swine influenza A (H1N1) is susceptible to the neuraminidase inhibitor antiviral medications zanamivir and oseltamivir. It is resistant to amantadine and rimantadine (http://www.cdc.gov/swineflu/recommendations.htm).
Treatment recommendations are as follows:
Suspected cases: Treat with zanamivir alone or with a combination of oseltamivir and either amantadine or rimantadine as soon as possible after the onset of symptoms and for a duration of 5 days.
Confirmed cases: Zanamivir or oseltamivir should be administered for 5 days.
Pregnant women: Antiviral medications are in Pregnancy Category C, so they should be used during pregnancy only if the potential benefit outweighs the potential risk to the embryo or fetus.
Children younger than 1 year: Because infants typically have high rates of morbidity and mortality from influenza, infants with swine influenza A (H1N1) infections may benefit from treatment with oseltamivir.
Detailed guidance on antiviral treatment for swine flu may be found here: http://www.cdc.gov/swineflu/recommendations.htm
Should Antiviral Chemoprophylaxis Be Considered for Specific Populations?
Chemoprophylaxis is recommended for 7 days after the last known exposure to a confirmed case of swine influenza A (H1N1) virus. See http://www.cdc.gov/flu/professionals/antivirals/dosagetable.htm#table for dosing and schedules.
The CDC recommends that the following populations receive chemoprophylaxis:
1.Household close contacts of a confirmed or suspected case who are at high risk for complications of influenza (persons with certain chronic medical conditions, elderly).
2.School children who are at high risk for complications of influenza (persons with certain chronic medical conditions) who have had close contact (face-to-face) with a confirmed or suspected case.
3.Travelers to Mexico who are at high risk for complications of influenza (persons with certain chronic medical conditions, elderly).
4.Border workers (Mexico) who are at high risk for complications of influenza (persons with certain chronic medical conditions, elderly).
5.Healthcare workers or public health workers who have had unprotected close contact with a person with confirmed swine influenza A (H1N1) virus infection during the infectious period. (Detailed guidance on this topic is available at http://www.cdc.gov/swineflu/recommendations.htm)
For How Long Is Swine Flu Contagious?
Persons with swine flu are considered infectious for 1 day before onset of the illness to 7 days after the onset.
What Infection-Control Precautions Should Be Taken in Healthcare Settings?
Patients who have a suspected or confirmed case of swine flu and who need to be hospitalized should be placed in a single-patient room with the door kept closed. The patient should wear a mask when outside the room. Standard, droplet, and contact precautions should be implemented and maintained by healthcare professionals for 7 days after the illness onset or until symptoms have resolved (http://www.cdc.gov/swineflu/guidelines_infection_control.htm).
source :http://www.medscape.com/viewarticle/702050?sssdmh=dm1.464966&src=ddd
This article for doctors might be useful for you at this worrisome time.
Swine Flu: Guidance and Resources for Clinicians
Susan B. Yox, RN, EdD
Published: 04/28/2009
Swine influenza is a highly contagious respiratory disease of pigs caused by one of several swine influenza A viruses. Outbreaks are common in pigs year-round, but infection in humans historically is a result of close contact with infected animals. This current virus is a novel influenza A virus, more properly termed a new subtype of influenza A (H1N1) that was not previously detected in swine or humans. More important is that this new strain appears to be spread by human-to-human transmission.
It is likely that most people, particularly those who do not have regular contact with pigs, do not have any immunity to swine influenza viruses. Thus the concern is that if efficient human-to-human transmission is established, a pandemic is possible.
Government and public health officials are monitoring this situation worldwide to assess the threat from swine flu and to provide guidance to healthcare professionals and the public. Because the situation is changing rapidly, it is important to check regularly for changes in recommendations as new information becomes available.
This article is based on guidance and resources available from both the United States Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO); they have been summarized here with the objective of offering practicing clinicians a one-stop resource for clinical practice concerns related to swine flu.
What Is the Clinical Presentation of Swine Flu?
Persons infected with swine flu may appear similar to those with seasonal influenza, presenting with symptoms of acute respiratory illness. Symptoms include at least 2 of the following:
Rhinorrhea or nasal congestion;
Sore throat;
Cough; and
Fever.
In addition, persons with swine flu may have other typical symptoms of influenza, including body aches, headache, chills, fatigue, and possibly diarrhea and vomiting.
Who Is Most at Risk for Swine Flu?
The CDC recommends that clinicians particularly consider the possibility of swine influenza A (H1N1) virus infection in patients with fevers and respiratory symptoms who:
1.Live in areas in the United States with confirmed human cases of swine influenza A (H1N1) virus infection. (To find the most up-to-date information on areas with confirmed swine influenza cases, go to http://www.cdc.gov/swineflu/index.htm)
2.Traveled recently to Mexico or were in contact with persons who had febrile respiratory illness and were in areas of the United States with confirmed swine influenza cases or Mexico in the 7 days preceding illness onset.
3.In addition, a person with an acute respiratory illness who has a recent history of contact with an animal with confirmed swine influenza should also be suspected (http://www.cdc.gov/swineflu/recommendations.htm).
What Is the Range of Illness Severity Seen With Swine Flu?
Many cases of swine flu may be mild or even asymptomatic. In the past, cases were identified by chance as part of regular seasonal influenza surveillance. Most of the recent cases seen in the United States thus far have been mild as well.
However, in Mexico, many patients' illnesses have been much more severe, have presented in young adults, and have included pneumonia, respiratory failure, and acute respiratory distress syndrome. Illness-related fatalities have been recorded in Mexico. At this time, it is not clear why such differences in illness severity have been seen. Early in epidemics it is difficult to gauge severity because the overall denominator of people infected is unknown.
How Should Swine Flu Be Diagnosed?
Preferred specimens. If swine flu is suspected, clinicians should obtain a respiratory specimen for analysis. In an ideal situation, the best method is via nasal pharyngeal aspirate or nasal wash aspirate into viral culture media; however, some experts are recommending the use of Dacron nasal swabs to decrease aerosolization of the virus. If these specimens cannot be collected, a combined nasal swab with an oropharyngeal swab is also acceptable and will be feasible in most settings. (Ideally, swab specimens should be collected using swabs with a synthetic tip and an aluminum or plastic shaft. Swabs with cotton tips and wooden shafts are not recommended. Specimens collected with swabs made of calcium alginate are not acceptable.)
The specimen should be placed in a 4°C refrigerator (not a freezer) or immediately placed on ice or cold packs for transport to the laboratory. Once collected, make contact with the state or local health department to facilitate transport and timely diagnosis at a state public health laboratory.
Recommended tests. The CDC currently recommends "real-time RT-PCR for influenza A, B, H1, H3 conducted at a State Health Department Laboratory. Currently, swine influenza A (H1N1) virus will test positive for influenza A and negative for H1 and H3 by real-time RT-PCR. If reactivity of real-time RT-PCR for influenza A is strong (e.g., Ct ≤ 30) it is more suggestive of a novel influenza A virus." Confirmation as swine influenza A (H1N1) virus is now performed at the CDC but may be available in state public health laboratories soon.
Rapid influenza testing. Rapid testing for swine flu likely is similar to that for seasonal flu, meaning that sensitivities range between 50% and 70% of cases (no better than using fever and cough as a marker in a patient during influenza season), depending on the manufacturer. Therefore, negative rapid tests should not indicate a lack of influenza. (For general guidance on rapid influenza testing, see http://www.cdc.gov/flu/professionals/diagnosis/rapidlab.htm)
Rapid tests can distinguish between influenza A and B viruses. A patient with a positive rapid test for influenza A may meet criteria for a probable case of swine flu, but again, a negative rapid test could be a false negative and should not be assumed a final diagnostic test for swine influenza infection.
Other tests. Immunofluorescence (DFA or IFA) tests can distinguish between influenza A and B viruses. A patient who is positive for influenza A by immunofluorescence may meet criteria for a probable case of swine influenza. However, a negative immunofluorescence could be a false negative and should not be assumed a final diagnostic test for swine influenza infection.
Isolation of swine influenza A (H1N1) virus by viral culture is also diagnostic of infection but may not yield timely results for clinical management. A negative viral culture does not exclude infection with swine influenza A (H1N1) virus.
To stay up-to-date on the latest recommendations for testing, check regularly at: http://www.cdc.gov/swineflu/specimencollection.htm
How Can Swine Flu Be Treated?
According to the CDC, swine influenza A (H1N1) is susceptible to the neuraminidase inhibitor antiviral medications zanamivir and oseltamivir. It is resistant to amantadine and rimantadine (http://www.cdc.gov/swineflu/recommendations.htm).
Treatment recommendations are as follows:
Suspected cases: Treat with zanamivir alone or with a combination of oseltamivir and either amantadine or rimantadine as soon as possible after the onset of symptoms and for a duration of 5 days.
Confirmed cases: Zanamivir or oseltamivir should be administered for 5 days.
Pregnant women: Antiviral medications are in Pregnancy Category C, so they should be used during pregnancy only if the potential benefit outweighs the potential risk to the embryo or fetus.
Children younger than 1 year: Because infants typically have high rates of morbidity and mortality from influenza, infants with swine influenza A (H1N1) infections may benefit from treatment with oseltamivir.
Detailed guidance on antiviral treatment for swine flu may be found here: http://www.cdc.gov/swineflu/recommendations.htm
Should Antiviral Chemoprophylaxis Be Considered for Specific Populations?
Chemoprophylaxis is recommended for 7 days after the last known exposure to a confirmed case of swine influenza A (H1N1) virus. See http://www.cdc.gov/flu/professionals/antivirals/dosagetable.htm#table for dosing and schedules.
The CDC recommends that the following populations receive chemoprophylaxis:
1.Household close contacts of a confirmed or suspected case who are at high risk for complications of influenza (persons with certain chronic medical conditions, elderly).
2.School children who are at high risk for complications of influenza (persons with certain chronic medical conditions) who have had close contact (face-to-face) with a confirmed or suspected case.
3.Travelers to Mexico who are at high risk for complications of influenza (persons with certain chronic medical conditions, elderly).
4.Border workers (Mexico) who are at high risk for complications of influenza (persons with certain chronic medical conditions, elderly).
5.Healthcare workers or public health workers who have had unprotected close contact with a person with confirmed swine influenza A (H1N1) virus infection during the infectious period. (Detailed guidance on this topic is available at http://www.cdc.gov/swineflu/recommendations.htm)
For How Long Is Swine Flu Contagious?
Persons with swine flu are considered infectious for 1 day before onset of the illness to 7 days after the onset.
What Infection-Control Precautions Should Be Taken in Healthcare Settings?
Patients who have a suspected or confirmed case of swine flu and who need to be hospitalized should be placed in a single-patient room with the door kept closed. The patient should wear a mask when outside the room. Standard, droplet, and contact precautions should be implemented and maintained by healthcare professionals for 7 days after the illness onset or until symptoms have resolved (http://www.cdc.gov/swineflu/guidelines_infection_control.htm).
source :http://www.medscape.com/viewarticle/702050?sssdmh=dm1.464966&src=ddd
Saturday, April 25, 2009
Breast Self Exam Accurate in High Risk women
Breast Self-Exam as Accurate as Mammography, MRI in High-Risk Women
From Medscape Medical News April 24, 2009 By Nick Mulcahy
Breast self-examination (BSE) is as accurate as mammography and magnetic resonance imaging (MRI) at detecting new breast cancers in high-risk women, according to the authors of a study presented at the American Society of Breast Surgeons 10th Annual Meeting, held in San Diego, California.
"Breast self-examination remains an important contributor to early detection in women at high risk for the development of breast cancer," said lead study author Lee Gravatt Wilke, MD, assistant professor of surgery at Duke University Health System, in Durham, North Carolina.
Breast self-exam should be emphasized and well taught to high-risk women.
In addition to high-risk women, BSE plays a role in screening young women, suggested Barbara Smith, MD, PhD, associate professor of surgery at Harvard Medical School, in Boston, Massachusetts.
"Only certain groups of women have a critical need for self-exam," Dr. Smith told Medscape Oncology, noting that they include high-risk and young women. BSE becomes important if such women are not receiving mammograms/MRI, genetic testing, or clinical breast exams — which are the preferred screening tools, she emphasized.
Based on a number of clinical-trial results, monthly BSE is no longer a recommendation for breast cancer screening in the population at large, noted Dr. Wilke. The recommendation was dropped in recent years after several large clinical trials indicated that BSE did not improve breast cancer mortality rates, as reported by Medscape Oncology .
Discussion With Patient Is Key
The way in which breast awareness is discussed with women is key to its being a help or a hindrance, suggested meeting attendee William H Goodson, MD, senior clinical research scientist at the California Pacific Medical Center Research Institute, in San Francisco, and founder of the 2 Minute Breast Exam Web site, which encourages physician use of the clinical breast exam.
"There's a difference between encouraging women to be familiar with their bodies and issuing a strong directive to self-exam via public programs,"
Formal BSE education programs that place a lot of responsibility for detecting masses on the patient — be it a woman who is young, at high risk, or in the general population — are highly problematic, he added. "For example, such programs can cause women who end up with breast cancer to blame themselves for not detecting it immediately, and can generate a sense of failure."
He also reiterated the well-known point that major clinical trials of BSE have not been shown to improve mortality. "There are only 2 things that randomized clinical trials of breast self-exam have ever shown — the exams cause women to find more abnormalities in their breasts and to undergo more biopsies," he said.
Furthermore, Dr. Goodson said that history is not on the side of BSE being a successful public-health tool. "Physicians have been trying to get patients to perform self-exams for more than 50 years. It's a very difficult thing to do. Some patients are very capable, some are freaked out. I can sympathize. I have attempted to do a testicular exam myself and it is not easy."
BSE vs MRI and Mammography
The new results reported by Dr. Wilke at the meeting come from an ongoing study of 147 women at Duke University who were at high risk by virtue of a 5-year Gail risk calculation of 1.7% or more; a previous biopsy with atypical hyperplasia, lobular, or ductal carcinoma in situ or contralateral invasive breast cancer; a BRCA1/2 mutation; or mantel radiation. The women received mammography and MRI screening and BSE training at study entry, and every 12 months thereafter. They performed BSE every 6 months.
At 3-year follow-up, there have been 14 cancers detected. The different modalities all detected cancers (as opposed to false positives) at a rate of 1 out of 4.
"Of the 24 masses that study participants found using SBE, 6 turned out to be cancer," explained Dr. Wilke. "Of the 8 abnormal mammograms, 2 turned out to be cancer, and of the 23 abnormal MRIs, 6 were cancer. The proportions were about the same across the board."
Dr. Goodson suggested that he was not surprised at the results for the BSE. "A test in a high-risk population always works better than it will in a general population," he said.
Nevertheless, Dr. Wilke defended BSE, even its use in general populations. Commenting on the fact that 3 trials have not shown an impact on mortality with routine BSE, she pointed out that 2 of the 3 studies — conducted in China and Russia, respectively — had low compliance.
Young Women With Breast Cancer Are Frequently at High Risk
Another study presented at the meeting, by Dr. Smith of Harvard, looked retrospectively at 628 women with breast cancer under the age of 40. The investigators found that 71% of the breast cancers were initially detected by BSE.
However, in those same women, 98% of the cancers were subsequently detectable by MRI/mammography. Furthermore, 50% of the 628 women in the study had a family history of breast cancer. In other words, many of those women should have received genetic counseling and related mammography/MRI.
So, while not disparaging the importance of BSE, Dr. Smith emphasized that there need to be better ways to get screenings in women with a family history of breast cancer.
"Underutilization of genetic testing and breast imaging potentially delays the diagnosis of breast cancer in women aged 40 and under," she concluded.
American Society of Breast Surgeons 10th Annual Meeting: Abstracts 9 and 20.
From Medscape Medical News April 24, 2009 By Nick Mulcahy
Breast self-examination (BSE) is as accurate as mammography and magnetic resonance imaging (MRI) at detecting new breast cancers in high-risk women, according to the authors of a study presented at the American Society of Breast Surgeons 10th Annual Meeting, held in San Diego, California.
"Breast self-examination remains an important contributor to early detection in women at high risk for the development of breast cancer," said lead study author Lee Gravatt Wilke, MD, assistant professor of surgery at Duke University Health System, in Durham, North Carolina.
Breast self-exam should be emphasized and well taught to high-risk women.
In addition to high-risk women, BSE plays a role in screening young women, suggested Barbara Smith, MD, PhD, associate professor of surgery at Harvard Medical School, in Boston, Massachusetts.
"Only certain groups of women have a critical need for self-exam," Dr. Smith told Medscape Oncology, noting that they include high-risk and young women. BSE becomes important if such women are not receiving mammograms/MRI, genetic testing, or clinical breast exams — which are the preferred screening tools, she emphasized.
Based on a number of clinical-trial results, monthly BSE is no longer a recommendation for breast cancer screening in the population at large, noted Dr. Wilke. The recommendation was dropped in recent years after several large clinical trials indicated that BSE did not improve breast cancer mortality rates, as reported by Medscape Oncology .
Discussion With Patient Is Key
The way in which breast awareness is discussed with women is key to its being a help or a hindrance, suggested meeting attendee William H Goodson, MD, senior clinical research scientist at the California Pacific Medical Center Research Institute, in San Francisco, and founder of the 2 Minute Breast Exam Web site, which encourages physician use of the clinical breast exam.
"There's a difference between encouraging women to be familiar with their bodies and issuing a strong directive to self-exam via public programs,"
Formal BSE education programs that place a lot of responsibility for detecting masses on the patient — be it a woman who is young, at high risk, or in the general population — are highly problematic, he added. "For example, such programs can cause women who end up with breast cancer to blame themselves for not detecting it immediately, and can generate a sense of failure."
He also reiterated the well-known point that major clinical trials of BSE have not been shown to improve mortality. "There are only 2 things that randomized clinical trials of breast self-exam have ever shown — the exams cause women to find more abnormalities in their breasts and to undergo more biopsies," he said.
Furthermore, Dr. Goodson said that history is not on the side of BSE being a successful public-health tool. "Physicians have been trying to get patients to perform self-exams for more than 50 years. It's a very difficult thing to do. Some patients are very capable, some are freaked out. I can sympathize. I have attempted to do a testicular exam myself and it is not easy."
BSE vs MRI and Mammography
The new results reported by Dr. Wilke at the meeting come from an ongoing study of 147 women at Duke University who were at high risk by virtue of a 5-year Gail risk calculation of 1.7% or more; a previous biopsy with atypical hyperplasia, lobular, or ductal carcinoma in situ or contralateral invasive breast cancer; a BRCA1/2 mutation; or mantel radiation. The women received mammography and MRI screening and BSE training at study entry, and every 12 months thereafter. They performed BSE every 6 months.
At 3-year follow-up, there have been 14 cancers detected. The different modalities all detected cancers (as opposed to false positives) at a rate of 1 out of 4.
"Of the 24 masses that study participants found using SBE, 6 turned out to be cancer," explained Dr. Wilke. "Of the 8 abnormal mammograms, 2 turned out to be cancer, and of the 23 abnormal MRIs, 6 were cancer. The proportions were about the same across the board."
Dr. Goodson suggested that he was not surprised at the results for the BSE. "A test in a high-risk population always works better than it will in a general population," he said.
Nevertheless, Dr. Wilke defended BSE, even its use in general populations. Commenting on the fact that 3 trials have not shown an impact on mortality with routine BSE, she pointed out that 2 of the 3 studies — conducted in China and Russia, respectively — had low compliance.
Young Women With Breast Cancer Are Frequently at High Risk
Another study presented at the meeting, by Dr. Smith of Harvard, looked retrospectively at 628 women with breast cancer under the age of 40. The investigators found that 71% of the breast cancers were initially detected by BSE.
However, in those same women, 98% of the cancers were subsequently detectable by MRI/mammography. Furthermore, 50% of the 628 women in the study had a family history of breast cancer. In other words, many of those women should have received genetic counseling and related mammography/MRI.
So, while not disparaging the importance of BSE, Dr. Smith emphasized that there need to be better ways to get screenings in women with a family history of breast cancer.
"Underutilization of genetic testing and breast imaging potentially delays the diagnosis of breast cancer in women aged 40 and under," she concluded.
American Society of Breast Surgeons 10th Annual Meeting: Abstracts 9 and 20.
Low intake of Vit A & C linked to Asthma & Wheeze
Diet Low in Vitamins A and C Linked to Asthma and Wheeze CME
News Author: Laurie Barclay, MD
CME Author: Charles Vega, MD, FAAFP
April 23, 2009
Relatively low dietary intakes of vitamins A and C are associated with statistically significant increased odds of asthma and wheeze, according to the results of a systematic review and meta-analysis reported in the April 16 Online First issue of Thorax.
"Epidemiological studies suggest that dietary intake of vitamins A, C and E may be associated with the occurrence of asthma," write S. Allen, from the University of Nottingham in Nottingham, United Kingdom, and colleagues. "However, randomized controlled trials of vitamin supplementation in asthma thus far have been inconclusive. In view of this apparent inconsistency between the observational and experimental data, we have attempted to determine the magnitude of the overall associations of these vitamins estimated by the observational studies by carrying out a systematic review and meta-analysis to provide pooled quantitative estimates of the likely magnitude of the effect of dietary intake and blood levels of antioxidant vitamins on a range of measures of asthma and asthma severity."
The reviewers searched MEDLINE, EMBASE, CINAHL, CAB abstracts, and AMED up to November 2007 for studies of asthma, wheeze, or airway responsiveness in association with dietary intakes and serum concentrations of vitamins A, C, and E. Conference proceedings and bibliographies of identified studies were also searched. Random-effects models allowed estimates of pooled odds ratios (ORs) or mean differences with 95% confidence intervals (CIs).
The review included 40 studies meeting the above criteria. Compared with people without asthma, those with asthma had significantly lower dietary vitamin A intake (mean difference, –182 µg/day; 95% CI, –288 to –75 µg/day; 3 studies). In addition, people with severe asthma had significantly lower dietary vitamin A intake vs those with mild asthma (mean difference, –344 µg/day; 2 studies).
The odds of asthma were also increased in patients with lower quantile dietary intakes (OR, 1.12; 95% CI, 1.04 - 1.21; 9 studies) and in those with lower serum levels of vitamin C. Although vitamin E intake was generally not associated with asthma status, it was significantly lower in patients with severe asthma vs those with mild asthma (mean difference, –1.20 µg/day; 95% CI, –2.3 to –0.1 µg/day; 2 studies).
"Relatively low dietary intakes of vitamins A and C are associated with statistically significant increased odds of asthma and wheeze," the study authors write. "Vitamin E intake does not appear to be related to asthma status."
Limitations of this study include methods used to determine levels of the antioxidant vitamins not consistent across studies, levels of antioxidant vitamins assessed after the onset of asthma in most studies, and most of the studies not reporting adjusted results.
"The epidemiological evidence thus suggests that vitamins A and C are linked to asthma," the study authors conclude. "Epidemiological studies and metaanalyses are useful for identifying association between exposures and diseases but cannot reliably establish causation. Further investigations are necessary to account for the observed associations using well-designed randomised controlled trials of vitamin supplementation in asthma."
This study was internally funded by the University of Nottingham. The study authors have disclosed no relevant financial relationships.
Thorax. Published online April 16, 2009.
News Author: Laurie Barclay, MD
CME Author: Charles Vega, MD, FAAFP
April 23, 2009
Relatively low dietary intakes of vitamins A and C are associated with statistically significant increased odds of asthma and wheeze, according to the results of a systematic review and meta-analysis reported in the April 16 Online First issue of Thorax.
"Epidemiological studies suggest that dietary intake of vitamins A, C and E may be associated with the occurrence of asthma," write S. Allen, from the University of Nottingham in Nottingham, United Kingdom, and colleagues. "However, randomized controlled trials of vitamin supplementation in asthma thus far have been inconclusive. In view of this apparent inconsistency between the observational and experimental data, we have attempted to determine the magnitude of the overall associations of these vitamins estimated by the observational studies by carrying out a systematic review and meta-analysis to provide pooled quantitative estimates of the likely magnitude of the effect of dietary intake and blood levels of antioxidant vitamins on a range of measures of asthma and asthma severity."
The reviewers searched MEDLINE, EMBASE, CINAHL, CAB abstracts, and AMED up to November 2007 for studies of asthma, wheeze, or airway responsiveness in association with dietary intakes and serum concentrations of vitamins A, C, and E. Conference proceedings and bibliographies of identified studies were also searched. Random-effects models allowed estimates of pooled odds ratios (ORs) or mean differences with 95% confidence intervals (CIs).
The review included 40 studies meeting the above criteria. Compared with people without asthma, those with asthma had significantly lower dietary vitamin A intake (mean difference, –182 µg/day; 95% CI, –288 to –75 µg/day; 3 studies). In addition, people with severe asthma had significantly lower dietary vitamin A intake vs those with mild asthma (mean difference, –344 µg/day; 2 studies).
The odds of asthma were also increased in patients with lower quantile dietary intakes (OR, 1.12; 95% CI, 1.04 - 1.21; 9 studies) and in those with lower serum levels of vitamin C. Although vitamin E intake was generally not associated with asthma status, it was significantly lower in patients with severe asthma vs those with mild asthma (mean difference, –1.20 µg/day; 95% CI, –2.3 to –0.1 µg/day; 2 studies).
"Relatively low dietary intakes of vitamins A and C are associated with statistically significant increased odds of asthma and wheeze," the study authors write. "Vitamin E intake does not appear to be related to asthma status."
Limitations of this study include methods used to determine levels of the antioxidant vitamins not consistent across studies, levels of antioxidant vitamins assessed after the onset of asthma in most studies, and most of the studies not reporting adjusted results.
"The epidemiological evidence thus suggests that vitamins A and C are linked to asthma," the study authors conclude. "Epidemiological studies and metaanalyses are useful for identifying association between exposures and diseases but cannot reliably establish causation. Further investigations are necessary to account for the observed associations using well-designed randomised controlled trials of vitamin supplementation in asthma."
This study was internally funded by the University of Nottingham. The study authors have disclosed no relevant financial relationships.
Thorax. Published online April 16, 2009.
Thursday, April 23, 2009
Sugar sweetened Beverage linked to Diabetes in Adolescents
Sugar-Sweetened Beverages, Physical Activity Independently Linked to Insulin Resistance
Laurie Barclay, MD
April 10, 2009 — Sugar-sweetened beverage intake and physical activity levels are each independently liked to insulin resistance in adolescents, according to the results of a cross-sectional analysis of the National Health and Nutrition Examination Survey (NHANES) data, collected by the National Center for Health Statistics, reported in the April issue of the Archives of Pediatrics & Adolescent Medicine.
"Two lifestyle behaviors associated with obesity, insulin resistance, and metabolic syndrome are (1) high levels of sugar-sweetened beverage...intake and (2) low levels of physical activity," write Andrew A. Bremer, MD, PhD, from the University of California Davis School of Medicine in Sacramento, and colleagues.
"Dietary modifications and consistent exercise are thus 2 recommendations typically given by pediatricians to children and adolescents either at risk for or currently diagnosed with these disorders. Experimental studies support the hypothesis that [sugar-sweetened beverages] may increase energy intake and induce weight gain via their reduced satiety response, the promotion of a positive energy balance by liquid calories relative to isoenergetic solid calories, and their dysregulation of energy homeostasis."
The goal of this study was to examine the association between insulin resistance–associated metabolic parameters and anthropometric measurements with sugar-sweetened beverage intake and physical activity levels, using a nationally representative sample of 6967 US adolescents participating in NHANES during the years 1999 to 2004. Age range was 12 to 19 years.
Sugar-sweetened beverages were defined as caloric soft drinks, colas, sugar-sweetened fruit drinks, and any other sugar-sweetened drinks.
The exposure of interest was sugar-sweetened beverage consumption and physical activity levels, and the main endpoints were glucose and insulin concentrations; a homeostasis model assessment of insulin resistance (HOMA-IR); total, high-density lipoprotein, and low-density lipoprotein cholesterol concentrations; triglyceride concentrations; systolic and diastolic blood pressure; waist circumference; and body mass index percentile for age and sex. Body mass index was calculated as weight in kilograms divided by height in meters squared.
Increased sugar-sweetened beverage intake was independently associated with increased HOMA-IR, systolic blood pressure, waist circumference, and body mass index percentile for age and sex and decreased high-density lipoprotein cholesterol concentrations, based on multivariate linear regression analyses. Increased physical activity levels were independently associated with reduced HOMA-IR, low-density lipoprotein cholesterol concentrations, and triglyceride concentrations and increased high-density lipoprotein cholesterol concentrations.
"Low sugar-sweetened beverage intake and high physical activity levels appear to modify each others' effects of decreasing HOMA-IR and triglyceride concentrations and increasing high-density lipoprotein cholesterol concentrations," the study authors write. "Sugar-sweetened beverage intake and physical activity levels are each independently associated with insulin resistance–associated metabolic parameters and anthropometric measurements in adolescents."
Limitations of this study include cross-sectional design precluding determination of causality, inability to adjust for the subjects' degree of sexual maturation, and use of questionnaire data with inherent limitations.
"Although prospective studies are needed to directly test the effects of dietary modification and consistent exercise on the development of obesity, insulin resistance, and metabolic syndrome in the pediatric population, pediatricians should continue promoting these lifestyle modifications in efforts to improve overall health," the study authors conclude.
The National Center for Research Resources, a component of the National Institutes of Health (NIH), and NIH Roadmap for Medical Research supported this study. The authors have disclosed no relevant financial relationships.
Arch Pediatr Adolesc Med. 2009;163:328–335.
Laurie Barclay, MD
April 10, 2009 — Sugar-sweetened beverage intake and physical activity levels are each independently liked to insulin resistance in adolescents, according to the results of a cross-sectional analysis of the National Health and Nutrition Examination Survey (NHANES) data, collected by the National Center for Health Statistics, reported in the April issue of the Archives of Pediatrics & Adolescent Medicine.
"Two lifestyle behaviors associated with obesity, insulin resistance, and metabolic syndrome are (1) high levels of sugar-sweetened beverage...intake and (2) low levels of physical activity," write Andrew A. Bremer, MD, PhD, from the University of California Davis School of Medicine in Sacramento, and colleagues.
"Dietary modifications and consistent exercise are thus 2 recommendations typically given by pediatricians to children and adolescents either at risk for or currently diagnosed with these disorders. Experimental studies support the hypothesis that [sugar-sweetened beverages] may increase energy intake and induce weight gain via their reduced satiety response, the promotion of a positive energy balance by liquid calories relative to isoenergetic solid calories, and their dysregulation of energy homeostasis."
The goal of this study was to examine the association between insulin resistance–associated metabolic parameters and anthropometric measurements with sugar-sweetened beverage intake and physical activity levels, using a nationally representative sample of 6967 US adolescents participating in NHANES during the years 1999 to 2004. Age range was 12 to 19 years.
Sugar-sweetened beverages were defined as caloric soft drinks, colas, sugar-sweetened fruit drinks, and any other sugar-sweetened drinks.
The exposure of interest was sugar-sweetened beverage consumption and physical activity levels, and the main endpoints were glucose and insulin concentrations; a homeostasis model assessment of insulin resistance (HOMA-IR); total, high-density lipoprotein, and low-density lipoprotein cholesterol concentrations; triglyceride concentrations; systolic and diastolic blood pressure; waist circumference; and body mass index percentile for age and sex. Body mass index was calculated as weight in kilograms divided by height in meters squared.
Increased sugar-sweetened beverage intake was independently associated with increased HOMA-IR, systolic blood pressure, waist circumference, and body mass index percentile for age and sex and decreased high-density lipoprotein cholesterol concentrations, based on multivariate linear regression analyses. Increased physical activity levels were independently associated with reduced HOMA-IR, low-density lipoprotein cholesterol concentrations, and triglyceride concentrations and increased high-density lipoprotein cholesterol concentrations.
"Low sugar-sweetened beverage intake and high physical activity levels appear to modify each others' effects of decreasing HOMA-IR and triglyceride concentrations and increasing high-density lipoprotein cholesterol concentrations," the study authors write. "Sugar-sweetened beverage intake and physical activity levels are each independently associated with insulin resistance–associated metabolic parameters and anthropometric measurements in adolescents."
Limitations of this study include cross-sectional design precluding determination of causality, inability to adjust for the subjects' degree of sexual maturation, and use of questionnaire data with inherent limitations.
"Although prospective studies are needed to directly test the effects of dietary modification and consistent exercise on the development of obesity, insulin resistance, and metabolic syndrome in the pediatric population, pediatricians should continue promoting these lifestyle modifications in efforts to improve overall health," the study authors conclude.
The National Center for Research Resources, a component of the National Institutes of Health (NIH), and NIH Roadmap for Medical Research supported this study. The authors have disclosed no relevant financial relationships.
Arch Pediatr Adolesc Med. 2009;163:328–335.
Saturday, April 11, 2009
Confinement Home Kuching Sarawak
Expecting a baby and looking for professional postnatal care?
The first of its kind in Sarawak, Havilah Confinement Home has been licensed by the Ministry of Health to provide medically supervised confinement service 24/7.
Set in a quiet neighbourhood, mum and baby can stay for any duration up to 60 days post delivery. Only well mums and babies will be accepted. They will be reviewed by our doctor regularly.
Mum will be helped to establish breast feeding and learn to express and store breast milk.
Where bottle feeding is preferred, hygeinic handling of bottles will be taught.
During the stay we will help you learn how to soothe, bathe, and massage babies.
You will also learn Child Health 101 from our inhouse pediatrician and nurse, based on the book "Congratulations, You're a Mum and Dad - caring for your baby from Day One" written by Dr Tan Poh Tin.
Aesthetic pampering eg massage, facial, hair care, manicure and pedicure can also be arranged.
By the end of your stay with us, you will not only have a restful confinement recovery, we are committed to equip you with parenting skills to become more informed parents.
For more information or booking call +06 082366452 or +060168520200
or email havilahconfinement@gmail.com
Visit our website at:
http://havilah.wsiefusion.net/
The first of its kind in Sarawak, Havilah Confinement Home has been licensed by the Ministry of Health to provide medically supervised confinement service 24/7.
Set in a quiet neighbourhood, mum and baby can stay for any duration up to 60 days post delivery. Only well mums and babies will be accepted. They will be reviewed by our doctor regularly.
Mum will be helped to establish breast feeding and learn to express and store breast milk.
Where bottle feeding is preferred, hygeinic handling of bottles will be taught.
During the stay we will help you learn how to soothe, bathe, and massage babies.
You will also learn Child Health 101 from our inhouse pediatrician and nurse, based on the book "Congratulations, You're a Mum and Dad - caring for your baby from Day One" written by Dr Tan Poh Tin.
Aesthetic pampering eg massage, facial, hair care, manicure and pedicure can also be arranged.
By the end of your stay with us, you will not only have a restful confinement recovery, we are committed to equip you with parenting skills to become more informed parents.
For more information or booking call +06 082366452 or +060168520200
or email havilahconfinement@gmail.com
Visit our website at:
http://havilah.wsiefusion.net/
Thursday, April 9, 2009
Hypertriglyceridemia Is Common Among US Adults
Laurie Barclay, MD
http://www.medscape.com/viewarticle/590457?src=mp&spon=17&uac=71630FV
April 1, 2009 — Hypertriglyceridemia is common among US adults and should be treated with lifestyle change in most cases, according to the results of a study reported in the March 23 issue of the Archives of Internal Medicine.
"Increasing evidence supports triglyceride (TG) concentration as a risk factor for cardiovascular disease," write Earl S. Ford, MD, MPH, from the National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, and colleagues. "The prevalence of hypertriglyceridemia during a period of rising prevalence of obesity and its pharmacological treatment among US adults are poorly understood."
The study sample consisted of 5610 adults aged 20 years or older enrolled in the National Health and Nutrition Examination Surveys (NHANES) from 1999 to 2004. Unadjusted prevalence rates (percentages) of TG concentration ranges in milligrams per deciliter were determined (to convert TG to millimoles per liter, multiply by 0.0113).
TG concentration of 150 mg/dL or higher occurred in 33.1% of participants (standard error [SE], 0.8%), a concentration of 200 mg/dL or higher occurred in 17.9% of participants (SE, 0.7%), a concentration of 500 mg/dL or higher occurred in 1.7% of participants (SE, 0.2%), and a concentration of 1000 mg/dL or higher occurred in 0.4% of participants (SE, 0.1%).
Use of 1 of 3 prescription medications indicated to treat hypertriglyceridemia (fenofibrate, gemfibrozil, or niacin) occurred in 1.3% of participants overall (SE, 0.2%), in 2.6% of participants with a TG concentration of 150 mg/dL or higher (SE, 0.4%), and in 3.6% of those with a TG concentration of 200 mg/dL or higher (SE, 0.7%).
"Among US adults, hypertriglyceridemia is common," the study authors write. "Until the benefits of treating hypertriglyceridemia that is not characterized by extreme elevations of TG concentration with medications are incontrovertible, therapeutic lifestyle change remains the preferred treatment."
Limitations of this study include a lack of certainty that the intended use of medications was for lowering elevated TG concentrations rather than raising high-density lipoprotein cholesterol concentrations, as well as the possible effects of oral contraceptives and hormone therapy on TG concentrations in women.
"The prevalence of hypertriglyceridemia is high among US adults, the use of pharmacologic treatment is low, and the prevalence of modifiable causes of hypertriglyceridemia, such as physical inactivity and overweight or obesity, is high," the study authors conclude. "Because measuring TG concentrations is routinely performed in clinical practice, physicians have to regularly decide on the need for treatment in many of their patients. As research clarifies uncertainties in the relation between TG concentration and cardiovascular disease, guidelines to treat hypertriglyceridemia will likely be modified."
In an accompanying commentary, Warren G. Thompson, MD, and Gerald T. Gau, MD, from the Mayo Clinic College of Medicine in Rochester, Minnesota, agree that llifestyle modification is the cornerstone of management of TG concentrations between 150 and 500 mg/dL. They note that if the patient does not make lifestyle changes in diet and exercise, it is difficult to normalize TG concentration with medication alone.
If medications are necessary, Dr. Thompson and Dr. Gau suggest trying statins first, as these have proven effects on mortality.
"Some have argued that statins reduce mortality by only 30% and that additional pharmacologic therapy to treat elevated TG concentration is warranted," Dr. Thompson and Dr. Gau write.
"However, there are no data proving that additional drug treatment will reduce mortality. If statins and lifestyle change are insufficient, then fish oil or niacin should be considered. Fibrates should be reserved for TG concentrations higher than 1000 mg/dL that do not respond to other treatments."
Arch Intern Med. 2009;169:572–578, 578–579.
-->
Laurie Barclay, MD is a freelance reviewer and writer for Medscape LLC
http://www.medscape.com/viewarticle/590457?src=mp&spon=17&uac=71630FV
April 1, 2009 — Hypertriglyceridemia is common among US adults and should be treated with lifestyle change in most cases, according to the results of a study reported in the March 23 issue of the Archives of Internal Medicine.
"Increasing evidence supports triglyceride (TG) concentration as a risk factor for cardiovascular disease," write Earl S. Ford, MD, MPH, from the National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, and colleagues. "The prevalence of hypertriglyceridemia during a period of rising prevalence of obesity and its pharmacological treatment among US adults are poorly understood."
The study sample consisted of 5610 adults aged 20 years or older enrolled in the National Health and Nutrition Examination Surveys (NHANES) from 1999 to 2004. Unadjusted prevalence rates (percentages) of TG concentration ranges in milligrams per deciliter were determined (to convert TG to millimoles per liter, multiply by 0.0113).
TG concentration of 150 mg/dL or higher occurred in 33.1% of participants (standard error [SE], 0.8%), a concentration of 200 mg/dL or higher occurred in 17.9% of participants (SE, 0.7%), a concentration of 500 mg/dL or higher occurred in 1.7% of participants (SE, 0.2%), and a concentration of 1000 mg/dL or higher occurred in 0.4% of participants (SE, 0.1%).
Use of 1 of 3 prescription medications indicated to treat hypertriglyceridemia (fenofibrate, gemfibrozil, or niacin) occurred in 1.3% of participants overall (SE, 0.2%), in 2.6% of participants with a TG concentration of 150 mg/dL or higher (SE, 0.4%), and in 3.6% of those with a TG concentration of 200 mg/dL or higher (SE, 0.7%).
"Among US adults, hypertriglyceridemia is common," the study authors write. "Until the benefits of treating hypertriglyceridemia that is not characterized by extreme elevations of TG concentration with medications are incontrovertible, therapeutic lifestyle change remains the preferred treatment."
Limitations of this study include a lack of certainty that the intended use of medications was for lowering elevated TG concentrations rather than raising high-density lipoprotein cholesterol concentrations, as well as the possible effects of oral contraceptives and hormone therapy on TG concentrations in women.
"The prevalence of hypertriglyceridemia is high among US adults, the use of pharmacologic treatment is low, and the prevalence of modifiable causes of hypertriglyceridemia, such as physical inactivity and overweight or obesity, is high," the study authors conclude. "Because measuring TG concentrations is routinely performed in clinical practice, physicians have to regularly decide on the need for treatment in many of their patients. As research clarifies uncertainties in the relation between TG concentration and cardiovascular disease, guidelines to treat hypertriglyceridemia will likely be modified."
In an accompanying commentary, Warren G. Thompson, MD, and Gerald T. Gau, MD, from the Mayo Clinic College of Medicine in Rochester, Minnesota, agree that llifestyle modification is the cornerstone of management of TG concentrations between 150 and 500 mg/dL. They note that if the patient does not make lifestyle changes in diet and exercise, it is difficult to normalize TG concentration with medication alone.
If medications are necessary, Dr. Thompson and Dr. Gau suggest trying statins first, as these have proven effects on mortality.
"Some have argued that statins reduce mortality by only 30% and that additional pharmacologic therapy to treat elevated TG concentration is warranted," Dr. Thompson and Dr. Gau write.
"However, there are no data proving that additional drug treatment will reduce mortality. If statins and lifestyle change are insufficient, then fish oil or niacin should be considered. Fibrates should be reserved for TG concentrations higher than 1000 mg/dL that do not respond to other treatments."
Arch Intern Med. 2009;169:572–578, 578–579.
-->
Laurie Barclay, MD is a freelance reviewer and writer for Medscape LLC
Is Gardasil® Recommended for Young Women Already Exposed to HPV?
From Medscape Pharmacists
Ask the Experts about Pharmacotherapy
Posted 04/01/2009
Laurie L. Briceland, PharmDAuthor Information
Should Gardasil® (human papillomavirus [HPV] quadrivalent [types 6, 11, 16, and 18] vaccine) be administered to young women who test positive for oncogenic-risk HPV strains, or to those who have abnormal Papanicolaou ("Pap") smear results?
Response from Laurie L. Briceland, PharmDProfessor and Director, Experiential Education, Department of Pharmacy Practice, Albany College of Pharmacy, Albany, New York
Genital human papillomavirus (HPV) is the most common sexually transmitted infection in the United States, with an estimated 20 million people already infected and over 6 million people infected annually.[1]
Although most infections prove to be self-limiting or asymptomatic, persistent infection with oncogenic strains (such as types 16 and 18) can lead to cervical cancer.
Seventy percent of cervical cancers are attributed to HPV types 16 and 18; HPV types 6 and 11 contribute to 90% of cases of genital warts.[2]
The HPV quadrivalent (types 6, 11, 16, and 18) vaccine (Gardasil®) was approved by the US Food and Drug Administration in 2006 and is indicated for use in 9- to 26-year-old females for the prevention of diseases caused by those 4 virus strains.
These diseases include cervical, vulvar, and vaginal cancer caused by HPV types 16 and 18; cervical, vaginal, and vulvar cancer precursor and dysplastic lesions; and genital warts caused by HPV types 6 and 11.[3]
Clinical trials indicate that the vaccine is effective in preventing HPV infection and precancerous lesions in females who have not already been infected with the respective HPV type.[2]
Thus, the goal is to administer the vaccine series to females prior to their sexual activity debut, with the recommended age being 11-12 years.[2]
Vaccination is also recommended for 13- to 26-year-old females who have not been vaccinated, or who have not completed the vaccination series, even if the female is already sexually active and could have contracted HPV infection.
No evidence exists of protection against vaccine HPV types that have already infected the female at the time of vaccination.
However, females infected with fewer than all 4 of the vaccine HPV types before vaccination would likely receive protection and partial benefit against the other vaccine types upon vaccination.[2]
Vaccination is recommended for females with an abnormal Pap test in order to impart partial benefit from vaccine type(s) to which the female has not already been infected.
As Pap test results increase in severity, risk for infection with HPV 16 or 18 increases, potentially decreasing the benefit of vaccination.[2]
Patients should be counseled that the vaccine will not have any therapeutic benefit on existing HPV infection or lesions based on clinical trial data.[2]
It is important to note that patients who receive Gardasil® should continue to undergo routine cervical cancer screenings by Pap test as recommended by their physicians.[2,3]
Ask the Experts about Pharmacotherapy
Posted 04/01/2009
Laurie L. Briceland, PharmDAuthor Information
Should Gardasil® (human papillomavirus [HPV] quadrivalent [types 6, 11, 16, and 18] vaccine) be administered to young women who test positive for oncogenic-risk HPV strains, or to those who have abnormal Papanicolaou ("Pap") smear results?
Response from Laurie L. Briceland, PharmDProfessor and Director, Experiential Education, Department of Pharmacy Practice, Albany College of Pharmacy, Albany, New York
Genital human papillomavirus (HPV) is the most common sexually transmitted infection in the United States, with an estimated 20 million people already infected and over 6 million people infected annually.[1]
Although most infections prove to be self-limiting or asymptomatic, persistent infection with oncogenic strains (such as types 16 and 18) can lead to cervical cancer.
Seventy percent of cervical cancers are attributed to HPV types 16 and 18; HPV types 6 and 11 contribute to 90% of cases of genital warts.[2]
The HPV quadrivalent (types 6, 11, 16, and 18) vaccine (Gardasil®) was approved by the US Food and Drug Administration in 2006 and is indicated for use in 9- to 26-year-old females for the prevention of diseases caused by those 4 virus strains.
These diseases include cervical, vulvar, and vaginal cancer caused by HPV types 16 and 18; cervical, vaginal, and vulvar cancer precursor and dysplastic lesions; and genital warts caused by HPV types 6 and 11.[3]
Clinical trials indicate that the vaccine is effective in preventing HPV infection and precancerous lesions in females who have not already been infected with the respective HPV type.[2]
Thus, the goal is to administer the vaccine series to females prior to their sexual activity debut, with the recommended age being 11-12 years.[2]
Vaccination is also recommended for 13- to 26-year-old females who have not been vaccinated, or who have not completed the vaccination series, even if the female is already sexually active and could have contracted HPV infection.
No evidence exists of protection against vaccine HPV types that have already infected the female at the time of vaccination.
However, females infected with fewer than all 4 of the vaccine HPV types before vaccination would likely receive protection and partial benefit against the other vaccine types upon vaccination.[2]
Vaccination is recommended for females with an abnormal Pap test in order to impart partial benefit from vaccine type(s) to which the female has not already been infected.
As Pap test results increase in severity, risk for infection with HPV 16 or 18 increases, potentially decreasing the benefit of vaccination.[2]
Patients should be counseled that the vaccine will not have any therapeutic benefit on existing HPV infection or lesions based on clinical trial data.[2]
It is important to note that patients who receive Gardasil® should continue to undergo routine cervical cancer screenings by Pap test as recommended by their physicians.[2,3]
Hot Tea drinking increase Cancer esophagus
April 3, 2009 — Drinking hot tea was strongly associated with a higher risk for esophageal cancer according to the results of a northern Iranian population-based case-control study reported online first on March 27 in the British Medical Journal.
"An association between drinking hot beverages and risk of oesophageal cancer has been reported in several studies from different parts of the world," write Farhad Islami, MD, from Shariati Hospital, Tehran University of Medical Sciences in Iran, and colleagues. "In Golestan, tea and water are the only drinks commonly consumed, with comparable average intake. An ecological study showed that inhabitants of Golestan drank more tea and at a higher temperature than people living in a nearby area with a low incidence of oesophageal cancer."
The goal of this study was to evaluate the relationship between characteristics of tea drinking habits in Golestan province in northern Iran, which is an area with a high incidence of esophageal squamous cell carcinoma (SCC), and risk for that disease. Patterns of tea drinking and temperature at which tea was usually drunk were also determined for healthy persons enrolled in a cohort study.
Tea drinking among 300 patients with histologically proven esophageal SCC was compared with that in 571 matched neighborhood controls in the case-control study and in 48,582 participants in the cohort study. The primary study endpoint was the odds ratio (OR) of esophageal SCC associated with drinking hot tea.
Regular drinking of black tea was reported by 98% of the cohort participants, with mean daily volume more than 1 L. Reported temperature of tea was less than 60°C in 39.0% of participants, 60°C to 64°C in 38.9%, and 65°C or higher in 22.0%. Reported temperature agreed moderately with actual temperature measurements (weighted κ, 0.49).
In the case-control study, risk for esophageal cancer was increased for drinking hot tea (OR, 2.07; 95% confidence interval [CI], 1.28 – 3.35) or very hot tea (OR, 8.16; 95% CI, 3.93 – 16.9) vs lukewarm or warm tea. Risk was also significantly increased for drinking tea 2 to 3 minutes after pouring (OR, 2.49; 95% CI, 1.62 – 3.83) or less than 2 minutes after pouring (OR, 5.41; 95% CI, 2.63 – 11.1) vs drinking tea at least 4 minutes after being poured. Responses to the questions about temperature at which tea was drunk agreed strongly with interval from tea being poured to being drunk (weighted κ, 0.68).
"Drinking hot tea, a habit common in Golestan province, was strongly associated with a higher risk of oesophageal cancer," the study authors write.
Limitations of this study include possible information bias regarding the amount and temperature of consumed tea, validation study performed among healthy people, possible selection bias, and some missing data.
"A large proportion of Golestan inhabitants drink hot tea, so this habit may account for a substantial proportion of the cases of oesophageal cancer in this population," the study authors write. "Informing the population about the hazards of drinking hot tea may be helpful in reducing the incidence of oesophageal cancer in Golestan and in other high risk populations where similar habits are prevalent."
In an accompanying editorial, David C, Whiteman, from Queensland Institute of Medical Research at Royal Brisbane Hospital in Australia, recommends allowing tea to cool for 5 minutes before drinking.
"The mechanism through which heat promotes the development of tumours warrants further exploration and might be given renewed impetus on the basis of these findings," Dr. Whiteman writes. "These findings are not cause for alarm, however, and they should not reduce public enthusiasm for the time honoured ritual of drinking tea. Rather, we should follow the advice … [that suggests] a five to 10 minute interval between making and pouring tea, by which time the tea will be sufficiently flavoursome and unlikely to cause thermal injury."
The Digestive Disease Research Center of Tehran University of Medical Sciences, the National Cancer Institute, National Institutes of Health, and the International Agency for Research on Cancer supported this study. The study authors and Dr. Whiteman have disclosed no relevant financial relationships.
BMJ. Published online March 27, 2009.
http://www.medscape.com/viewarticle/590589?sssdmh=dm1.454091&src=nldne
"An association between drinking hot beverages and risk of oesophageal cancer has been reported in several studies from different parts of the world," write Farhad Islami, MD, from Shariati Hospital, Tehran University of Medical Sciences in Iran, and colleagues. "In Golestan, tea and water are the only drinks commonly consumed, with comparable average intake. An ecological study showed that inhabitants of Golestan drank more tea and at a higher temperature than people living in a nearby area with a low incidence of oesophageal cancer."
The goal of this study was to evaluate the relationship between characteristics of tea drinking habits in Golestan province in northern Iran, which is an area with a high incidence of esophageal squamous cell carcinoma (SCC), and risk for that disease. Patterns of tea drinking and temperature at which tea was usually drunk were also determined for healthy persons enrolled in a cohort study.
Tea drinking among 300 patients with histologically proven esophageal SCC was compared with that in 571 matched neighborhood controls in the case-control study and in 48,582 participants in the cohort study. The primary study endpoint was the odds ratio (OR) of esophageal SCC associated with drinking hot tea.
Regular drinking of black tea was reported by 98% of the cohort participants, with mean daily volume more than 1 L. Reported temperature of tea was less than 60°C in 39.0% of participants, 60°C to 64°C in 38.9%, and 65°C or higher in 22.0%. Reported temperature agreed moderately with actual temperature measurements (weighted κ, 0.49).
In the case-control study, risk for esophageal cancer was increased for drinking hot tea (OR, 2.07; 95% confidence interval [CI], 1.28 – 3.35) or very hot tea (OR, 8.16; 95% CI, 3.93 – 16.9) vs lukewarm or warm tea. Risk was also significantly increased for drinking tea 2 to 3 minutes after pouring (OR, 2.49; 95% CI, 1.62 – 3.83) or less than 2 minutes after pouring (OR, 5.41; 95% CI, 2.63 – 11.1) vs drinking tea at least 4 minutes after being poured. Responses to the questions about temperature at which tea was drunk agreed strongly with interval from tea being poured to being drunk (weighted κ, 0.68).
"Drinking hot tea, a habit common in Golestan province, was strongly associated with a higher risk of oesophageal cancer," the study authors write.
Limitations of this study include possible information bias regarding the amount and temperature of consumed tea, validation study performed among healthy people, possible selection bias, and some missing data.
"A large proportion of Golestan inhabitants drink hot tea, so this habit may account for a substantial proportion of the cases of oesophageal cancer in this population," the study authors write. "Informing the population about the hazards of drinking hot tea may be helpful in reducing the incidence of oesophageal cancer in Golestan and in other high risk populations where similar habits are prevalent."
In an accompanying editorial, David C, Whiteman, from Queensland Institute of Medical Research at Royal Brisbane Hospital in Australia, recommends allowing tea to cool for 5 minutes before drinking.
"The mechanism through which heat promotes the development of tumours warrants further exploration and might be given renewed impetus on the basis of these findings," Dr. Whiteman writes. "These findings are not cause for alarm, however, and they should not reduce public enthusiasm for the time honoured ritual of drinking tea. Rather, we should follow the advice … [that suggests] a five to 10 minute interval between making and pouring tea, by which time the tea will be sufficiently flavoursome and unlikely to cause thermal injury."
The Digestive Disease Research Center of Tehran University of Medical Sciences, the National Cancer Institute, National Institutes of Health, and the International Agency for Research on Cancer supported this study. The study authors and Dr. Whiteman have disclosed no relevant financial relationships.
BMJ. Published online March 27, 2009.
http://www.medscape.com/viewarticle/590589?sssdmh=dm1.454091&src=nldne
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