From Medscape Medical News
Caroline Cassels
January 26, 2010 — A blood test to aid in the diagnosis of schizophrenia may be available within the year.
An article in the January 18 issue of Chemical & Engineering News, the American Chemical Society's weekly news magazine, highlights the groundbreaking work led by Sabine Bahn, MD, PhD, MRCPsych, director of the Cambridge Institute of Psychiatric Research at the University of Cambridge in the United Kingdom, which reveals that up to 40% of changes that occur in the brains of schizophrenic patients also occur in other body parts.
Reporter Celia Henry Arnaud writes that the scientists are studying these biomarkers in the skin, immune cells, and serum to find samples that give a real-time picture of the disease. In contrast, she notes, most previous studies of schizophrenia have focused on examining potential biomarkers in brain tissue harvested at autopsy.
In the article, Dr. Bahn is quoted as saying, "We were pleased that some of our previous findings could be reproduced in the fibroblast system. It was reassuring that we can trace central nervous system abnormalities in the peripheral system."
Although the investigators initially studied fibroblasts, they are now using immune cells in schizophrenia studies because they have an added advantage of being involved in more signaling pathways, Ms. Arnaud reports.
The researchers are reportedly working with the company Rules-Based Medicine, located in Austin, Texas, and Lake Placid, New York, on the development of a diagnostic blood test. The hope is that the test will help clinicians confirm schizophrenia diagnoses and facilitate earlier treatment of the disease, which affects approximately 2 million Americans.
"The customary window is often a delay of several years until someone is confirmed and diagnosed. We know very well that if patients are treated early in the disease process, we improve outcome," said Dr. Bahn.
Chemical & Engineering News. 2010;88:26.
Thursday, January 28, 2010
Vitamin D May Lower Colon Cancer Risk
From WebMD Health News
Kelli Miller Stacy
January 25, 2010 — Soaking in more sunlight and drinking more dairy may help you ward off colon cancer.
Researchers in Europe have found that people with abundant levels of vitamin D -- the so-called sunshine vitamin -- have a much lower risk of colon cancer. The findings add to a growing body of evidence that suggest vitamin D may have the power to help prevent colon cancer and possibly even improve survival in those who have the disease.
The body makes vitamin D after the skin absorbs some of the sun's rays.
You can also get vitamin D by consuming certain foods and beverages, such as milk and cereal, which have been fortified with the vitamin, but few foods naturally contain it.
For the current study, researchers looked at the link between blood levels of vitamin D as well as dietary vitamin D and calcium, and who was at risk for colorectal cancer. They based their findings on information from the European Prospective Investigation into Cancer Study (EPIC), a study of more than 520,000 people from 10 Western European countries. The study participants gave blood samples and completed detailed diet and lifestyle questionnaires between 1992 and 1998.
During the follow-up period, 1,248 patients were diagnosed with colorectal cancer. Researchers compared their lifestyle and diet backgrounds to the same number of healthy patients. They discovered that those with the highest blood levels of vitamin D had a nearly 40% decrease in colorectal cancer risk than those with the lowest levels.
However, the best way to boost your vitamin D level may be a matter of debate. As vitamin D's potential health benefits become more widely advertised, more people may advocate supplementation. However, the researchers say it's unclear if supplements are better at increasing blood levels of vitamin D than a balanced diet and moderate exposure to outdoor sunlight. They caution that the long-term effects of taking large doses of vitamin D supplements have not been well studied.
"Our findings suggest that the potential cancer risk benefits of higher vitamin D levels should be balanced with caution for the toxic potential," they write in today's online version of BMJ. "Before any public health recommendations can be made for vitamin D supplementation, new randomized trials are needed to test the hypothesis that increases in [blood levels of vitamin D] are effective in reducing colorectal cancer risk without inducing serious adverse events."
Colorectal cancer is the third most common cancer in men and women in the U.S., according to the American Cancer Society.
SOURCES:
News release, BMJ.
Jenab, M. BMJ, Jan. 20, 2010; vol 340.
American Cancer Society web site: "How Many People Get Colorectal Cancer."
National Institutes of Health web site: "Dietary Supplements: Vitamin D."
Kelli Miller Stacy
January 25, 2010 — Soaking in more sunlight and drinking more dairy may help you ward off colon cancer.
Researchers in Europe have found that people with abundant levels of vitamin D -- the so-called sunshine vitamin -- have a much lower risk of colon cancer. The findings add to a growing body of evidence that suggest vitamin D may have the power to help prevent colon cancer and possibly even improve survival in those who have the disease.
The body makes vitamin D after the skin absorbs some of the sun's rays.
You can also get vitamin D by consuming certain foods and beverages, such as milk and cereal, which have been fortified with the vitamin, but few foods naturally contain it.
For the current study, researchers looked at the link between blood levels of vitamin D as well as dietary vitamin D and calcium, and who was at risk for colorectal cancer. They based their findings on information from the European Prospective Investigation into Cancer Study (EPIC), a study of more than 520,000 people from 10 Western European countries. The study participants gave blood samples and completed detailed diet and lifestyle questionnaires between 1992 and 1998.
During the follow-up period, 1,248 patients were diagnosed with colorectal cancer. Researchers compared their lifestyle and diet backgrounds to the same number of healthy patients. They discovered that those with the highest blood levels of vitamin D had a nearly 40% decrease in colorectal cancer risk than those with the lowest levels.
However, the best way to boost your vitamin D level may be a matter of debate. As vitamin D's potential health benefits become more widely advertised, more people may advocate supplementation. However, the researchers say it's unclear if supplements are better at increasing blood levels of vitamin D than a balanced diet and moderate exposure to outdoor sunlight. They caution that the long-term effects of taking large doses of vitamin D supplements have not been well studied.
"Our findings suggest that the potential cancer risk benefits of higher vitamin D levels should be balanced with caution for the toxic potential," they write in today's online version of BMJ. "Before any public health recommendations can be made for vitamin D supplementation, new randomized trials are needed to test the hypothesis that increases in [blood levels of vitamin D] are effective in reducing colorectal cancer risk without inducing serious adverse events."
Colorectal cancer is the third most common cancer in men and women in the U.S., according to the American Cancer Society.
SOURCES:
News release, BMJ.
Jenab, M. BMJ, Jan. 20, 2010; vol 340.
American Cancer Society web site: "How Many People Get Colorectal Cancer."
National Institutes of Health web site: "Dietary Supplements: Vitamin D."
Consensus Guidelines for Psoriasis-Related Disease
From Medscape Rheumatology > Viewpoints
Kevin Deane, MD
Review data Treatment Recommendations for Psoriatic Arthritis
Ritchlin CT, Kavanaugh A, Gladman DD, et al; Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA)
Ann Rheum Dis. 2009;68:1387-1394
Study Summary
Treating the "heartbreak"* and "joint-ache" of psoriasis has become easier with the introduction of effective disease-modifying drugs such as methotrexate and leflunomide, and especially with the introduction of biological therapy such as anti-tumor necrosis factor (TNF)-alpha agents. However, given the wide range of literature on the diagnosis and treatment of psoriatic-associated conditions, it may be difficult for an individual clinician to know which treatments are best studied. These study authors reviewed the literature on the treatment of psoriatic conditions and made recommendations regarding the use of available therapies.
Members of the multinational Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) (including rheumatologists, dermatologists, and patients) reviewed the psoriasis literature and graded it according to criteria established by the Agency for Health Care Policy Research (AHCPR), with scores ranging from 1a and 1b (meta-analysis of randomized controlled trials [RCTs]) through 4 (expert committee/clinical experience). Next, on the basis of this literature review, subcommittees of GRAPPA members graded treatment recommendations regarding the 6 conditions related to psoriasis: peripheral arthritis, nail disease, spinal disease, skin disease, dactylitis, and enthesitis.
Grade A recommendations were based on evel 1a-1b evidence, with grade B recommendations based on 2a-2b evidence (1 or more controlled trials, no randomization, or other well-designed study). Finally, diagnostic and treatment recommendations were formed and sent in survey form to all members of GRAPPA, 70 of whom responded, and the level of agreement with the treatment recommendations was calculated.
Treatment options scored by GRAPPA as grade A for moderate-severe peripheral arthritis (with approximately 90% agreement) included: sulfasalazine, leflunomide, and TNF-alpha inhibitors. Of note, methotrexate was scored as grade B.
For psoriatic skin disease, phototherapy, methotrexate, TNF-alpha inhibitors, efalizumab, cyclosporine, leflunomide, and sulfasalazine were graded as A (approximately 69% agreement).
For spinal disease, nonsteroidal anti-inflammatory drugs (NSAIDs), physiotherapy, analgesia, sacroiliac joint injections, and TNF inhibitors were all grade A (approximately 86% agreement).
For enthesitis, TNF-alpha antagonists were graded A, with others, including NSAIDs and oral disease-modifying antirheumatic drugs, given a grade D (approximately 88% agreement).
Viewpoint
Consensus statements such as the one discussed here allow for an individual clinician to quickly review the available data and make diagnostic or treatment decisions based on expert review of the literature. These reviews are dependent on many factors, including: (1) the quality of literature review and expert panel evaluation; (2) the availability of good RCTs; and (3) timely updates. However, for a disease such as psoriasis, in which clinical manifestations are protean, and multiple types of physicians may care for patients, consensus statements such as this may be the best way to summarize large amounts of data for clinically useful recommendations.
*The term "heartbreak of psoriasis" originated with a 1960s advertising campaign for the coal-tar treatment Tegrin.
Abstract
Kevin Deane, MD
Review data Treatment Recommendations for Psoriatic Arthritis
Ritchlin CT, Kavanaugh A, Gladman DD, et al; Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA)
Ann Rheum Dis. 2009;68:1387-1394
Study Summary
Treating the "heartbreak"* and "joint-ache" of psoriasis has become easier with the introduction of effective disease-modifying drugs such as methotrexate and leflunomide, and especially with the introduction of biological therapy such as anti-tumor necrosis factor (TNF)-alpha agents. However, given the wide range of literature on the diagnosis and treatment of psoriatic-associated conditions, it may be difficult for an individual clinician to know which treatments are best studied. These study authors reviewed the literature on the treatment of psoriatic conditions and made recommendations regarding the use of available therapies.
Members of the multinational Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) (including rheumatologists, dermatologists, and patients) reviewed the psoriasis literature and graded it according to criteria established by the Agency for Health Care Policy Research (AHCPR), with scores ranging from 1a and 1b (meta-analysis of randomized controlled trials [RCTs]) through 4 (expert committee/clinical experience). Next, on the basis of this literature review, subcommittees of GRAPPA members graded treatment recommendations regarding the 6 conditions related to psoriasis: peripheral arthritis, nail disease, spinal disease, skin disease, dactylitis, and enthesitis.
Grade A recommendations were based on evel 1a-1b evidence, with grade B recommendations based on 2a-2b evidence (1 or more controlled trials, no randomization, or other well-designed study). Finally, diagnostic and treatment recommendations were formed and sent in survey form to all members of GRAPPA, 70 of whom responded, and the level of agreement with the treatment recommendations was calculated.
Treatment options scored by GRAPPA as grade A for moderate-severe peripheral arthritis (with approximately 90% agreement) included: sulfasalazine, leflunomide, and TNF-alpha inhibitors. Of note, methotrexate was scored as grade B.
For psoriatic skin disease, phototherapy, methotrexate, TNF-alpha inhibitors, efalizumab, cyclosporine, leflunomide, and sulfasalazine were graded as A (approximately 69% agreement).
For spinal disease, nonsteroidal anti-inflammatory drugs (NSAIDs), physiotherapy, analgesia, sacroiliac joint injections, and TNF inhibitors were all grade A (approximately 86% agreement).
For enthesitis, TNF-alpha antagonists were graded A, with others, including NSAIDs and oral disease-modifying antirheumatic drugs, given a grade D (approximately 88% agreement).
Viewpoint
Consensus statements such as the one discussed here allow for an individual clinician to quickly review the available data and make diagnostic or treatment decisions based on expert review of the literature. These reviews are dependent on many factors, including: (1) the quality of literature review and expert panel evaluation; (2) the availability of good RCTs; and (3) timely updates. However, for a disease such as psoriasis, in which clinical manifestations are protean, and multiple types of physicians may care for patients, consensus statements such as this may be the best way to summarize large amounts of data for clinically useful recommendations.
*The term "heartbreak of psoriasis" originated with a 1960s advertising campaign for the coal-tar treatment Tegrin.
Abstract
Guidance for Relief Workers and Others Traveling to Haiti for Earthquake Response
US Centers for Disease Control and Prevention
Posted: 01/20/2010
Editor's Note:
The following guidelines are provided by the US Centers for Disease Control and Prevention. They were last updated on January 16, 2010.
This notice is to advise relief workers and other personnel traveling to Haiti to assist with the humanitarian response following the January 12th earthquake near Port-au-Prince. Conditions in the area remain hazardous, including extensive damage to buildings, roads, and other infrastructure.
Before You Depart for Haiti
Recommended Vaccines
A number of vaccines are recommended for travelers to Haiti. See your doctor before you travel to make sure you have had all necessary vaccines.
Routine. Be sure that you are up to date on vaccines such as measles/mumps/rubella (MMR), diphtheria/pertussis/tetanus (DPT), polio, seasonal and H1N1 flu, and varicella. It is especially important to have a current tetanus shot.
Hepatitis A or immune globulin (IG). Even if your departure is imminent, one dose of hepatitis A vaccine provides adequate short-term protection for healthy people. For long-term protection, a second dose is required 6-18 months after the first dose, depending on the brand of vaccine used.
Typhoid. There are 2 vaccines available for typhoid prevention. The injectable vaccine may be preferable to the oral vaccine in cases where travel is imminent. The oral vaccine requires refrigeration and 4 tablets taken every other day over one week.
Hepatitis B. If your departure is imminent, the first in a 3-dose series (day 0, 1 month and 6 months) may provide some protection. An accelerated dosing schedule may be used (doses at days 0, 7, and at 21-30 days with a booster at 12 months).
Insect-borne Diseases
Malaria
Malaria occurs in all parts of Haiti. Ways to prevent malaria include the following:
Taking a prescription antimalarial drug
Using insect repellent and wearing long pants and sleeves to prevent mosquito bites
Sleeping in air-conditioned or well-screened rooms or using bed nets.
No antimalarial drug is 100% protective, so it is important to use all three ways to prevent malaria.
All of the following antimalarial drugs are equal options for preventing malaria in Haiti: atovaquone/proguanil (Malarone®), chloroquine, doxycycline, or mefloquine. Each drug has its own side effects, contraindications, and precautions. You will need to talk to your doctor to decide which of these drugs would be best for you, depending on your current health, medical history, drug allergies, and specific needs. Additional information can be found on the Drugs to Prevent Malaria page.
Malaria is always a serious disease and may be a deadly illness. If you become ill with a fever or flu-like illness either while in Haiti or after you return home (for up to 1 year), you should seek immediate medical attention and should tell the doctor that you have recently been in Haiti.
Dengue
Dengue is a common infection in Haiti. Dengue is a disease caused by a virus transmitted to people by the bite of an infected mosquito. Some important information to know about dengue as you travel to Haiti:
No vaccine or medications are available to prevent dengue.
The best way to reduce your risk of dengue is to protect yourself from mosquito bites (see the section below called "Protection Against Insects and Animals").
The mosquitoes that spread dengue usually bite at dusk and dawn but may bite at any time during the day.
Symptoms and signs are high fever, chills, headache and muscle pain. Additionally, a faint rash on the trunk and upper arms may appear on the second to third day of illness.
There are no specific medicines to treat dengue, so treatment is supportive with fever-reducing medicines and fluids.
You can help control mosquito populations by draining all standing water that you find in open containers left outdoors.
If you are in the Dominican Republic awaiting entry into Haiti, be aware that dengue is also common there.
Other Infectious Diseases
HIV
Haiti has a high prevalence of HIV infection. To reduce the risk of HIV and other sexually transmitted diseases, always use latex condoms. Healthcare workers should also take the following additional precautions:
Wear gloves for touching blood and body fluids, mucous membranes, or broken skin and for handling items or surfaces soiled with blood or body fluids.
Use masks and protective eyewear or face shields to prevent exposure of the mouth, nose, and eyes during procedures that are likely to generate droplets of blood or body fluids.
Wear gowns or aprons during procedures that are likely to generate splashes of blood
Tuberculosis (TB)
Rates of tuberculosis are very high in Haiti.
If you anticipate giving medical care or working closely with ill or injured victims, a tuberculin skin test (ideally, a two-step test) is recommended prior to travel and then 6-8 weeks after return.
If exposure to known TB patients will occur, traveling with personal respiratory protective devices (e.g., N-95 respirators), along with training, is recommended.
Anthrax
Anthrax occurs in Haiti and is primarily transmitted by direct contact with infected animals or with contaminated products from infected animals. Cases of cutaneous and inhalation anthrax have been reported among the local population.
Symptoms of anthrax can occur within 7 days of infection. Symptoms include: fever (>100° F) and chills or night sweats; cough; chest discomfort; shortness of breath; fatigue; muscle aches; sore throat followed by difficulty swallowing; enlarged lymph nodes; headache; nausea; loss of appetite; abdominal discomfort, vomiting, or diarrhea; a sore, especially on your face, arms, or hands that starts as a raised bump and develops into a painless ulcer with a black area in the center.
If you develop any of these symptoms, see a healthcare provider immediately.
Key Items to Bring
There will be almost no infrastructure support available in Haiti for the immediate future. Relief workers, volunteers, and other travelers will need to be self-sufficient.
Pack basic supplies, including:
Food and water sufficient for the length of your stay.
Insect protection: insect repellent and a bed net.
Medications: antimalarial pills, medications for the treatment of travelers' diarrhea (e.g., loperamide and an antibiotic), personal prescriptions (including extras), any preferred over-the-counter medications, and copies of all your prescriptions.
An extra set of prescription eyeglasses and/or contacts.
Water purification tablets (iodine or chlorine), bleach, or a water purifier.
Persons with pre-existing health conditions should consider wearing an alert-bracelet and make sure this information is on a contact card in their wallet or travel documents. A contact card should include the following information:
Name and contact information of U.S. family member or close contact.
Name and contact information of U.S. health-care provider.
Pre-existing health conditions and treatment.
Personal protective equipment (PPE): safety glasses or goggles, work boots, leather gloves for physical labor, rubber gloves for handling blood or body fluids, surgical masks, hard hat, ear plugs, N-95 respirators for those who are fit-tested.
Due to severe damage to health facilities and shortages of medical supplies, carry a first aid kit for your own protection. Minimum suggested contents:
Bandages (roller, adhesive, triangular)
Sterile gauze pads
Disposable gloves
Scissors
Tweezers
Cold compress
Antiseptic wipes
Antibiotic ointment
Hydrocortisone ointment
Commercial suture/syringe kits to be used by a local health-care provider. These items will require a letter from the prescribing physician on letterhead stationery. Pack these items in checked baggage, since they may be considered sharp objects and confiscated by airport or airline security if packed in carry-on bags.
While in Haiti
Wash your hands often with soap and clean water or use an alcohol-based hand cleaner (with at least 60% alcohol). Clean your hands especially before you eat or prepare food.
Safe Food and Drinks
Eat foods that are packaged or that are freshly cooked and served hot.
Do not eat raw and undercooked meats and seafood or unpeeled fruits and vegetables.
Drink only bottled, boiled, or chemically treated water and bottled or canned carbonated beverages. When using bottled drinks, make sure that the seal has not been broken.
Avoid tap water, fountain drinks, and ice cubes.
To disinfect your own water: boil for 1 minute or filter the water and add 2 drops of household bleach or 1/2 an iodine tablet per liter of water.
Use bottled, boiled, or chemically treated water to wash dishes, brush your teeth, wash and prepare food, or make ice.
Protection Against Insects and Animals
Insects. Insect-borne diseases such as malaria and dengue are risks in Haiti. Prevent insect bites by:
Using insect repellent (bug spray) that contains one of the following active ingredients: DEET, picaridin (KBR 3023), Oil of Lemon Eucalyptus/PMD, or IR3535. Always follow the instructions on the label when you use the repellent.
In general, repellents protect longer against mosquito bites when they have a higher concentration (percentage) of the active ingredient. However, concentrations above 50% do not offer a marked increase in protection time. Products with less than 10% of an active ingredient may offer only limited protection, often no longer than 1-2 hours.
Wearing lightweight long-sleeved shirts, long pants, and a hat outdoors. For greater protection, clothing may also be sprayed with repellent containing permethrin or another EPA-registered repellent. (Remember: don't use permethrin on skin.)
Remaining indoors in a screened area or using insect repellent frequently on uncovered skin during the peak biting period for malaria (dusk and dawn) and dengue (any time of day).
Sleeping in beds covered by a bed net (preferably treated with permethrin), if not sleeping in an air-conditioned or well-screened room.
Spraying rooms with products effective against flying insects, such as those containing pyrethroid.
For detailed information about insect repellent use, see Insect and Arthropod Protection.
Animals. Direct contact with animals can spread diseases like rabies or cause serious injury or illness. Displaced animals may revert to the wild and go about in packs. They will also be hungry and may be searching for food and may be more likely to bite. It is important to prevent animal bites and scratches:
Stay away from all animals, including dogs and cats. Even animals that look like healthy pets can have rabies or other diseases.
If you are bitten or scratched, wash the wound well with soap and clean water and seek medical care right away. If you have a povidone-iodine solution (such as Betadine®), use that to clean the wound after washing it.
Resist the urge to rescue animals with the intent to bring them home to the United States. Dogs and cats may be infected with rabies but not show signs until several days or weeks after you first encounter them.
After you return from Haiti, be sure to tell your doctor or state health department if you were bitten or scratched during travel.
For more information about how to protect yourself from other risks related to animals, see Animal-Associated Hazards. To learn more about rabies see CDC's Rabies homepage.
Injury
The risk of injury after an earthquake is high. Hazards such as electrocution from downed power lines and structural damage to buildings and roads all pose a risk. Accidents and violence are documented risks for humanitarian workers and cause more deaths than disease and natural causes.
The majority of the road network in Haiti is not paved. Haiti is predominately mountainous and has extensive deforestation and soil erosion, making travel over roadways especially hazardous. Exercise extreme care when traveling on roads particularly in rural areas.
There has been extensive structural damage to buildings in Haiti. Avoid unstable structures if possible.
Other potential hazards to be aware of in collapsed buildings include standing water from water system breaks, natural gas leaks, airborne smoke and dusk, hazardous materials such as ammonia or leaking fuels, exposure to germs from sewer line breaks, and exposed wiring.
Use personal protection equipment, such as hard hats and steel-toed boots, if in areas with damaged buildings.
Exposure to Human Remains
Human remains may contain blood-borne viruses and diarrhea-causing bacteria. Relief workers who are handling remains should take precautions to avoid being exposed to these organisms:
Protect your face from splashes of body fluids and fecal material by using a plastic face shield or a combination of eye protection and surgical mask. In extreme situations, a cloth tied over the nose and mouth can be used to block splashes.
Protect your hands from direct contact with body fluids and from injuries that break the skin by using a combination of a cut-proof inner layer glove and a latex (or similar) outer layer.
Wash your hands with soap and water or with an alcohol-based hand cleaner immediately after you remove the gloves.
Protect your feet and ankles against sharp debris by wearing foot wear that covers the entire foot and has thick soles.
Give prompt care -- including immediate cleansing with soap and water, and a tetanus booster if indicated -- to anyone who is injured during work with human remains.
For more extensive information about working with human remains after a disaster, see the Interim Health Recommendations for Workers who Handle Human Remains After a Disaster fact sheet.
Posted: 01/20/2010
Editor's Note:
The following guidelines are provided by the US Centers for Disease Control and Prevention. They were last updated on January 16, 2010.
This notice is to advise relief workers and other personnel traveling to Haiti to assist with the humanitarian response following the January 12th earthquake near Port-au-Prince. Conditions in the area remain hazardous, including extensive damage to buildings, roads, and other infrastructure.
Before You Depart for Haiti
Recommended Vaccines
A number of vaccines are recommended for travelers to Haiti. See your doctor before you travel to make sure you have had all necessary vaccines.
Routine. Be sure that you are up to date on vaccines such as measles/mumps/rubella (MMR), diphtheria/pertussis/tetanus (DPT), polio, seasonal and H1N1 flu, and varicella. It is especially important to have a current tetanus shot.
Hepatitis A or immune globulin (IG). Even if your departure is imminent, one dose of hepatitis A vaccine provides adequate short-term protection for healthy people. For long-term protection, a second dose is required 6-18 months after the first dose, depending on the brand of vaccine used.
Typhoid. There are 2 vaccines available for typhoid prevention. The injectable vaccine may be preferable to the oral vaccine in cases where travel is imminent. The oral vaccine requires refrigeration and 4 tablets taken every other day over one week.
Hepatitis B. If your departure is imminent, the first in a 3-dose series (day 0, 1 month and 6 months) may provide some protection. An accelerated dosing schedule may be used (doses at days 0, 7, and at 21-30 days with a booster at 12 months).
Insect-borne Diseases
Malaria
Malaria occurs in all parts of Haiti. Ways to prevent malaria include the following:
Taking a prescription antimalarial drug
Using insect repellent and wearing long pants and sleeves to prevent mosquito bites
Sleeping in air-conditioned or well-screened rooms or using bed nets.
No antimalarial drug is 100% protective, so it is important to use all three ways to prevent malaria.
All of the following antimalarial drugs are equal options for preventing malaria in Haiti: atovaquone/proguanil (Malarone®), chloroquine, doxycycline, or mefloquine. Each drug has its own side effects, contraindications, and precautions. You will need to talk to your doctor to decide which of these drugs would be best for you, depending on your current health, medical history, drug allergies, and specific needs. Additional information can be found on the Drugs to Prevent Malaria page.
Malaria is always a serious disease and may be a deadly illness. If you become ill with a fever or flu-like illness either while in Haiti or after you return home (for up to 1 year), you should seek immediate medical attention and should tell the doctor that you have recently been in Haiti.
Dengue
Dengue is a common infection in Haiti. Dengue is a disease caused by a virus transmitted to people by the bite of an infected mosquito. Some important information to know about dengue as you travel to Haiti:
No vaccine or medications are available to prevent dengue.
The best way to reduce your risk of dengue is to protect yourself from mosquito bites (see the section below called "Protection Against Insects and Animals").
The mosquitoes that spread dengue usually bite at dusk and dawn but may bite at any time during the day.
Symptoms and signs are high fever, chills, headache and muscle pain. Additionally, a faint rash on the trunk and upper arms may appear on the second to third day of illness.
There are no specific medicines to treat dengue, so treatment is supportive with fever-reducing medicines and fluids.
You can help control mosquito populations by draining all standing water that you find in open containers left outdoors.
If you are in the Dominican Republic awaiting entry into Haiti, be aware that dengue is also common there.
Other Infectious Diseases
HIV
Haiti has a high prevalence of HIV infection. To reduce the risk of HIV and other sexually transmitted diseases, always use latex condoms. Healthcare workers should also take the following additional precautions:
Wear gloves for touching blood and body fluids, mucous membranes, or broken skin and for handling items or surfaces soiled with blood or body fluids.
Use masks and protective eyewear or face shields to prevent exposure of the mouth, nose, and eyes during procedures that are likely to generate droplets of blood or body fluids.
Wear gowns or aprons during procedures that are likely to generate splashes of blood
Tuberculosis (TB)
Rates of tuberculosis are very high in Haiti.
If you anticipate giving medical care or working closely with ill or injured victims, a tuberculin skin test (ideally, a two-step test) is recommended prior to travel and then 6-8 weeks after return.
If exposure to known TB patients will occur, traveling with personal respiratory protective devices (e.g., N-95 respirators), along with training, is recommended.
Anthrax
Anthrax occurs in Haiti and is primarily transmitted by direct contact with infected animals or with contaminated products from infected animals. Cases of cutaneous and inhalation anthrax have been reported among the local population.
Symptoms of anthrax can occur within 7 days of infection. Symptoms include: fever (>100° F) and chills or night sweats; cough; chest discomfort; shortness of breath; fatigue; muscle aches; sore throat followed by difficulty swallowing; enlarged lymph nodes; headache; nausea; loss of appetite; abdominal discomfort, vomiting, or diarrhea; a sore, especially on your face, arms, or hands that starts as a raised bump and develops into a painless ulcer with a black area in the center.
If you develop any of these symptoms, see a healthcare provider immediately.
Key Items to Bring
There will be almost no infrastructure support available in Haiti for the immediate future. Relief workers, volunteers, and other travelers will need to be self-sufficient.
Pack basic supplies, including:
Food and water sufficient for the length of your stay.
Insect protection: insect repellent and a bed net.
Medications: antimalarial pills, medications for the treatment of travelers' diarrhea (e.g., loperamide and an antibiotic), personal prescriptions (including extras), any preferred over-the-counter medications, and copies of all your prescriptions.
An extra set of prescription eyeglasses and/or contacts.
Water purification tablets (iodine or chlorine), bleach, or a water purifier.
Persons with pre-existing health conditions should consider wearing an alert-bracelet and make sure this information is on a contact card in their wallet or travel documents. A contact card should include the following information:
Name and contact information of U.S. family member or close contact.
Name and contact information of U.S. health-care provider.
Pre-existing health conditions and treatment.
Personal protective equipment (PPE): safety glasses or goggles, work boots, leather gloves for physical labor, rubber gloves for handling blood or body fluids, surgical masks, hard hat, ear plugs, N-95 respirators for those who are fit-tested.
Due to severe damage to health facilities and shortages of medical supplies, carry a first aid kit for your own protection. Minimum suggested contents:
Bandages (roller, adhesive, triangular)
Sterile gauze pads
Disposable gloves
Scissors
Tweezers
Cold compress
Antiseptic wipes
Antibiotic ointment
Hydrocortisone ointment
Commercial suture/syringe kits to be used by a local health-care provider. These items will require a letter from the prescribing physician on letterhead stationery. Pack these items in checked baggage, since they may be considered sharp objects and confiscated by airport or airline security if packed in carry-on bags.
While in Haiti
Wash your hands often with soap and clean water or use an alcohol-based hand cleaner (with at least 60% alcohol). Clean your hands especially before you eat or prepare food.
Safe Food and Drinks
Eat foods that are packaged or that are freshly cooked and served hot.
Do not eat raw and undercooked meats and seafood or unpeeled fruits and vegetables.
Drink only bottled, boiled, or chemically treated water and bottled or canned carbonated beverages. When using bottled drinks, make sure that the seal has not been broken.
Avoid tap water, fountain drinks, and ice cubes.
To disinfect your own water: boil for 1 minute or filter the water and add 2 drops of household bleach or 1/2 an iodine tablet per liter of water.
Use bottled, boiled, or chemically treated water to wash dishes, brush your teeth, wash and prepare food, or make ice.
Protection Against Insects and Animals
Insects. Insect-borne diseases such as malaria and dengue are risks in Haiti. Prevent insect bites by:
Using insect repellent (bug spray) that contains one of the following active ingredients: DEET, picaridin (KBR 3023), Oil of Lemon Eucalyptus/PMD, or IR3535. Always follow the instructions on the label when you use the repellent.
In general, repellents protect longer against mosquito bites when they have a higher concentration (percentage) of the active ingredient. However, concentrations above 50% do not offer a marked increase in protection time. Products with less than 10% of an active ingredient may offer only limited protection, often no longer than 1-2 hours.
Wearing lightweight long-sleeved shirts, long pants, and a hat outdoors. For greater protection, clothing may also be sprayed with repellent containing permethrin or another EPA-registered repellent. (Remember: don't use permethrin on skin.)
Remaining indoors in a screened area or using insect repellent frequently on uncovered skin during the peak biting period for malaria (dusk and dawn) and dengue (any time of day).
Sleeping in beds covered by a bed net (preferably treated with permethrin), if not sleeping in an air-conditioned or well-screened room.
Spraying rooms with products effective against flying insects, such as those containing pyrethroid.
For detailed information about insect repellent use, see Insect and Arthropod Protection.
Animals. Direct contact with animals can spread diseases like rabies or cause serious injury or illness. Displaced animals may revert to the wild and go about in packs. They will also be hungry and may be searching for food and may be more likely to bite. It is important to prevent animal bites and scratches:
Stay away from all animals, including dogs and cats. Even animals that look like healthy pets can have rabies or other diseases.
If you are bitten or scratched, wash the wound well with soap and clean water and seek medical care right away. If you have a povidone-iodine solution (such as Betadine®), use that to clean the wound after washing it.
Resist the urge to rescue animals with the intent to bring them home to the United States. Dogs and cats may be infected with rabies but not show signs until several days or weeks after you first encounter them.
After you return from Haiti, be sure to tell your doctor or state health department if you were bitten or scratched during travel.
For more information about how to protect yourself from other risks related to animals, see Animal-Associated Hazards. To learn more about rabies see CDC's Rabies homepage.
Injury
The risk of injury after an earthquake is high. Hazards such as electrocution from downed power lines and structural damage to buildings and roads all pose a risk. Accidents and violence are documented risks for humanitarian workers and cause more deaths than disease and natural causes.
The majority of the road network in Haiti is not paved. Haiti is predominately mountainous and has extensive deforestation and soil erosion, making travel over roadways especially hazardous. Exercise extreme care when traveling on roads particularly in rural areas.
There has been extensive structural damage to buildings in Haiti. Avoid unstable structures if possible.
Other potential hazards to be aware of in collapsed buildings include standing water from water system breaks, natural gas leaks, airborne smoke and dusk, hazardous materials such as ammonia or leaking fuels, exposure to germs from sewer line breaks, and exposed wiring.
Use personal protection equipment, such as hard hats and steel-toed boots, if in areas with damaged buildings.
Exposure to Human Remains
Human remains may contain blood-borne viruses and diarrhea-causing bacteria. Relief workers who are handling remains should take precautions to avoid being exposed to these organisms:
Protect your face from splashes of body fluids and fecal material by using a plastic face shield or a combination of eye protection and surgical mask. In extreme situations, a cloth tied over the nose and mouth can be used to block splashes.
Protect your hands from direct contact with body fluids and from injuries that break the skin by using a combination of a cut-proof inner layer glove and a latex (or similar) outer layer.
Wash your hands with soap and water or with an alcohol-based hand cleaner immediately after you remove the gloves.
Protect your feet and ankles against sharp debris by wearing foot wear that covers the entire foot and has thick soles.
Give prompt care -- including immediate cleansing with soap and water, and a tetanus booster if indicated -- to anyone who is injured during work with human remains.
For more extensive information about working with human remains after a disaster, see the Interim Health Recommendations for Workers who Handle Human Remains After a Disaster fact sheet.
Sunday, January 24, 2010
Flu Pandemic Remains Moderate, Easing in Areas: WHO
From Reuters Health Information
GENEVA (Reuters) Jan 18 - The H1N1 flu pandemic remains moderate and its effects are probably closer to those of 1957 and 1968 than the far more deadly 1918 version, the World Health Organisation (WHO) said on Monday.
Margaret Chan, WHO director-general, also said the H1N1 pandemic appeared to be easing in the northern hemisphere but could still cause infections until winter ends in April. It was too soon to say what would happen once the southern hemisphere enters winter and the virus becomes more infectious.
"An event similar to the 1918 pandemic was feared when what happened was probably closer to the 1957 or 1968 pandemics," Chan said in a speech opening a week-long meeting of the WHO's executive board.
The 1918 pandemic, known as the Spanish flu, swept around the world at the end of World War One, killing some 40-50 million people.
Governments have taken appropriate steps this time to protect their populations and will ultimately earn "the highest marks", said Chan, a former health director of Hong Kong. "Though the burden on emergency rooms and intensive care units has been heavy, nearly all health systems have coped well."
Populations should continue to be vaccinated, she added, reiterating that the vaccine was safe and effective.
In public health crises, it was better to "err on the side of caution", Chan said. "I believe we would all rather see a moderate pandemic with ample supplies of vaccine than a severe pandemic with inadequate vaccine."
Nearly 14,000 official deaths have been reported by more than 200 countries since the virus emerged in North America last April, but it will take at least 1-2 years after the pandemic ends to establish the true toll, she said.
WHO experts say the actual death rate could be much higher than the number of laboratory-confirmed cases so far.
Data on H1N1 outbreaks in Africa was scarce, she warned.
"We are concerned that some countries in the western part of the continent remain susceptible to intense waves of transmission," Chan said.
GENEVA (Reuters) Jan 18 - The H1N1 flu pandemic remains moderate and its effects are probably closer to those of 1957 and 1968 than the far more deadly 1918 version, the World Health Organisation (WHO) said on Monday.
Margaret Chan, WHO director-general, also said the H1N1 pandemic appeared to be easing in the northern hemisphere but could still cause infections until winter ends in April. It was too soon to say what would happen once the southern hemisphere enters winter and the virus becomes more infectious.
"An event similar to the 1918 pandemic was feared when what happened was probably closer to the 1957 or 1968 pandemics," Chan said in a speech opening a week-long meeting of the WHO's executive board.
The 1918 pandemic, known as the Spanish flu, swept around the world at the end of World War One, killing some 40-50 million people.
Governments have taken appropriate steps this time to protect their populations and will ultimately earn "the highest marks", said Chan, a former health director of Hong Kong. "Though the burden on emergency rooms and intensive care units has been heavy, nearly all health systems have coped well."
Populations should continue to be vaccinated, she added, reiterating that the vaccine was safe and effective.
In public health crises, it was better to "err on the side of caution", Chan said. "I believe we would all rather see a moderate pandemic with ample supplies of vaccine than a severe pandemic with inadequate vaccine."
Nearly 14,000 official deaths have been reported by more than 200 countries since the virus emerged in North America last April, but it will take at least 1-2 years after the pandemic ends to establish the true toll, she said.
WHO experts say the actual death rate could be much higher than the number of laboratory-confirmed cases so far.
Data on H1N1 outbreaks in Africa was scarce, she warned.
"We are concerned that some countries in the western part of the continent remain susceptible to intense waves of transmission," Chan said.
New Data Prompt Renewed Calls for Public-Health Initiative to Cut Salt in US Diet
From Heartwire
Lisa Nainggolan
January 21, 2010 (San Francisco, California)— New statistical projections suggest that slashing salt in the US diet by 3 g per day would have huge benefits, reducing the annual number of new cases of coronary heart disease, strokes, and MIs and potentially saving up to 90 000 lives a year. [1].
And even a more modest reduction of 1 g of salt per day would still have significant benefits, Dr Kirsten Bibbins-Domingo (University of California, San Francisco) and colleagues estimate in their paper published online January 20, 2010 in the New England Journal of Medicine. They call for urgent action in terms of a populationwide effort to reduce dietary salt in the US.
In an accompanying editorial [2], Drs Lawrence J Appel and Cheryl AM Anderson (Johns Hopkins University, Baltimore, MD) applaud the new research and say it extends the findings of other studies by demonstrating that such reductions in salt intake could be as beneficial as interventions aimed at smoking cessation, weight reduction, or the use of lipid-lowering medication.
The findings, along with other research, should spur efforts to swiftly implement a public-health approach to salt reduction in the US, they say. The US currently "lags behind many countries when it comes to translating this research into policies that achieve meaningful reductions in dietary salt," say Appel and Anderson. "As we deliberate healthcare reform, let us not neglect this inexpensive yet highly effective public-health intervention for the prevention of disease."
But Dr Michael Alderman (Albert Einstein College of Medicine, Bronx, NY), a well-known critic of policies to reduce salt intake at the population level, does not agree. He told heartwire that while this new study "seems to be a competent estimate of what might happen if BP were reduced--without other effects--based upon what we know from the clinical effects of antihypertensive medications, there is nothing new here but the hope that the effect on a single surrogate end point would translate into a remarkable reduction in morbidity and mortality." This, he says, would be "wonderful if true, but is still without adequate scientific foundation."
New Recommendations on Salt Expected Soon in US?
In their editorial, Appel and Anderson say that despite 40 years of consumer education in the US to try to get people to change their behavior and reduce salt intake, the per capita consumption appears to be increasing or is at best unchanged.
Anderson told heartwire in a recent interview that the situation is pressing: "People are not aware of how much salt they consume, and they are struggling to meet the recommendations." Much of this is due to "the ubiquitous nature of sodium in the food supply," she explains, with approximately 75% of dietary salt coming from processed foods.
As a result, there are currently many initiatives ongoing in the US to try to address the amount of salt added to the food supply. Underpinning these was a petition submitted to the FDA some time ago, to try to revoke its current designation of salt as a food additive "generally regarded as safe."
The agency subsequently held a public meeting, and the Institute of Medicine (IoM) was commissioned to issue a report, "Population-based strategies for reducing salt intake," which is due to come out this spring.
Anderson sits on the IoM panel discussing this issue, and while she says she can't reveal the contents of the upcoming report, "You can imagine there will be recommendations that might be quite different from the 40 years' experience that we have had, because excessive [salt] intake has continued to occur."
Findings Underscore the Need for an Urgent Call to Action
In their study, Bibbins-Domingo et al used the Coronary Heart Disease Policy Model to estimate the benefits of potentially achievable populationwide reductions in dietary salt of up to 3 g per day (1200 mg of sodium per day). Such a reduction would reduce the number of new cases of CHD by 60 000 to 120 000 per year, stroke cases by 32 000 to 66 000, and MIs by up to 99 000, as well as cutting all-cause mortality by almost 100 000, they calculate. This intervention could also save up to 392 000 quality-adjusted life-years and up to $24 billion in healthcare costs annually, they predict.
This postulated dietary reduction of 3 g of salt per day is within the range targeted by some developed countries that have already successfully adopted programs to reduce salt intake, they say.
But recognizing that a 3-g/day reduction may be difficult--given that mean salt intake in the US is extremely high and well above the current daily recommended upper limit of 5.8 g a day--even just a 1-g/day cut in salt intake would provide substantial health benefits and warrant implementation, the researchers note. Such a reduction, gradually achieved between 2010 and 2019, would still be more cost effective than using medications to lower BP in all those with hypertension, for example, they say.
"Lowering salt in the US diet would result in small but measurable reductions in blood pressure across the entire US population, thereby reducing rates of CVD among all adults at risk." In addition, salt reduction would be of proportionately greater benefit in certain subgroups, they note, such as African Americans, who have high rates of hypertension and CVD.
"Our findings underscore the need for an urgent call to action that will make it possible to achieve these readily attainable cardiovascular benefits," they conclude.
Modeling Relies on Assumptions; But Is Evidence Compelling or Not?
Appel and Anderson point out that a feature of the modeling by Bibbins-Domingo et al is "a series of linked assumptions--namely that salt reduction lowers blood pressure and that lowering blood pressure reduces the risk of stroke and CHD."
There is direct evidence of a link between salt and cardiovascular disease from some prospective observational studies and a few available trials with clinical outcomes that concern cardiovascular disease, they note.
"The evidence supporting the call to reduce salt intake as a means of preventing cardiovascular disease is compelling," they state. "There is also evidence that salt reduction may reduce the risk of gastric cancer, end-stage kidney disease, left ventricular hypertrophy, congestive heart failure, and osteoporosis," they add.
But Alderman begs to differ: "As I and others have pointed out, reducing dietary sodium has multiple effects." He says that, "disappointingly," both the editorial and paper "fail to note the complexity . . . the scientific issues involved, and the potential for unintended consequences."
The subject of reducing salt intake via societywide strategies will be probed in an upcoming feature on heartwire .
.
References
Lisa Nainggolan
January 21, 2010 (San Francisco, California)— New statistical projections suggest that slashing salt in the US diet by 3 g per day would have huge benefits, reducing the annual number of new cases of coronary heart disease, strokes, and MIs and potentially saving up to 90 000 lives a year. [1].
And even a more modest reduction of 1 g of salt per day would still have significant benefits, Dr Kirsten Bibbins-Domingo (University of California, San Francisco) and colleagues estimate in their paper published online January 20, 2010 in the New England Journal of Medicine. They call for urgent action in terms of a populationwide effort to reduce dietary salt in the US.
In an accompanying editorial [2], Drs Lawrence J Appel and Cheryl AM Anderson (Johns Hopkins University, Baltimore, MD) applaud the new research and say it extends the findings of other studies by demonstrating that such reductions in salt intake could be as beneficial as interventions aimed at smoking cessation, weight reduction, or the use of lipid-lowering medication.
The findings, along with other research, should spur efforts to swiftly implement a public-health approach to salt reduction in the US, they say. The US currently "lags behind many countries when it comes to translating this research into policies that achieve meaningful reductions in dietary salt," say Appel and Anderson. "As we deliberate healthcare reform, let us not neglect this inexpensive yet highly effective public-health intervention for the prevention of disease."
But Dr Michael Alderman (Albert Einstein College of Medicine, Bronx, NY), a well-known critic of policies to reduce salt intake at the population level, does not agree. He told heartwire that while this new study "seems to be a competent estimate of what might happen if BP were reduced--without other effects--based upon what we know from the clinical effects of antihypertensive medications, there is nothing new here but the hope that the effect on a single surrogate end point would translate into a remarkable reduction in morbidity and mortality." This, he says, would be "wonderful if true, but is still without adequate scientific foundation."
New Recommendations on Salt Expected Soon in US?
In their editorial, Appel and Anderson say that despite 40 years of consumer education in the US to try to get people to change their behavior and reduce salt intake, the per capita consumption appears to be increasing or is at best unchanged.
Anderson told heartwire in a recent interview that the situation is pressing: "People are not aware of how much salt they consume, and they are struggling to meet the recommendations." Much of this is due to "the ubiquitous nature of sodium in the food supply," she explains, with approximately 75% of dietary salt coming from processed foods.
As a result, there are currently many initiatives ongoing in the US to try to address the amount of salt added to the food supply. Underpinning these was a petition submitted to the FDA some time ago, to try to revoke its current designation of salt as a food additive "generally regarded as safe."
The agency subsequently held a public meeting, and the Institute of Medicine (IoM) was commissioned to issue a report, "Population-based strategies for reducing salt intake," which is due to come out this spring.
Anderson sits on the IoM panel discussing this issue, and while she says she can't reveal the contents of the upcoming report, "You can imagine there will be recommendations that might be quite different from the 40 years' experience that we have had, because excessive [salt] intake has continued to occur."
Findings Underscore the Need for an Urgent Call to Action
In their study, Bibbins-Domingo et al used the Coronary Heart Disease Policy Model to estimate the benefits of potentially achievable populationwide reductions in dietary salt of up to 3 g per day (1200 mg of sodium per day). Such a reduction would reduce the number of new cases of CHD by 60 000 to 120 000 per year, stroke cases by 32 000 to 66 000, and MIs by up to 99 000, as well as cutting all-cause mortality by almost 100 000, they calculate. This intervention could also save up to 392 000 quality-adjusted life-years and up to $24 billion in healthcare costs annually, they predict.
This postulated dietary reduction of 3 g of salt per day is within the range targeted by some developed countries that have already successfully adopted programs to reduce salt intake, they say.
But recognizing that a 3-g/day reduction may be difficult--given that mean salt intake in the US is extremely high and well above the current daily recommended upper limit of 5.8 g a day--even just a 1-g/day cut in salt intake would provide substantial health benefits and warrant implementation, the researchers note. Such a reduction, gradually achieved between 2010 and 2019, would still be more cost effective than using medications to lower BP in all those with hypertension, for example, they say.
"Lowering salt in the US diet would result in small but measurable reductions in blood pressure across the entire US population, thereby reducing rates of CVD among all adults at risk." In addition, salt reduction would be of proportionately greater benefit in certain subgroups, they note, such as African Americans, who have high rates of hypertension and CVD.
"Our findings underscore the need for an urgent call to action that will make it possible to achieve these readily attainable cardiovascular benefits," they conclude.
Modeling Relies on Assumptions; But Is Evidence Compelling or Not?
Appel and Anderson point out that a feature of the modeling by Bibbins-Domingo et al is "a series of linked assumptions--namely that salt reduction lowers blood pressure and that lowering blood pressure reduces the risk of stroke and CHD."
There is direct evidence of a link between salt and cardiovascular disease from some prospective observational studies and a few available trials with clinical outcomes that concern cardiovascular disease, they note.
"The evidence supporting the call to reduce salt intake as a means of preventing cardiovascular disease is compelling," they state. "There is also evidence that salt reduction may reduce the risk of gastric cancer, end-stage kidney disease, left ventricular hypertrophy, congestive heart failure, and osteoporosis," they add.
But Alderman begs to differ: "As I and others have pointed out, reducing dietary sodium has multiple effects." He says that, "disappointingly," both the editorial and paper "fail to note the complexity . . . the scientific issues involved, and the potential for unintended consequences."
The subject of reducing salt intake via societywide strategies will be probed in an upcoming feature on heartwire .
.
References
Friday, January 22, 2010
Blood Tests Promising for Early Detection of Cancers of pancreas and colon
From Medscape Medical News
Caroline Helwick
January 21, 2010 (Orlando, Florida) — Investigators reported promising results from 2 blood tests that could allow for the early detection of colorectal and pancreatic cancers here at the 2010 Gastrointestinal Cancers Symposium.
The annual meeting is cosponsored by the American Gastroenterological Association, the American Society of Clinical Oncology, the American Society for Radiation Oncology, and the Society of Surgical Oncology.
A team from Israel reported that a simple test for blood levels of the CD24 protein is more than 90% sensitive and specific for detecting colorectal cancer, and more than 80% accurate at identifying adenomas.
The CD24 protein is a cell-surface protein and P-selectin ligand that is involved in cell adhesion and metastasis, and has previously been associated with colorectal cancer (CRC) (Gastroenterology. 2006;131:630-639). The aim of the current study was to evaluate CD24 protein expression in peripheral blood lymphocytes (PBLs) from normal subjects and from subjects with CRC or adenomas.
"There is currently no serum-based test that is of sufficient sensitivity or specificity to be useful," said Sarah Kraus, PhD, who presented the findings. Dr. Kraus heads the research laboratory at Tel Aviv Souraski Medical Center in Israel.
"We found that serum CD24 is elevated in the majority of patients with CRC or adenomas. We believe a simple blood test that measures the level of CD24 in PBLs can successfully distinguish healthy subjects from those with neoplasia, and may serve as a biomarker for early detection and surveillance of CRC," she said at a press briefing.
In the study, 150 consecutive subjects underwent colonoscopy. PBLs were isolated from serum samples, and protein extracts were analyzed for these subjects. The same procedure was followed in a second validation trial of 73 consecutive subjects, for whom results were presented here.
CD24 protein levels proved to be sensitive and specific for distinguishing patients with no abnormal findings on colonoscopy from those with CRC and adenoma, Dr. Kraus reported. The protein levels were approximately 2000 OD/mm2 in normal subjects and 12,000 OD/mm2 in patients with either adenomas or cancer.
The sensitivity for the detection of CRC was 92.3% and for adenomas was 75.0%. The specificity for each, respectively, was 83.8% and 89.2%. In the analysis of both groups combined, sensitivity was 78.4% and specificity was 86.8%.
Pancreatic Cancer Also Detected Early
In another study, an immunoassay showed promise for detecting early-stage pancreatic cancer with a high degree of accuracy. The assay identifies and quantifies serum PAM4 protein, an antigen that is present in nearly 90% of pancreatic cancers but is not typically observed in association with benign lesions or other malignancies.
"We found that the PAM4 protein is quite accurate at identifying patients with pancreatic cancer and, if validated in larger studies, would be a promising tool for detecting the disease when our potentially curative procedures have a better chance for a good outcome," said David V. Gold, PhD, from the Garden State Cancer Center in Belleville, New Jersey. The study was done in collaboration with Johns Hopkins Medical Institutes in Baltimore, Maryland.
The PAM4 monoclonal antibody, also known as clivatuzumab, identifies a unique biomarker with a high specificity for a mucin glycoprotein expressed by pancreatic adenocarcinoma. The protein is not detectable in normal pancreatic cells or in cells of patients with chronic pancreatitis, a condition that can be otherwise hard to distinguish from cancer.
"The PAM4 test has the ability to detect PAM4 antigen in the blood, a protein produced by the tumor that may act as a marker, not only for diagnosis but for targeted therapies," Dr. Gold told media representatives.
The PAM4 enzyme immunoassay was performed on 68 patients who had undergone pancreatic surgery and 19 healthy controls. Its overall sensitivity for detecting pancreatic cancer was 81%; it has 62% sensitivity for detecting stage I pancreatic cancer, 86% sensitivity for stage II disease, and 91% sensitivity for stage III/IV disease, Dr. Gold reported.
"The PAM4 assay detected the overwhelming majority of patients with early-stage pancreatic cancer and 91% with late-stage disease," he said. "PAM4 is very specific for pancreatic cancer. It indicates a high possibility that a patient will have pancreatic cancer."
Dr. Gold predicted that the test will not be used for universal screening, but would best be applied to individuals suspected of having cancer or deemed to be at high risk for pancreatic cancer. This includes people with long-term chronic pancreatitis and diabetes, heavy smokers and drinkers, and those with a family history of hereditary forms of pancreatitis or pancreatic cancer, he said.
Both investigators indicated their assays are being further developed and might be clinically applicable within 2 to 3 years.
Robert Sticca, MD, professor of surgery at North Dakota School of Medicine and Health Sciences in Grand Forks, who moderated the press briefing, explained that these investigations are part of a larger research effort to develop tests that are highly accurate for detecting gastrointestinal cancers at an early stage.
"For pancreatic cancer, the medical profession has long struggled with the treatment of this disease, and these are very exciting data. If we had a test to detect it earlier, we would certainly do much better at managing it and preventing deaths," he said.
"The colorectal data are also preliminary, but if this test can be validated, it should be very beneficial in preventing deaths from this very common form of cancer."
The researchers have disclosed no relevant financial relationships.
2010 Gastrointestinal Cancers Symposium: Abstracts OP162 and 135. Presented January 22-24, 2010.
Caroline Helwick
January 21, 2010 (Orlando, Florida) — Investigators reported promising results from 2 blood tests that could allow for the early detection of colorectal and pancreatic cancers here at the 2010 Gastrointestinal Cancers Symposium.
The annual meeting is cosponsored by the American Gastroenterological Association, the American Society of Clinical Oncology, the American Society for Radiation Oncology, and the Society of Surgical Oncology.
A team from Israel reported that a simple test for blood levels of the CD24 protein is more than 90% sensitive and specific for detecting colorectal cancer, and more than 80% accurate at identifying adenomas.
The CD24 protein is a cell-surface protein and P-selectin ligand that is involved in cell adhesion and metastasis, and has previously been associated with colorectal cancer (CRC) (Gastroenterology. 2006;131:630-639). The aim of the current study was to evaluate CD24 protein expression in peripheral blood lymphocytes (PBLs) from normal subjects and from subjects with CRC or adenomas.
"There is currently no serum-based test that is of sufficient sensitivity or specificity to be useful," said Sarah Kraus, PhD, who presented the findings. Dr. Kraus heads the research laboratory at Tel Aviv Souraski Medical Center in Israel.
"We found that serum CD24 is elevated in the majority of patients with CRC or adenomas. We believe a simple blood test that measures the level of CD24 in PBLs can successfully distinguish healthy subjects from those with neoplasia, and may serve as a biomarker for early detection and surveillance of CRC," she said at a press briefing.
In the study, 150 consecutive subjects underwent colonoscopy. PBLs were isolated from serum samples, and protein extracts were analyzed for these subjects. The same procedure was followed in a second validation trial of 73 consecutive subjects, for whom results were presented here.
CD24 protein levels proved to be sensitive and specific for distinguishing patients with no abnormal findings on colonoscopy from those with CRC and adenoma, Dr. Kraus reported. The protein levels were approximately 2000 OD/mm2 in normal subjects and 12,000 OD/mm2 in patients with either adenomas or cancer.
The sensitivity for the detection of CRC was 92.3% and for adenomas was 75.0%. The specificity for each, respectively, was 83.8% and 89.2%. In the analysis of both groups combined, sensitivity was 78.4% and specificity was 86.8%.
Pancreatic Cancer Also Detected Early
In another study, an immunoassay showed promise for detecting early-stage pancreatic cancer with a high degree of accuracy. The assay identifies and quantifies serum PAM4 protein, an antigen that is present in nearly 90% of pancreatic cancers but is not typically observed in association with benign lesions or other malignancies.
"We found that the PAM4 protein is quite accurate at identifying patients with pancreatic cancer and, if validated in larger studies, would be a promising tool for detecting the disease when our potentially curative procedures have a better chance for a good outcome," said David V. Gold, PhD, from the Garden State Cancer Center in Belleville, New Jersey. The study was done in collaboration with Johns Hopkins Medical Institutes in Baltimore, Maryland.
The PAM4 monoclonal antibody, also known as clivatuzumab, identifies a unique biomarker with a high specificity for a mucin glycoprotein expressed by pancreatic adenocarcinoma. The protein is not detectable in normal pancreatic cells or in cells of patients with chronic pancreatitis, a condition that can be otherwise hard to distinguish from cancer.
"The PAM4 test has the ability to detect PAM4 antigen in the blood, a protein produced by the tumor that may act as a marker, not only for diagnosis but for targeted therapies," Dr. Gold told media representatives.
The PAM4 enzyme immunoassay was performed on 68 patients who had undergone pancreatic surgery and 19 healthy controls. Its overall sensitivity for detecting pancreatic cancer was 81%; it has 62% sensitivity for detecting stage I pancreatic cancer, 86% sensitivity for stage II disease, and 91% sensitivity for stage III/IV disease, Dr. Gold reported.
"The PAM4 assay detected the overwhelming majority of patients with early-stage pancreatic cancer and 91% with late-stage disease," he said. "PAM4 is very specific for pancreatic cancer. It indicates a high possibility that a patient will have pancreatic cancer."
Dr. Gold predicted that the test will not be used for universal screening, but would best be applied to individuals suspected of having cancer or deemed to be at high risk for pancreatic cancer. This includes people with long-term chronic pancreatitis and diabetes, heavy smokers and drinkers, and those with a family history of hereditary forms of pancreatitis or pancreatic cancer, he said.
Both investigators indicated their assays are being further developed and might be clinically applicable within 2 to 3 years.
Robert Sticca, MD, professor of surgery at North Dakota School of Medicine and Health Sciences in Grand Forks, who moderated the press briefing, explained that these investigations are part of a larger research effort to develop tests that are highly accurate for detecting gastrointestinal cancers at an early stage.
"For pancreatic cancer, the medical profession has long struggled with the treatment of this disease, and these are very exciting data. If we had a test to detect it earlier, we would certainly do much better at managing it and preventing deaths," he said.
"The colorectal data are also preliminary, but if this test can be validated, it should be very beneficial in preventing deaths from this very common form of cancer."
The researchers have disclosed no relevant financial relationships.
2010 Gastrointestinal Cancers Symposium: Abstracts OP162 and 135. Presented January 22-24, 2010.
Red Yeast Rice Comparable to Pravastatin for Statin-Intolerant Patients
From Heartwire
Michael O'Riordan
January 21, 2010 (Philadelphia, Pennsylvania) — Red-yeast-rice extract is as well tolerated as pravastatin in patients who previously developed a statin-associated myalgia and withdrew from therapy, research shows [1]. Withdrawals from the red-yeast-rice and pravastatin treatment arms were low; and both groups achieved comparable reductions in LDL-cholesterol levels, report researchers.
"Statin-associated myalgia is an important clinical problem that will likely become more prevalent owing to the ever-expanding indications for statin use," write lead author Dr Steven Halbert (University of Pennsylvania School of Medicine, Philadelphia, PA) and colleagues in the January 15, 2010 issue of the American Journal of Cardiology. "Although no definitive conclusions could be drawn, our data showed that red yeast rice was as well tolerated as pravastatin and achieved clinically significant levels of LDL-cholesterol reduction in a population with previous statin intolerance."
Halbert, along with senior author Dr David Becker (University of Pennsylvania Health System, Philadelphia, PA), previously showed that red yeast rice and a therapeutic lifestyle change significantly reduced LDL-cholesterol levels in statin-intolerant patients with dyslipidemia. As Becker told heartwire at the time, red yeast rice, if properly regulated to control for potential contaminants and regulate consistency between different manufacturers, might represent an option for these difficult-to-treat patients.
Dr Richard Karas (Tufts Medical Center, Boston, MA), who was not part of the study, said that in the real world, statin-associated myopathy is a common and difficult problem for clinicians.
"One of the reasons is that having aches and pains is extremely common in older people," Karas told heartwire . "That circle then intersects with the circle of a lot of older people treated with statins. We don't have a specific test to identify whether a patient is achy because of their statin or because they're older. It's often very difficult for a physician to determine whether that statin should be stopped."
Lovastatin in Certain Types of Red Yeast Rice
In this latest study, Halbert and colleagues wanted to test the tolerability of red yeast rice 2400 mg twice daily in patients who previously discontinued at least one statin, other than pravastatin, because of muscle pain. Extracts of red yeast rice have been widely used in China for therapy in patients with circulatory and digestive disorders for centuries, and preparations of red yeast rice have been shown to lower plasma LDL levels. Lovastatin occurs naturally in certain forms of red yeast rice that are made when the rice is cultivated with the mold Monascus purpureus.
In total, 43 adults with dyslipidemia and a history of discontinuing statins were randomized to red yeast rice or pravastatin 20 mg twice daily for 12 weeks. In addition to the active treatment, patients were also concomitantly enrolled in a 12-week therapeutic lifestyle-change program that emphasized improved nutrition, regular exercise, and relaxation techniques.
After 12 weeks of treatment, red yeast rice reduced LDL-cholesterol levels 30% from baseline, from 181 mg/dL to 126 mg/dL, while pravastatin reduced LDL-cholesterol levels 27%, a nonstatistical difference between treatments. Similarly, there were no significant differences observed in changes in total cholesterol, triglycerides, or HDL-cholesterol levels.
Changes in Lipid Measures From Baseline Treatment Total cholesterol (mg/dL) LDL cholesterol (mg/dL) Triglycerides (mg/dL)
Red yeast rice
Baseline 260.7 181.2 142.2
12 wk 200.9 126.1 120.9
Mean percentage change -23.0 -30.2 -7.8
Pravastatin
Baseline 253.4 163.6 148.4
12 wk 198.6 120.3 126.1
Mean percentage change -19.6 -27.0 -7.0
Regarding the primary end point, the incidence of treatment discontinuation because of myalgia, both red yeast rice and pravastatin were equivalent. In the red-yeast-rice arm, one patient of 21 (5%) withdrew because of muscle pain, while two patients of 22 (9%) withdrew in the pravastatin arm. Also, there were no reported differences in the mean pain severity scores with the two treatments.
Halbert and colleagues note that both groups had low rates of recurrent myalgia and that they were unable to show an advantage with red yeast rice compared with pravastatin. They suggest that their initial power calculations, which used the published 50% myalgia recurrence rate for statins, might have been too high. Also, pravastatin, which has hydrophilic properties, might have a lower recurrence rate than other statins, and the 40-mg dose might have been low enough to be well tolerated.
Speaking with heartwire , Karas praised the investigators for attempting to provide efficacy data on a supplement that is used by a large number of people in the US to treat their own LDL-cholesterol levels.
Like Becker, however, he cautioned that red yeast rice, despite the tolerability shown in this trial and despite how difficult it is to treat these patients, is not regulated by the Food and Drug Administration, leading to a lack of consistency from manufacturer to manufacturer. His own preference in treating statin-intolerant patients referred to him is to initiate a long washout of the statin, typically three months, to identify whether the aches and pains are common without the drug, and if so, to try again with a different statin.
"I think the impact of the study is a little difficult to know because basically what they showed was that red yeast rice was as safe as pravastatin," said Karas. "But I think you could interpret that as saying that the vast majority of patients they studied did fine on pravastatin. So the finding isn't really a strengthening of the validity of using red yeast rice as much as saying that, at least in this population-based study, you're perfectly fine putting them on pravastatin, which is a well-controlled, well-regulated product that we have extensive experience with."
References
Michael O'Riordan
January 21, 2010 (Philadelphia, Pennsylvania) — Red-yeast-rice extract is as well tolerated as pravastatin in patients who previously developed a statin-associated myalgia and withdrew from therapy, research shows [1]. Withdrawals from the red-yeast-rice and pravastatin treatment arms were low; and both groups achieved comparable reductions in LDL-cholesterol levels, report researchers.
"Statin-associated myalgia is an important clinical problem that will likely become more prevalent owing to the ever-expanding indications for statin use," write lead author Dr Steven Halbert (University of Pennsylvania School of Medicine, Philadelphia, PA) and colleagues in the January 15, 2010 issue of the American Journal of Cardiology. "Although no definitive conclusions could be drawn, our data showed that red yeast rice was as well tolerated as pravastatin and achieved clinically significant levels of LDL-cholesterol reduction in a population with previous statin intolerance."
Halbert, along with senior author Dr David Becker (University of Pennsylvania Health System, Philadelphia, PA), previously showed that red yeast rice and a therapeutic lifestyle change significantly reduced LDL-cholesterol levels in statin-intolerant patients with dyslipidemia. As Becker told heartwire at the time, red yeast rice, if properly regulated to control for potential contaminants and regulate consistency between different manufacturers, might represent an option for these difficult-to-treat patients.
Dr Richard Karas (Tufts Medical Center, Boston, MA), who was not part of the study, said that in the real world, statin-associated myopathy is a common and difficult problem for clinicians.
"One of the reasons is that having aches and pains is extremely common in older people," Karas told heartwire . "That circle then intersects with the circle of a lot of older people treated with statins. We don't have a specific test to identify whether a patient is achy because of their statin or because they're older. It's often very difficult for a physician to determine whether that statin should be stopped."
Lovastatin in Certain Types of Red Yeast Rice
In this latest study, Halbert and colleagues wanted to test the tolerability of red yeast rice 2400 mg twice daily in patients who previously discontinued at least one statin, other than pravastatin, because of muscle pain. Extracts of red yeast rice have been widely used in China for therapy in patients with circulatory and digestive disorders for centuries, and preparations of red yeast rice have been shown to lower plasma LDL levels. Lovastatin occurs naturally in certain forms of red yeast rice that are made when the rice is cultivated with the mold Monascus purpureus.
In total, 43 adults with dyslipidemia and a history of discontinuing statins were randomized to red yeast rice or pravastatin 20 mg twice daily for 12 weeks. In addition to the active treatment, patients were also concomitantly enrolled in a 12-week therapeutic lifestyle-change program that emphasized improved nutrition, regular exercise, and relaxation techniques.
After 12 weeks of treatment, red yeast rice reduced LDL-cholesterol levels 30% from baseline, from 181 mg/dL to 126 mg/dL, while pravastatin reduced LDL-cholesterol levels 27%, a nonstatistical difference between treatments. Similarly, there were no significant differences observed in changes in total cholesterol, triglycerides, or HDL-cholesterol levels.
Changes in Lipid Measures From Baseline Treatment Total cholesterol (mg/dL) LDL cholesterol (mg/dL) Triglycerides (mg/dL)
Red yeast rice
Baseline 260.7 181.2 142.2
12 wk 200.9 126.1 120.9
Mean percentage change -23.0 -30.2 -7.8
Pravastatin
Baseline 253.4 163.6 148.4
12 wk 198.6 120.3 126.1
Mean percentage change -19.6 -27.0 -7.0
Regarding the primary end point, the incidence of treatment discontinuation because of myalgia, both red yeast rice and pravastatin were equivalent. In the red-yeast-rice arm, one patient of 21 (5%) withdrew because of muscle pain, while two patients of 22 (9%) withdrew in the pravastatin arm. Also, there were no reported differences in the mean pain severity scores with the two treatments.
Halbert and colleagues note that both groups had low rates of recurrent myalgia and that they were unable to show an advantage with red yeast rice compared with pravastatin. They suggest that their initial power calculations, which used the published 50% myalgia recurrence rate for statins, might have been too high. Also, pravastatin, which has hydrophilic properties, might have a lower recurrence rate than other statins, and the 40-mg dose might have been low enough to be well tolerated.
Speaking with heartwire , Karas praised the investigators for attempting to provide efficacy data on a supplement that is used by a large number of people in the US to treat their own LDL-cholesterol levels.
Like Becker, however, he cautioned that red yeast rice, despite the tolerability shown in this trial and despite how difficult it is to treat these patients, is not regulated by the Food and Drug Administration, leading to a lack of consistency from manufacturer to manufacturer. His own preference in treating statin-intolerant patients referred to him is to initiate a long washout of the statin, typically three months, to identify whether the aches and pains are common without the drug, and if so, to try again with a different statin.
"I think the impact of the study is a little difficult to know because basically what they showed was that red yeast rice was as safe as pravastatin," said Karas. "But I think you could interpret that as saying that the vast majority of patients they studied did fine on pravastatin. So the finding isn't really a strengthening of the validity of using red yeast rice as much as saying that, at least in this population-based study, you're perfectly fine putting them on pravastatin, which is a well-controlled, well-regulated product that we have extensive experience with."
References
HbA1c May Be Useful for Diabetes Screening, Diagnosis in Routine Clinical Practice
From Medscape Medical News
Laurie Barclay, MD
January 22, 2010 — Hemoglobin A1c (HbA1c) may be useful for diabetes screening and diagnosis in routine clinical practice, according to the results of a study reported online in the January 12 issue of Diabetes Care.
"With current screening tools (fasting plasma glucose [FPG] ± oral glucose tolerance test [OGTT]), the prevalence of undiagnosed diabetes in Australia remains high," write Zhong X. Lu, PhD, from Melbourne Pathology Services in Australia, and colleagues. "HbA1c provides a practical alternative for screening [that] is more convenient and reproducible than is blood glucose. As optimal cut-offs are still in debate, we here explore HbA1c levels that confidently 'rule-out' and 'rule-in' diabetes in two different Australian populations."
The goal of the study was to assess the value of HbA1c for screening and diagnosis of undiagnosed type 2 diabetes, as determined by OGTT, in clinical and general populations. In a clinical group (MP population) of 2494 persons, the prevalence of undiagnosed diabetes was 34.6%. This group was used to derive HbA1c cutoff values, which were 5.5% or more to "rule out" and at least 7.0% to "rule in" diabetes. These values were tested in a population-based sample (AusDiab) of 6015 persons, in which the prevalence of undiagnosed diabetes was 4.6%.
Using an HbA1c cutoff value of 5.5% or less, sensitivity for diabetes was 98.7% in MP and 83.5% in AusDiab. With use of an HbA1c cutoff value of 7.0% or more, specificity was 98.2% for MP and 100% for AusDiab. In both populations, glucose status was abnormal in 61.9% to 69.3% of those with impaired HbA1c levels (5.6% - 6.9%).
"HbA1c <5.5% and >7.0% predicts absence or presence of Type 2 diabetes while at HbA1c 6.5-6.9%, diabetes is highly probable in clinical and population settings," the study authors write. "A high proportion of people with IA1c [impaired A1c] have abnormal glucose status requiring follow-up."
Limitations of HbA1c as a screening/diagnostic tool include method bias, certain confounding medical conditions such as hemoglobinopathies and anemia, and cost.
"Although the cost of HbA1c is slightly higher than for FPG, the overall efficiency of using HbA1c as first line for diabetes screening may facilitate early diagnosis and reduce the health burden associated with diabetes complications," the study authors conclude. "Our study supports recommendations to use HbA1c for diabetes screening and diagnosis. Using two, rather than one, cut-off values for HbA1c achieved high sensitivity for screening plus optimal specificity for diabetes diagnosis."
Diabetes Care. Published online January 12, 2010. Abstract
.
Laurie Barclay, MD
January 22, 2010 — Hemoglobin A1c (HbA1c) may be useful for diabetes screening and diagnosis in routine clinical practice, according to the results of a study reported online in the January 12 issue of Diabetes Care.
"With current screening tools (fasting plasma glucose [FPG] ± oral glucose tolerance test [OGTT]), the prevalence of undiagnosed diabetes in Australia remains high," write Zhong X. Lu, PhD, from Melbourne Pathology Services in Australia, and colleagues. "HbA1c provides a practical alternative for screening [that] is more convenient and reproducible than is blood glucose. As optimal cut-offs are still in debate, we here explore HbA1c levels that confidently 'rule-out' and 'rule-in' diabetes in two different Australian populations."
The goal of the study was to assess the value of HbA1c for screening and diagnosis of undiagnosed type 2 diabetes, as determined by OGTT, in clinical and general populations. In a clinical group (MP population) of 2494 persons, the prevalence of undiagnosed diabetes was 34.6%. This group was used to derive HbA1c cutoff values, which were 5.5% or more to "rule out" and at least 7.0% to "rule in" diabetes. These values were tested in a population-based sample (AusDiab) of 6015 persons, in which the prevalence of undiagnosed diabetes was 4.6%.
Using an HbA1c cutoff value of 5.5% or less, sensitivity for diabetes was 98.7% in MP and 83.5% in AusDiab. With use of an HbA1c cutoff value of 7.0% or more, specificity was 98.2% for MP and 100% for AusDiab. In both populations, glucose status was abnormal in 61.9% to 69.3% of those with impaired HbA1c levels (5.6% - 6.9%).
"HbA1c <5.5% and >7.0% predicts absence or presence of Type 2 diabetes while at HbA1c 6.5-6.9%, diabetes is highly probable in clinical and population settings," the study authors write. "A high proportion of people with IA1c [impaired A1c] have abnormal glucose status requiring follow-up."
Limitations of HbA1c as a screening/diagnostic tool include method bias, certain confounding medical conditions such as hemoglobinopathies and anemia, and cost.
"Although the cost of HbA1c is slightly higher than for FPG, the overall efficiency of using HbA1c as first line for diabetes screening may facilitate early diagnosis and reduce the health burden associated with diabetes complications," the study authors conclude. "Our study supports recommendations to use HbA1c for diabetes screening and diagnosis. Using two, rather than one, cut-off values for HbA1c achieved high sensitivity for screening plus optimal specificity for diabetes diagnosis."
Diabetes Care. Published online January 12, 2010. Abstract
.
Diagnosis and Management of Red Eye in Primary Care Reviewed
From Medscape Medical News
Laurie Barclay, MD
January 20, 2010 — Diagnosis and management of red eye in the primary care setting are reviewed in the January 15 issue of the American Family Physician. Eye discharge, redness, pain, photophobia, itching, and visual changes are the characteristic signs and symptoms of red eye.
"Red eye is the cardinal sign of ocular inflammation," write Holly Cronau, MD, Ramana, Reddy Kankanala, MD, and Thomas Mauger, MD, from the Ohio State University College of Medicine in Columbus. "The condition is usually benign and can be managed by primary care physicians. Conjunctivitis is the most common cause of red eye."
Both viral and bacterial conjunctivitis are usually self-limiting and rarely lead to serious complications. Most patients with conjunctivitis are typically treated with broad-spectrum antibiotics because, to date, there is no specific diagnostic test to distinguish viral from bacterial conjunctivitis. Allergies or irritants also may cause conjunctivitis.
Other common causes of red eye conjunctivitis include blepharitis, corneal abrasion, foreign body, subconjunctival hemorrhage, keratitis, iritis, glaucoma, chemical burn, and scleritis.
Complete patient history and thorough eye examination are needed to diagnose the cause of red eye. Useful questions to cover in the history include duration of symptoms and whether they are unilateral or bilateral, type and amount of discharge, visual changes, pain severity, photophobia, response to previous treatments, use of contact lenses, and history of allergies or systemic illness.
Ocular examination should include thorough inspection of the eyelids, lacrimal sac, pupil size and reactivity to light, corneal involvement, and the pattern and location of hyperemia, as well as visual acuity and the presence or absence of preauricular lymph node involvement.
In viral conjunctivitis, vision, pupil size, and reaction to light are typically normal. Findings may include diffuse conjunctival injections (redness), preauricular lymphadenopathy, and a lymphoid follicle on the undersurface of the eyelid. Pain is usually mild or absent, but there may be occasional gritty discomfort with mild itching and watery to serous discharge. Photophobia is uncommon but, when present, is often unilateral at onset, becoming bilateral within 1 or 2 days. Severe cases may be complicated by subepithelial corneal opacities and pseudomembranes. Adenovirus is the most common cause of viral conjunctivitis, and other causes include enterovirus, coxsackievirus, varicella zoster virus, Epstein-Barr virus, herpes simplex virus, and influenza.
Herpes zoster ophthalmicus is associated with a vesicular rash, keratitis, and uveitis. Rash and conjunctivitis usually precede the pain and tingling sensation in a dermatomal distribution, followed by periocular vesicles.
Acute and chronic bacterial conjunctivitis are associated with eyelid edema, conjunctival injection, mild to moderate pain with stinging foreign-body sensation, and mild to moderate purulent discharge. Visual acuity is usually preserved, with normal pupil reaction and no corneal involvement. The most predictive factor is the presence of mucopurulent secretions with bilateral glued eyes on awakening. Staphylococcus aureus is the most common pathogen in adults, and Streptococcus pneumoniae and nontypeable Haemophilus influenzae are most common in children.
The underlying cause of red eye determines the appropriate course of treatment. In the primary care management of red eye, a crucial objective is to recognize when emergent referral to an ophthalmologist is required. Conditions mandating referral include severe pain refractory to topical anesthetics, need for topical steroids, vision loss, copious purulent discharge, corneal involvement, traumatic eye injury, recent ocular surgery, distorted pupil, herpes infection, or recurrent ocular infections.
"Red eye is one of the most common ophthalmologic conditions in the primary care setting," the review authors write. "Inflammation of almost any part of the eye, including the lacrimal glands and eyelids, or faulty tear film can lead to red eye. Primary care physicians often effectively manage red eye, although knowing when to refer patients to an ophthalmologist is crucial."
Specific key clinical recommendations for practice, and their accompanying level of evidence rating, are as follows:
Meticulous hand washing and other good hygiene practices are keys to reducing transmission of acute viral conjunctivitis (level of evidence, C).
For the treatment of acute bacterial conjunctivitis, any ophthalmic antibiotics may be considered because of their similar cure rates (level of evidence, A).
An over-the-counter antihistamine/vasoconstrictor agent, or a more effective second-generation topical histamine H1 receptor antagonist, may be used to treat mild allergic conjunctivitis (level of evidence, C).
For moderate dry eye, appropriate therapies include anti-inflammatory agents, such as topical corticosteroids, topical cyclosporine, and systemic omega-3 fatty acids (level of evidence, C).
An oral tetracycline or doxycycline may be helpful for patients with chronic blepharitis in whom response to eyelid hygiene and topical antibiotics is inadequate.
"To prevent the spread of viral conjunctivitis, patients should be counseled to practice strict hand washing and avoid sharing personal items; food handlers and health care workers should not work until eye discharge ceases; and physicians should clean instruments after every use," the review authors conclude. "Referral to an ophthalmologist is necessary if symptoms do not resolve after seven to 10 days or if there is corneal involvement. Topical corticosteroid therapy for any cause of red eye is used only under direct supervision of an ophthalmologist. Suspected ocular herpetic infection also warrants immediate ophthalmology referral."
The study authors have disclosed no relevant financial relationships.
Am Fam Physician. 2010;81:137-144.
.
Laurie Barclay, MD
January 20, 2010 — Diagnosis and management of red eye in the primary care setting are reviewed in the January 15 issue of the American Family Physician. Eye discharge, redness, pain, photophobia, itching, and visual changes are the characteristic signs and symptoms of red eye.
"Red eye is the cardinal sign of ocular inflammation," write Holly Cronau, MD, Ramana, Reddy Kankanala, MD, and Thomas Mauger, MD, from the Ohio State University College of Medicine in Columbus. "The condition is usually benign and can be managed by primary care physicians. Conjunctivitis is the most common cause of red eye."
Both viral and bacterial conjunctivitis are usually self-limiting and rarely lead to serious complications. Most patients with conjunctivitis are typically treated with broad-spectrum antibiotics because, to date, there is no specific diagnostic test to distinguish viral from bacterial conjunctivitis. Allergies or irritants also may cause conjunctivitis.
Other common causes of red eye conjunctivitis include blepharitis, corneal abrasion, foreign body, subconjunctival hemorrhage, keratitis, iritis, glaucoma, chemical burn, and scleritis.
Complete patient history and thorough eye examination are needed to diagnose the cause of red eye. Useful questions to cover in the history include duration of symptoms and whether they are unilateral or bilateral, type and amount of discharge, visual changes, pain severity, photophobia, response to previous treatments, use of contact lenses, and history of allergies or systemic illness.
Ocular examination should include thorough inspection of the eyelids, lacrimal sac, pupil size and reactivity to light, corneal involvement, and the pattern and location of hyperemia, as well as visual acuity and the presence or absence of preauricular lymph node involvement.
In viral conjunctivitis, vision, pupil size, and reaction to light are typically normal. Findings may include diffuse conjunctival injections (redness), preauricular lymphadenopathy, and a lymphoid follicle on the undersurface of the eyelid. Pain is usually mild or absent, but there may be occasional gritty discomfort with mild itching and watery to serous discharge. Photophobia is uncommon but, when present, is often unilateral at onset, becoming bilateral within 1 or 2 days. Severe cases may be complicated by subepithelial corneal opacities and pseudomembranes. Adenovirus is the most common cause of viral conjunctivitis, and other causes include enterovirus, coxsackievirus, varicella zoster virus, Epstein-Barr virus, herpes simplex virus, and influenza.
Herpes zoster ophthalmicus is associated with a vesicular rash, keratitis, and uveitis. Rash and conjunctivitis usually precede the pain and tingling sensation in a dermatomal distribution, followed by periocular vesicles.
Acute and chronic bacterial conjunctivitis are associated with eyelid edema, conjunctival injection, mild to moderate pain with stinging foreign-body sensation, and mild to moderate purulent discharge. Visual acuity is usually preserved, with normal pupil reaction and no corneal involvement. The most predictive factor is the presence of mucopurulent secretions with bilateral glued eyes on awakening. Staphylococcus aureus is the most common pathogen in adults, and Streptococcus pneumoniae and nontypeable Haemophilus influenzae are most common in children.
The underlying cause of red eye determines the appropriate course of treatment. In the primary care management of red eye, a crucial objective is to recognize when emergent referral to an ophthalmologist is required. Conditions mandating referral include severe pain refractory to topical anesthetics, need for topical steroids, vision loss, copious purulent discharge, corneal involvement, traumatic eye injury, recent ocular surgery, distorted pupil, herpes infection, or recurrent ocular infections.
"Red eye is one of the most common ophthalmologic conditions in the primary care setting," the review authors write. "Inflammation of almost any part of the eye, including the lacrimal glands and eyelids, or faulty tear film can lead to red eye. Primary care physicians often effectively manage red eye, although knowing when to refer patients to an ophthalmologist is crucial."
Specific key clinical recommendations for practice, and their accompanying level of evidence rating, are as follows:
Meticulous hand washing and other good hygiene practices are keys to reducing transmission of acute viral conjunctivitis (level of evidence, C).
For the treatment of acute bacterial conjunctivitis, any ophthalmic antibiotics may be considered because of their similar cure rates (level of evidence, A).
An over-the-counter antihistamine/vasoconstrictor agent, or a more effective second-generation topical histamine H1 receptor antagonist, may be used to treat mild allergic conjunctivitis (level of evidence, C).
For moderate dry eye, appropriate therapies include anti-inflammatory agents, such as topical corticosteroids, topical cyclosporine, and systemic omega-3 fatty acids (level of evidence, C).
An oral tetracycline or doxycycline may be helpful for patients with chronic blepharitis in whom response to eyelid hygiene and topical antibiotics is inadequate.
"To prevent the spread of viral conjunctivitis, patients should be counseled to practice strict hand washing and avoid sharing personal items; food handlers and health care workers should not work until eye discharge ceases; and physicians should clean instruments after every use," the review authors conclude. "Referral to an ophthalmologist is necessary if symptoms do not resolve after seven to 10 days or if there is corneal involvement. Topical corticosteroid therapy for any cause of red eye is used only under direct supervision of an ophthalmologist. Suspected ocular herpetic infection also warrants immediate ophthalmology referral."
The study authors have disclosed no relevant financial relationships.
Am Fam Physician. 2010;81:137-144.
.
Thursday, January 21, 2010
Acute Treatment of Disaster Survivors
Author: Roy H Lubit, MD, PhD, Assistant Clinical Professor, Mount Sinai School of Medicine; Clinical Faculty, Department of Child Psychiatry, New York University School of Medicine; Private Practice
Updated: Aug 28, 2008
Introduction
Disaster victims and those who love them are vulnerable to considerable emotional turmoil and a variety of symptoms following a traumatic event and the loss of loved ones. This article discusses common reactions to traumatic events and to the loss of loved ones. This article also explores when to seek professional help, ways that loved ones and friends can help victims and their families, and what professionals can do in these situations. In addition, specific assistance for children who have experienced emotional trauma or loss is discussed.
All people experience traumatic events in their lives. All people lose loved ones, 1 in 4 women experience rape or attempted rape during their lifetime, and 1 million children a year are abused or neglected. In 2000, one quarter of a million Americans were raped or sexually assaulted, three quarters of a million were robbed, and half a million were assaulted. Millions of children are bullied in school, 7% of men and 22% of women are assaulted by an intimate partner, and 3 million people a year are involved in car accidents. Most Americans were shocked by the loss of thousands of lives in the terrorist attack on the World Trade Center.
Psychiatric trauma
Freud defined trauma as the experience of having the ego rendered helpless by overstimulation. Winnicot said trauma was pathogenic for children because it catastrophically destroyed the child's illusion of omnipotence and the illusion that his parents would protect him. Trauma establishes a new possibility for the child of what can happen in the world and a preoccupation with danger and vulnerability.
In 1996, Van Der Kolk wrote that posttraumatic stress disorder (PTSD) involves the combination of a conditioned fear response to trauma-related stimuli, altered neurobiological processes leading to increased arousal, and altered cognitive schemata and social apprehension.
Horowitz said that trauma occurs when an individual is faced with an overwhelming and negative experience that is incongruent within existing schema. The individual repeatedly recollects the event in an attempt to integrate it and to accommodate existing cognitive schema with the new information. Meanwhile, numbness and withdrawal arise in an attempt to cope with the pain of memories. In 1993, Lifton discussed how trauma could transform the structure of the self.
Emotional response to disaster
Impact phase: During the first few days, individuals often feel stunned. In the first week, disbelief, numbness, fear, and possibly confusion to the point of disorganization occur.
Crisis phase: After the initial impact has been absorbed, individuals can experience a number of feelings.
Individuals may alternate between denial and intrusive symptoms with hyperarousal.
Persons may experience somatic symptoms (eg, fatigue, dizziness, headaches, nausea) as well as anger, irritability, apathy, and social withdrawal. Individuals may be angry with caregivers who fail to solve problems or who are unable to respond in a fully organized way in the chaos of the crisis.
Resolution phase: Grief, guilt, and depression are often prominent during the first year as individuals continue to cope with their losses.
Reconstruction phase: During this phase, reappraisal, assignment of meaning, and the integration of the event into a new self-concept occur.
Potential outcomes of traumatic events
Traumatic events can lead to a wide variety of emotional reactions. The treating clinician must understand that underneath the individual's reaction is an attempt to cope with the traumatic event. The first 6 symptoms are particularly common. Most individuals have some symptoms following a significant traumatic event. A minority have sufficient symptoms to fulfill the diagnostic criteria for acute stress disorder (ASD) or PTSD.
Relatively common symptoms following traumatic events
Physical reactions - Difficulty sleeping, exaggerated startle response, tension, fatigue, irritability, aches and pains, tachycardia, nausea, change in appetite, change in libido
Interpersonal reactions - Distrust, conflict, withdrawal, work problems, school problems, irritability, decreased intimacy, domineering demeanor, feeling rejected or abandoned; children may become clingy or oppositional
More significant symptoms that call for professional consultation
Severe persistent problematic symptoms - Marked depression (eg, hopelessness, feeling worthless, overwhelmed with worry), marked hyperarousal (eg, panic attacks, rage, extreme irritability, intense agitation), extreme numbness, inability to control emotions even when important to do so, persistent problems in work or school, significant problems in self-care
Exacerbation or reoccurrence of preexisting psychiatric problems
Dissociative symptoms (eg, depersonalization, derealization, fugue, amnesia)
Intrusive reexperiencing - Terrifying memories, persistent nightmares, flashbacks
Acute stress disorder
PTSD (occurs in 10-30% of individuals who are highly exposed to the traumatic event)
Substance abuse
Aggression
In children, aggression, risk taking, sexual acting out
Acute stress disorder
ASD is a diagnosable Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) axis I disorder that includes a number of significant symptoms and often leads to PTSD. The main differences between ASD and PTSD are duration (ASD lasts only briefly) and the presence of several dissociative symptoms in ASD.
In ASD, a person has been exposed to a traumatic event in which both of the following occurred:
Person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury or that involved a threat to the physical integrity of oneself or others.
The person's response involved intense fear, helplessness, or horror.
Either while experiencing or after experiencing the distressing event, the individual exhibits 3 or more of the following dissociative symptoms:
Subjective sense of numbness, detachment, or absence of emotional responsiveness
Reduction in awareness of his or her surroundings (being in a daze)
Derealization
Depersonalization
Dissociative amnesia
The traumatic event is persistently reexperienced in at least 1 of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience. Distress is observed on exposure to reminders of the traumatic event.
The individual displays marked avoidance of stimuli that arouse recollections of the trauma.
Marked symptoms of anxiety or increased arousal (eg, difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness) are observed.
The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or impairs the individual's ability to pursue some necessary task, such as obtaining necessary assistance or mobilizing personal resources by telling family members about the traumatic experience.
The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic event.
Signs and symptoms of ASD are as follows:
The individual experienced intense fear, helplessness, or horror in response to exposure to a serious traumatic event that caused or threatened serious harm of injury or violation of bodily integrity. Children may experience disorganized or agitated behavior.
The traumatic event is reexperienced in 1 or more of the following ways:
Distressing recurrent and intrusive recollections of the event (In young children, repetitive play of themes or aspects of the traumatic event may occur.)
Recurrent distressing dreams (In children, their dreams are frightening, but they may not have recognizable content.)
Acting or feeling as if the traumatic event was recurring
Intense psychological distress at exposure to cues that symbolize or resemble an aspect of the traumatic event
Physiological reactivity on exposure to cues that symbolize or resemble an aspect of the traumatic event
Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by 3 (or more) of the following:
Efforts to avoid thoughts, feelings, or conversations associated with the trauma
Efforts to avoid activities, places, or people that arouse recollections of the trauma
Inability to recall an important aspect of the trauma
Markedly diminished interest or participation in significant activities
Feeling of detachment or estrangement from others
Restricted range of affect (eg, unable to have loving feelings)
Sense of a foreshortened future (eg, does not expect to have a career, marriage, children, or a normal life span)
Persistent symptoms of increased arousal (not present before the trauma), as indicated by 2 (or more) of the following:
Difficulty falling or staying asleep
Irritability or outbursts of anger
Difficulty concentrating
Hypervigilance
Exaggerated startle response
Symptoms of reexperiencing the trauma, avoidance, and persistent arousal last more than 1 month.
The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Risk factors for ASD and PTSD
Persons who lost a loved one
Individuals who experienced an injury
Persons who witnessed horrendous images
Persons who had dissociation at the time of the event
Those who experience serious depressive symptoms within a week and lasting for a month or more
Individuals with numbness, depersonalization, sense of reliving the trauma, and motor restlessness after the event
Those with preexisting psychiatric problems
Persons with prior trauma
Loss of home or community
Extended exposure to danger
Toxic exposure
Individuals with a lack of social supports or whose social supports were also traumatized and are unable to be adequately emotionally available
Signs the patient needs help
Task-oriented activities are not being performed.
Task-oriented activity is not goal-directed, organized, or effective.
The survivor is overwhelmed by emotion most of the time.
Emotions cannot be modulated when necessary.
The survivor inappropriately blames himself or herself, and the self-blame generalizes to the entire self.
The survivor is isolated and avoids the company of others.
Thoughts or plans of suicide or homicide.
Symptoms of Grief
Stages of bereavement and grief
Persons who have lost someone close or who have had a permanent injury experience grief and bereavement. Observers of the tragedy who did not lose someone are not affected. These stages may occur in any order.
Shocked disbelief
This stage lasts up to 2 weeks
Episodes of deep sighing, lack of strength and appetite, choking, and breathlessness may occur.
The individual may deny the death.
The individual may feel numb and cut off from the world.
Awareness develops
Loss of vitality, physical symptoms of stress, and development of symptoms similar to those of the deceased are possible.
Emotional symptoms include outbursts of weeping; hallucinations; searching; pining; guilt; idealization; loneliness; and anger at doctors, other family members, the deceased, or God.
Bargaining: Individual attempts to strike a deal, or bargain, with God to undo what occurred.
Depression
Depression may occur about 6 months after the trauma.
Loss of interest in the individual's own life and the lives of others occurs.
The individual's life may seem to be without purpose.
Existing personality problems may worsen.
Social isolation is possible.
Resolution
The individual now believes he or she can cope.
Resolution may take 1-2 years.
The individual can begin to enjoy life without feeling disloyal to the deceased.
Mental status
Appearance: Individuals may be disheveled and unclean and show the effects of dehydration and failure to care for themselves.
Affect/mood: The patient may appear sad, anxious, irritable, emotionally labile, apathetic, angry, or calm. Depressive illness occurs in 17-27% of survivors during the first year after a death.
Thought content: The individual may feel helpless, be in a state of disbelief, be confused, have markedly impaired concentration, have lowered self esteem, and likely be driven to search for the deceased.
Perceptions: At this time, the individual may have hallucinations (visual or auditory) that the deceased person is present. Flashbacks, feelings of unreality, numbness, and denial may occur.
Judgment/insight: Confusion in combination with preoccupation with those they have lost may impair individuals' judgment and insight.
Suicide: Suicidal thoughts occur in as many as 54% of survivors and may continue up to 6 months after the death.
Homicide: Thoughts or plans of homicide.
Physical complaints from grief
Loss of appetite
Changes in weight
Trouble going to sleep or staying asleep
Fatigue
Chest pain
Headache
Palpitations
Hair loss
Gastrointestinal distress
Complicated/traumatic grief
Traumatic grief is an example of a complicated grief reaction that occurs following the traumatic death of someone close.
Traumatic grief may occur when the death results from war, disasters, accidents, suicide, or homicide.
In traumatic bereavement, the individual is preoccupied with images of the traumatic event, rather than of the person who is deceased as in normal bereavement. Moreover, the individual has difficulty passing through the mourning process and moving on with his or her life.
The individual needs treatment for both trauma and grief. The individual also needs help in remembering an intact representation of the person who is deceased and not be filled with images of the person being killed. If no body is present following the death, placing a picture of the individual in nondegradable plastic in the coffin can be helpful.
Differential Diagnosis
Posttraumatic Stress Disorder
Exacerbation of preexisting mental condition
Brief psychotic episode
Substance abuse
Adjustment reaction
Anxiety Disorders
Depression (See Medscape's Depression Resource Center.)
Dissociative Disorders
Basic Principles of Intervention After Emotional Trauma
Reduce stress by all possible means.
Ensure that survivors have a safe environment.
Promote contact with loved ones and other sources of support (eg, religious organizations).
Support self-esteem. Help the individual to understand that their reaction to the trauma is a normal reaction to an abnormal situation, not a sign of weakness or psychopathology.
Help the person to focus on immediate needs, such as rest, food, shelter, social supports, or sense of community (some feel cut off and detached).
Promote coping mechanisms.
Help individuals to reframe any destructive cognitions, such as he or she acted terribly and is a terrible person or is weak for being so distraught, life is hopeless or worthless, or the world is totally unsafe.
Administer medication (eg, propranolol, alpha-agonists, benzodiazepines, nonactivating selective serotonin reuptake inhibitors [SSRIs]), if needed, to decrease arousal.
Avoid increasing stress.
Avoid prompting discussion of issues that cannot be resolved.
Avoid abreaction in groups and the resulting contagion effect.
Respect defenses, and do not force reality on persons who cannot handle it yet.
Debriefing may be harmful.
Share the experience with persons who want to talk about it, and avoid pressuring those who do not want to talk about it.
Identify persons at high risk: Screen for physical causes of psychiatric problems (eg, dehydration, head trauma, infection, metabolic abnormality, toxins).
Have faith in the normal healing processes.
Promote support networks.
Patient Education
Helping adults who are grieving
Be available, and do not allow a grieving person to become isolated.
Take action (eg, call, send a card, give hugs, help with practical matters).
Be available after others get back to their own lives.
Be a good listener, but do not give advice.
Do not be afraid to talk about the loss.
Talk about the person who died by name.
Do not minimize the loss; avoid clichés and easy answers.
Be patient with the bereaved; there are no shortcuts.
Encourage the bereaved to care for themselves.
Remember significant days and memories.
Do not try to distract the bereaved from grief through forced cheerfulness.
Helping children who are grieving or traumatized
Reassure children of their safety and the safety of their loved ones (as much as possible); tell them that such things are very rare, that people are there to take care of them, and that they will always be loved.
Be emotionally available to children despite personal loss (or fears).
Give children more time than usual.
Encourage them to share their feelings, to talk at weekly family meetings, and to use drawings and puppets to express their feelings.
Let them know it is all right to talk about unpleasant feelings (including sadness and anger) and listen to them. (Sharing personal feelings of sadness with them is all right as well.)
Check to see if children feel that they somehow caused the death or disaster or if they have other misunderstandings, and reassure them or correct the misunderstanding. Do not assume children are fine just because they are not saying anything.
Understand that children probably know more than you think.
Ask what the child knows and what questions the child has.
Monitor and limit TV watching after a disaster lest it flood them or desensitize them to violence.
When they watch TV, watch it with them and discuss the events.
Share only the details they can deal with. Do not overload them with facts. Be honest.
Encourage action, such as sending letters to victims, to keep them from feeling helpless.
Understand that regression, fear, sleep problems, and anger toward remaining family members are common after a loss or trauma.
Do not force children to go to the funeral if they do not want to, but help them create a ritual.
Maintain as normal a schedule as possible.
Eat balanced meals on time, drink fluids, sleep, relax, exercise, and avoid alcohol and caffeine.
Get help if serious signs appear and last more than a couple of weeks.
Extended depression and loss of interest in activities and events
Inability to sleep, loss of appetite, or prolonged fear of being alone
Extended period of marked regression
Excessive imitation of the deceased or repeated statements about wanting to join the deceased
Withdrawal from friends
Serious drop in school performance or refusal to go to school
Persistent fears
Persistent irritability and being easily startled
Behavior problems
Physical complaints
Online resources
The following are useful Web sites for patient and family education:
Duke University Health Services, Bereavement, Coping After a Traumatic Death
The University of Iowa, Coping with Death, Grief, and Loss
Helpguide.org, Coping with Grief and Loss: Guide to Grieving and Bereavement
Connect for Kids, Help with Healing, on the Web
For other patient education resources, visit eMedicine's Mental Health and Behavior Center. Also, see eMedicine's patient education articles Grief and Bereavement and Post-traumatic Stress Disorder (PTSD).
Care of Rescue Workers
Rescue workers may develop the same symptoms, including those of PTSD, as victims. As many as 1 in 3 rescue workers develop PTSD.
Encourage staying in touch with family and friends.
Be sure that rescue workers get rest, food, exercise, and relaxation.
Encourage understanding of survival guilt.
Explain how chaos and confusion inevitably leads to upset between individuals and groups that are participating in the rescue effort.
Develop a buddy system, and encourage support of coworkers.
Encourage workers to defuse after troubling incidents and following each shift.
After the rescue operation, workers should take a few days to decompress and attend a debriefing.
Do not overwhelm children with talk of experiences as a rescue worker; ask about their activities.
Therapeutic Interventions
Debriefing1,2,3,4,5
Critical incident stress debriefing is one of the most common interventions thought of following a traumatic event. (Caution: Critical incident stress debriefing has not been shown to reduce the later development of depression, anxiety, or PTSD, and it may harm individuals by increasing their arousal and overwhelming their defenses.)
Classically, critical incident stress debriefing has 7 stages, including (1) introduction (purpose of the session), (2) describing the traumatic event, (3) appraisal of the event, (4) exploring the participants' emotional reactions during and after the event, (5) discussion of the normal nature of symptoms after traumatic events, (6) outlining ways of dealing with further consequences of the event, and (7) discussion of the session and practical conclusions.
Research does not support the effectiveness of critical stress debriefing in the prevention of PTSD, depression, or anxiety, and, if performed poorly, debriefing can even be harmful. It can increase arousal and overwhelm the survivor's defenses. Operational debriefing, which focuses on normalizing emotional response, informing of services available, and providing general support, is safer. In engaging in a 1- to 2-session intervention following a traumatic event, a number of guidelines help avoid harm and maximize the chance of benefit for some individuals.
Provide trained individuals to perform the intervention.
Avoid ventilating feelings at high levels; this can lead to contagion and flooding, rather than calming and helping cope with feelings.
Do not pressure individuals to talk about things they do not want to; respect their defenses, including denial.
Critical tasks to cover include the following:
Psychoeducation to help patients see that the feelings they are having are not a sign of weakness or mental illness but a normal reaction to a very disturbing situation.
Discuss ways of improving coping skills, including getting adequate rest, recreation, food, and fluids.
Avoid excessive exposure to media coverage of the traumatic incident.
Discuss common cognitive distortions, such as survivor guilt and fears that the world is totally unsafe.
Explain the signs and symptoms indicating that someone should get professional help.
Cognitive behavior therapy6,7,8,9,10,11
While 70% of those receiving supportive therapy or no therapy develop PTSD, cognitive behavior therapy (CBT) used shortly after a trauma has been shown to reduce the rate of PTSD development to 10-20%. Moreover, patients who received CBT and CBT/hypnosis reported less re-experiencing and less avoidance symptoms than patients who received supportive counseling. Individuals are aided by the following:
Seeing that people are concerned about them
Learning about the range of normal responses to trauma and hearing that their emotional reactions are normal responses to an abnormal event (rather than a sign of weakness or pathology)
Being reminded to take care of concrete needs (eg, food, fluids, rest)
Cognitive restructuring (changing destructive schema, such as "having fun is a betrayal of the injured," "the world is totally unsafe," "I am responsible for the disaster," or "life is without meaning," to more constructive ones)
Learning relaxation techniques
Undergoing exposure to avoided situations either via guided imagery and imagination or in vivo
Resources permitting, current data suggest that a 4- to 5-session course of CBT should be offered to those at high risk for developing PTSD. CBT should be performed by someone trained in the technique. Severe, relatively common destructive cognitions may arise after a traumatic event and need to be addressed.
On the left side of the Table below are malignant schemata that an individual may have after a traumatic event. On the right side are more constructive schemata that a clinician can suggest for consideration by the individual.
Cognitive Interventions
http://emedicine.medscape.com/article/295003-overview
Updated: Aug 28, 2008
Introduction
Disaster victims and those who love them are vulnerable to considerable emotional turmoil and a variety of symptoms following a traumatic event and the loss of loved ones. This article discusses common reactions to traumatic events and to the loss of loved ones. This article also explores when to seek professional help, ways that loved ones and friends can help victims and their families, and what professionals can do in these situations. In addition, specific assistance for children who have experienced emotional trauma or loss is discussed.
All people experience traumatic events in their lives. All people lose loved ones, 1 in 4 women experience rape or attempted rape during their lifetime, and 1 million children a year are abused or neglected. In 2000, one quarter of a million Americans were raped or sexually assaulted, three quarters of a million were robbed, and half a million were assaulted. Millions of children are bullied in school, 7% of men and 22% of women are assaulted by an intimate partner, and 3 million people a year are involved in car accidents. Most Americans were shocked by the loss of thousands of lives in the terrorist attack on the World Trade Center.
Psychiatric trauma
Freud defined trauma as the experience of having the ego rendered helpless by overstimulation. Winnicot said trauma was pathogenic for children because it catastrophically destroyed the child's illusion of omnipotence and the illusion that his parents would protect him. Trauma establishes a new possibility for the child of what can happen in the world and a preoccupation with danger and vulnerability.
In 1996, Van Der Kolk wrote that posttraumatic stress disorder (PTSD) involves the combination of a conditioned fear response to trauma-related stimuli, altered neurobiological processes leading to increased arousal, and altered cognitive schemata and social apprehension.
Horowitz said that trauma occurs when an individual is faced with an overwhelming and negative experience that is incongruent within existing schema. The individual repeatedly recollects the event in an attempt to integrate it and to accommodate existing cognitive schema with the new information. Meanwhile, numbness and withdrawal arise in an attempt to cope with the pain of memories. In 1993, Lifton discussed how trauma could transform the structure of the self.
Emotional response to disaster
Impact phase: During the first few days, individuals often feel stunned. In the first week, disbelief, numbness, fear, and possibly confusion to the point of disorganization occur.
Crisis phase: After the initial impact has been absorbed, individuals can experience a number of feelings.
Individuals may alternate between denial and intrusive symptoms with hyperarousal.
Persons may experience somatic symptoms (eg, fatigue, dizziness, headaches, nausea) as well as anger, irritability, apathy, and social withdrawal. Individuals may be angry with caregivers who fail to solve problems or who are unable to respond in a fully organized way in the chaos of the crisis.
Resolution phase: Grief, guilt, and depression are often prominent during the first year as individuals continue to cope with their losses.
Reconstruction phase: During this phase, reappraisal, assignment of meaning, and the integration of the event into a new self-concept occur.
Potential outcomes of traumatic events
Traumatic events can lead to a wide variety of emotional reactions. The treating clinician must understand that underneath the individual's reaction is an attempt to cope with the traumatic event. The first 6 symptoms are particularly common. Most individuals have some symptoms following a significant traumatic event. A minority have sufficient symptoms to fulfill the diagnostic criteria for acute stress disorder (ASD) or PTSD.
Relatively common symptoms following traumatic events
Physical reactions - Difficulty sleeping, exaggerated startle response, tension, fatigue, irritability, aches and pains, tachycardia, nausea, change in appetite, change in libido
Interpersonal reactions - Distrust, conflict, withdrawal, work problems, school problems, irritability, decreased intimacy, domineering demeanor, feeling rejected or abandoned; children may become clingy or oppositional
More significant symptoms that call for professional consultation
Severe persistent problematic symptoms - Marked depression (eg, hopelessness, feeling worthless, overwhelmed with worry), marked hyperarousal (eg, panic attacks, rage, extreme irritability, intense agitation), extreme numbness, inability to control emotions even when important to do so, persistent problems in work or school, significant problems in self-care
Exacerbation or reoccurrence of preexisting psychiatric problems
Dissociative symptoms (eg, depersonalization, derealization, fugue, amnesia)
Intrusive reexperiencing - Terrifying memories, persistent nightmares, flashbacks
Acute stress disorder
PTSD (occurs in 10-30% of individuals who are highly exposed to the traumatic event)
Substance abuse
Aggression
In children, aggression, risk taking, sexual acting out
Acute stress disorder
ASD is a diagnosable Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) axis I disorder that includes a number of significant symptoms and often leads to PTSD. The main differences between ASD and PTSD are duration (ASD lasts only briefly) and the presence of several dissociative symptoms in ASD.
In ASD, a person has been exposed to a traumatic event in which both of the following occurred:
Person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury or that involved a threat to the physical integrity of oneself or others.
The person's response involved intense fear, helplessness, or horror.
Either while experiencing or after experiencing the distressing event, the individual exhibits 3 or more of the following dissociative symptoms:
Subjective sense of numbness, detachment, or absence of emotional responsiveness
Reduction in awareness of his or her surroundings (being in a daze)
Derealization
Depersonalization
Dissociative amnesia
The traumatic event is persistently reexperienced in at least 1 of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience. Distress is observed on exposure to reminders of the traumatic event.
The individual displays marked avoidance of stimuli that arouse recollections of the trauma.
Marked symptoms of anxiety or increased arousal (eg, difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness) are observed.
The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or impairs the individual's ability to pursue some necessary task, such as obtaining necessary assistance or mobilizing personal resources by telling family members about the traumatic experience.
The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic event.
Signs and symptoms of ASD are as follows:
The individual experienced intense fear, helplessness, or horror in response to exposure to a serious traumatic event that caused or threatened serious harm of injury or violation of bodily integrity. Children may experience disorganized or agitated behavior.
The traumatic event is reexperienced in 1 or more of the following ways:
Distressing recurrent and intrusive recollections of the event (In young children, repetitive play of themes or aspects of the traumatic event may occur.)
Recurrent distressing dreams (In children, their dreams are frightening, but they may not have recognizable content.)
Acting or feeling as if the traumatic event was recurring
Intense psychological distress at exposure to cues that symbolize or resemble an aspect of the traumatic event
Physiological reactivity on exposure to cues that symbolize or resemble an aspect of the traumatic event
Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by 3 (or more) of the following:
Efforts to avoid thoughts, feelings, or conversations associated with the trauma
Efforts to avoid activities, places, or people that arouse recollections of the trauma
Inability to recall an important aspect of the trauma
Markedly diminished interest or participation in significant activities
Feeling of detachment or estrangement from others
Restricted range of affect (eg, unable to have loving feelings)
Sense of a foreshortened future (eg, does not expect to have a career, marriage, children, or a normal life span)
Persistent symptoms of increased arousal (not present before the trauma), as indicated by 2 (or more) of the following:
Difficulty falling or staying asleep
Irritability or outbursts of anger
Difficulty concentrating
Hypervigilance
Exaggerated startle response
Symptoms of reexperiencing the trauma, avoidance, and persistent arousal last more than 1 month.
The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Risk factors for ASD and PTSD
Persons who lost a loved one
Individuals who experienced an injury
Persons who witnessed horrendous images
Persons who had dissociation at the time of the event
Those who experience serious depressive symptoms within a week and lasting for a month or more
Individuals with numbness, depersonalization, sense of reliving the trauma, and motor restlessness after the event
Those with preexisting psychiatric problems
Persons with prior trauma
Loss of home or community
Extended exposure to danger
Toxic exposure
Individuals with a lack of social supports or whose social supports were also traumatized and are unable to be adequately emotionally available
Signs the patient needs help
Task-oriented activities are not being performed.
Task-oriented activity is not goal-directed, organized, or effective.
The survivor is overwhelmed by emotion most of the time.
Emotions cannot be modulated when necessary.
The survivor inappropriately blames himself or herself, and the self-blame generalizes to the entire self.
The survivor is isolated and avoids the company of others.
Thoughts or plans of suicide or homicide.
Symptoms of Grief
Stages of bereavement and grief
Persons who have lost someone close or who have had a permanent injury experience grief and bereavement. Observers of the tragedy who did not lose someone are not affected. These stages may occur in any order.
Shocked disbelief
This stage lasts up to 2 weeks
Episodes of deep sighing, lack of strength and appetite, choking, and breathlessness may occur.
The individual may deny the death.
The individual may feel numb and cut off from the world.
Awareness develops
Loss of vitality, physical symptoms of stress, and development of symptoms similar to those of the deceased are possible.
Emotional symptoms include outbursts of weeping; hallucinations; searching; pining; guilt; idealization; loneliness; and anger at doctors, other family members, the deceased, or God.
Bargaining: Individual attempts to strike a deal, or bargain, with God to undo what occurred.
Depression
Depression may occur about 6 months after the trauma.
Loss of interest in the individual's own life and the lives of others occurs.
The individual's life may seem to be without purpose.
Existing personality problems may worsen.
Social isolation is possible.
Resolution
The individual now believes he or she can cope.
Resolution may take 1-2 years.
The individual can begin to enjoy life without feeling disloyal to the deceased.
Mental status
Appearance: Individuals may be disheveled and unclean and show the effects of dehydration and failure to care for themselves.
Affect/mood: The patient may appear sad, anxious, irritable, emotionally labile, apathetic, angry, or calm. Depressive illness occurs in 17-27% of survivors during the first year after a death.
Thought content: The individual may feel helpless, be in a state of disbelief, be confused, have markedly impaired concentration, have lowered self esteem, and likely be driven to search for the deceased.
Perceptions: At this time, the individual may have hallucinations (visual or auditory) that the deceased person is present. Flashbacks, feelings of unreality, numbness, and denial may occur.
Judgment/insight: Confusion in combination with preoccupation with those they have lost may impair individuals' judgment and insight.
Suicide: Suicidal thoughts occur in as many as 54% of survivors and may continue up to 6 months after the death.
Homicide: Thoughts or plans of homicide.
Physical complaints from grief
Loss of appetite
Changes in weight
Trouble going to sleep or staying asleep
Fatigue
Chest pain
Headache
Palpitations
Hair loss
Gastrointestinal distress
Complicated/traumatic grief
Traumatic grief is an example of a complicated grief reaction that occurs following the traumatic death of someone close.
Traumatic grief may occur when the death results from war, disasters, accidents, suicide, or homicide.
In traumatic bereavement, the individual is preoccupied with images of the traumatic event, rather than of the person who is deceased as in normal bereavement. Moreover, the individual has difficulty passing through the mourning process and moving on with his or her life.
The individual needs treatment for both trauma and grief. The individual also needs help in remembering an intact representation of the person who is deceased and not be filled with images of the person being killed. If no body is present following the death, placing a picture of the individual in nondegradable plastic in the coffin can be helpful.
Differential Diagnosis
Posttraumatic Stress Disorder
Exacerbation of preexisting mental condition
Brief psychotic episode
Substance abuse
Adjustment reaction
Anxiety Disorders
Depression (See Medscape's Depression Resource Center.)
Dissociative Disorders
Basic Principles of Intervention After Emotional Trauma
Reduce stress by all possible means.
Ensure that survivors have a safe environment.
Promote contact with loved ones and other sources of support (eg, religious organizations).
Support self-esteem. Help the individual to understand that their reaction to the trauma is a normal reaction to an abnormal situation, not a sign of weakness or psychopathology.
Help the person to focus on immediate needs, such as rest, food, shelter, social supports, or sense of community (some feel cut off and detached).
Promote coping mechanisms.
Help individuals to reframe any destructive cognitions, such as he or she acted terribly and is a terrible person or is weak for being so distraught, life is hopeless or worthless, or the world is totally unsafe.
Administer medication (eg, propranolol, alpha-agonists, benzodiazepines, nonactivating selective serotonin reuptake inhibitors [SSRIs]), if needed, to decrease arousal.
Avoid increasing stress.
Avoid prompting discussion of issues that cannot be resolved.
Avoid abreaction in groups and the resulting contagion effect.
Respect defenses, and do not force reality on persons who cannot handle it yet.
Debriefing may be harmful.
Share the experience with persons who want to talk about it, and avoid pressuring those who do not want to talk about it.
Identify persons at high risk: Screen for physical causes of psychiatric problems (eg, dehydration, head trauma, infection, metabolic abnormality, toxins).
Have faith in the normal healing processes.
Promote support networks.
Patient Education
Helping adults who are grieving
Be available, and do not allow a grieving person to become isolated.
Take action (eg, call, send a card, give hugs, help with practical matters).
Be available after others get back to their own lives.
Be a good listener, but do not give advice.
Do not be afraid to talk about the loss.
Talk about the person who died by name.
Do not minimize the loss; avoid clichés and easy answers.
Be patient with the bereaved; there are no shortcuts.
Encourage the bereaved to care for themselves.
Remember significant days and memories.
Do not try to distract the bereaved from grief through forced cheerfulness.
Helping children who are grieving or traumatized
Reassure children of their safety and the safety of their loved ones (as much as possible); tell them that such things are very rare, that people are there to take care of them, and that they will always be loved.
Be emotionally available to children despite personal loss (or fears).
Give children more time than usual.
Encourage them to share their feelings, to talk at weekly family meetings, and to use drawings and puppets to express their feelings.
Let them know it is all right to talk about unpleasant feelings (including sadness and anger) and listen to them. (Sharing personal feelings of sadness with them is all right as well.)
Check to see if children feel that they somehow caused the death or disaster or if they have other misunderstandings, and reassure them or correct the misunderstanding. Do not assume children are fine just because they are not saying anything.
Understand that children probably know more than you think.
Ask what the child knows and what questions the child has.
Monitor and limit TV watching after a disaster lest it flood them or desensitize them to violence.
When they watch TV, watch it with them and discuss the events.
Share only the details they can deal with. Do not overload them with facts. Be honest.
Encourage action, such as sending letters to victims, to keep them from feeling helpless.
Understand that regression, fear, sleep problems, and anger toward remaining family members are common after a loss or trauma.
Do not force children to go to the funeral if they do not want to, but help them create a ritual.
Maintain as normal a schedule as possible.
Eat balanced meals on time, drink fluids, sleep, relax, exercise, and avoid alcohol and caffeine.
Get help if serious signs appear and last more than a couple of weeks.
Extended depression and loss of interest in activities and events
Inability to sleep, loss of appetite, or prolonged fear of being alone
Extended period of marked regression
Excessive imitation of the deceased or repeated statements about wanting to join the deceased
Withdrawal from friends
Serious drop in school performance or refusal to go to school
Persistent fears
Persistent irritability and being easily startled
Behavior problems
Physical complaints
Online resources
The following are useful Web sites for patient and family education:
Duke University Health Services, Bereavement, Coping After a Traumatic Death
The University of Iowa, Coping with Death, Grief, and Loss
Helpguide.org, Coping with Grief and Loss: Guide to Grieving and Bereavement
Connect for Kids, Help with Healing, on the Web
For other patient education resources, visit eMedicine's Mental Health and Behavior Center. Also, see eMedicine's patient education articles Grief and Bereavement and Post-traumatic Stress Disorder (PTSD).
Care of Rescue Workers
Rescue workers may develop the same symptoms, including those of PTSD, as victims. As many as 1 in 3 rescue workers develop PTSD.
Encourage staying in touch with family and friends.
Be sure that rescue workers get rest, food, exercise, and relaxation.
Encourage understanding of survival guilt.
Explain how chaos and confusion inevitably leads to upset between individuals and groups that are participating in the rescue effort.
Develop a buddy system, and encourage support of coworkers.
Encourage workers to defuse after troubling incidents and following each shift.
After the rescue operation, workers should take a few days to decompress and attend a debriefing.
Do not overwhelm children with talk of experiences as a rescue worker; ask about their activities.
Therapeutic Interventions
Debriefing1,2,3,4,5
Critical incident stress debriefing is one of the most common interventions thought of following a traumatic event. (Caution: Critical incident stress debriefing has not been shown to reduce the later development of depression, anxiety, or PTSD, and it may harm individuals by increasing their arousal and overwhelming their defenses.)
Classically, critical incident stress debriefing has 7 stages, including (1) introduction (purpose of the session), (2) describing the traumatic event, (3) appraisal of the event, (4) exploring the participants' emotional reactions during and after the event, (5) discussion of the normal nature of symptoms after traumatic events, (6) outlining ways of dealing with further consequences of the event, and (7) discussion of the session and practical conclusions.
Research does not support the effectiveness of critical stress debriefing in the prevention of PTSD, depression, or anxiety, and, if performed poorly, debriefing can even be harmful. It can increase arousal and overwhelm the survivor's defenses. Operational debriefing, which focuses on normalizing emotional response, informing of services available, and providing general support, is safer. In engaging in a 1- to 2-session intervention following a traumatic event, a number of guidelines help avoid harm and maximize the chance of benefit for some individuals.
Provide trained individuals to perform the intervention.
Avoid ventilating feelings at high levels; this can lead to contagion and flooding, rather than calming and helping cope with feelings.
Do not pressure individuals to talk about things they do not want to; respect their defenses, including denial.
Critical tasks to cover include the following:
Psychoeducation to help patients see that the feelings they are having are not a sign of weakness or mental illness but a normal reaction to a very disturbing situation.
Discuss ways of improving coping skills, including getting adequate rest, recreation, food, and fluids.
Avoid excessive exposure to media coverage of the traumatic incident.
Discuss common cognitive distortions, such as survivor guilt and fears that the world is totally unsafe.
Explain the signs and symptoms indicating that someone should get professional help.
Cognitive behavior therapy6,7,8,9,10,11
While 70% of those receiving supportive therapy or no therapy develop PTSD, cognitive behavior therapy (CBT) used shortly after a trauma has been shown to reduce the rate of PTSD development to 10-20%. Moreover, patients who received CBT and CBT/hypnosis reported less re-experiencing and less avoidance symptoms than patients who received supportive counseling. Individuals are aided by the following:
Seeing that people are concerned about them
Learning about the range of normal responses to trauma and hearing that their emotional reactions are normal responses to an abnormal event (rather than a sign of weakness or pathology)
Being reminded to take care of concrete needs (eg, food, fluids, rest)
Cognitive restructuring (changing destructive schema, such as "having fun is a betrayal of the injured," "the world is totally unsafe," "I am responsible for the disaster," or "life is without meaning," to more constructive ones)
Learning relaxation techniques
Undergoing exposure to avoided situations either via guided imagery and imagination or in vivo
Resources permitting, current data suggest that a 4- to 5-session course of CBT should be offered to those at high risk for developing PTSD. CBT should be performed by someone trained in the technique. Severe, relatively common destructive cognitions may arise after a traumatic event and need to be addressed.
On the left side of the Table below are malignant schemata that an individual may have after a traumatic event. On the right side are more constructive schemata that a clinician can suggest for consideration by the individual.
Cognitive Interventions
http://emedicine.medscape.com/article/295003-overview
Use of Low-Dose Aspirin in Primary Prevention of Cardiovascular Events Not Recommended
From Heartwire
Fran Lowry
Medscape Conference Coverage, based on selected sessions at the:
European Society of Cardiology (ESC) Congress 2009
This coverage is not sanctioned by, nor a part of, the European Society of Cardiology.
August 30, 2009 (Barcelona, Spain) — The use of low-dose aspirin in the primary prevention of cardiovascular events in healthy individuals with asymptomatic atherosclerosis is currently not warranted, according to the lead researcher of a large "real-world" study presented today at the European Society of Cardiology (ESC) 2009 Congress.
In the randomized trial of 3350 subjects deemed at high risk for cardiovascular and cerebrovascular events because of a low ankle-brachial index (ABI) (<0.95), aspirin had absolutely no effect on reducing events compared with placebo, Dr Gerry Fowkes (University of Edinburgh, Scotland) reported on behalf of the Aspirin for Asymptomatic Atherosclerosis (AAA) trialists.
However, aspirin did increase the risk of major hemorrhage.
The bleeding effect "is a real obstacle," Fowkes told heartwire . "I don't think the evidence is convincing enough as yet that aspirin should be used routinely in the general population."
The results of the trial are in conflict with findings from a meta-analysis from the Antithrombotic Trialists' (ATT) collaboration, which was published earlier this year in the Lancet [1], discussant Dr Carlo Patrono (Catholic University School of Medicine, Rome, Italy) told ESC attendees. He questioned how the results of AAA could be interpreted in light of the 12% relative risk reduction in serious cardiovascular events, largely driven by a reduction in nonfatal MI, that was seen in the ATT trial.
AAA Done Where the Need for Prevention Is Great
The AAA was a pragmatic trial, Fowkes explained, conducted in a deprived population in central Scotland, where rates of coronary heart disease and related mortality are high. "We wanted to get at where the problem actually existed in the population," he said.
Between 1998 and 2001, the AAA trialists invited men and women 50 to 75 years of age to undergo screening for asymptomatic atherosclerosis by measuring their ABI. A low ABI in otherwise-healthy individuals has been shown to be related to an increased risk of future cardiovascular events. Because it is simple and noninvasive, the ABI has the potential to be used as a screening test to detect high-risk individuals, Fowkes explained.
Of the more than 166 000 invitations that were sent out, the trialists ended up screening 28 980 individuals. Of this number, 3350 had a low ABI and were thus eligible to be entered into the trial.
They were randomly allocated to 100-mg enteric coated aspirin daily or to placebo and followed for a mean of 8.2 years. The primary end point of the trial was the composite of an initial fatal or nonfatal coronary event, stroke, or revascularization.
Secondary end points were all vascular events, which included a composite of initial fatal or nonfatal coronary event, stroke, or revascularization, angina, intermittent claudication, transient ischemic attack, and all-cause mortality.
Patients in both groups were matched for age (mean age 62 years), gender (roughly 30% were men), and comorbidities. One-third of the study population consisted of smokers.
Aspirin had no effect in terms of reducing cardiovascular and cerebrovascular events. In all, there were 357 events, 181 (10.8%) in the aspirin group and 176 (10.5%) in the placebo group (hazard ratio 1.03, 95% CI 0.84–1.27).
Interestingly, cancer mortality was higher in the placebo group than in the aspirin group, Fowkes noted.
Adverse events, including major hemorrhage, were greater in the aspirin group (HR 1.71, 95% CI 0.99–2.97).
Fowkes pointed out that 40% of patients were noncompliant and did not take their aspirin as prescribed over the duration of the trial. Such a low compliance rate could have affected the results. "The 60% compliance rate is the typical level of compliance that you will find in the primary-prevention setting, and obviously there are many reasons that people stop taking aspirin. So whether aspirin is beneficial in clinical practice among patients who have a low ankle-brachial index and who are fully compliant with aspirin is unknown, and so our results cannot be extrapolated to that situation," he said.
heartwire asked Fowkes what he thinks may work for primary prevention in people with asymptomatic atherosclerosis, now that aspirin appears to be ineffective. "We don't have any strong evidence about what would work, but I think that given that these are high-risk individuals, it is probably reasonable to give them a statin. I think it would prove to be cost-effective to give a statin," he said. "Obviously, there is the possibility of giving a stronger antiplatelet such as clopidogrel or some of these new drugs that are being developed, but one would have to trial those properly."
AAA Underpowered
Patrono said the AAA study may have been underpowered and suggested that was one reason for its negative findings. "The sample size would have to be about four times larger to achieve the power to show a 12% relative risk reduction," he said.
Other reasons: "The presence of peripheral arterial disease, whether symptomatic or asymptomatic, may render platelet activation more critically dependent on ATP than thromboxane release, and there is some experimental as well as clinical evidence supporting this possibility."
An accelerated platelet turnover associated with peripheral arterial disease--at least in some patients--may also be a cause for the discrepancy, Patrono said.
To try to dissect out potential explanations, Fowkes and Dr Colin Baigent (Oxford University, UK), lead author of the ATT trial, have agreed to see how the AAA study would fit into the ATT meta-analysis. When available, the results will be posted by the Clinical Trial Service Unit, Patrono said.
Fowkes told heartwire that there is no reason to think that the relative reduction in cardiovascular events created by aspirin should be different in the primary or secondary setting.
It's just that the benefits in the secondary setting far outweigh the risks. "The absolute reduction is much higher in secondary prevention than in primary prevention, but the level of bleeding is the same.
So in secondary prevention, you've got a big reduction in events and a small amount of bleeding. In primary prevention, you have a smaller amount of reduction of events, and the same amount of bleeding. These two have got to be counterbalanced in the primary-prevention situation, and that is where the concern is at the moment."
Fran Lowry
Medscape Conference Coverage, based on selected sessions at the:
European Society of Cardiology (ESC) Congress 2009
This coverage is not sanctioned by, nor a part of, the European Society of Cardiology.
August 30, 2009 (Barcelona, Spain) — The use of low-dose aspirin in the primary prevention of cardiovascular events in healthy individuals with asymptomatic atherosclerosis is currently not warranted, according to the lead researcher of a large "real-world" study presented today at the European Society of Cardiology (ESC) 2009 Congress.
In the randomized trial of 3350 subjects deemed at high risk for cardiovascular and cerebrovascular events because of a low ankle-brachial index (ABI) (<0.95), aspirin had absolutely no effect on reducing events compared with placebo, Dr Gerry Fowkes (University of Edinburgh, Scotland) reported on behalf of the Aspirin for Asymptomatic Atherosclerosis (AAA) trialists.
However, aspirin did increase the risk of major hemorrhage.
The bleeding effect "is a real obstacle," Fowkes told heartwire . "I don't think the evidence is convincing enough as yet that aspirin should be used routinely in the general population."
The results of the trial are in conflict with findings from a meta-analysis from the Antithrombotic Trialists' (ATT) collaboration, which was published earlier this year in the Lancet [1], discussant Dr Carlo Patrono (Catholic University School of Medicine, Rome, Italy) told ESC attendees. He questioned how the results of AAA could be interpreted in light of the 12% relative risk reduction in serious cardiovascular events, largely driven by a reduction in nonfatal MI, that was seen in the ATT trial.
AAA Done Where the Need for Prevention Is Great
The AAA was a pragmatic trial, Fowkes explained, conducted in a deprived population in central Scotland, where rates of coronary heart disease and related mortality are high. "We wanted to get at where the problem actually existed in the population," he said.
Between 1998 and 2001, the AAA trialists invited men and women 50 to 75 years of age to undergo screening for asymptomatic atherosclerosis by measuring their ABI. A low ABI in otherwise-healthy individuals has been shown to be related to an increased risk of future cardiovascular events. Because it is simple and noninvasive, the ABI has the potential to be used as a screening test to detect high-risk individuals, Fowkes explained.
Of the more than 166 000 invitations that were sent out, the trialists ended up screening 28 980 individuals. Of this number, 3350 had a low ABI and were thus eligible to be entered into the trial.
They were randomly allocated to 100-mg enteric coated aspirin daily or to placebo and followed for a mean of 8.2 years. The primary end point of the trial was the composite of an initial fatal or nonfatal coronary event, stroke, or revascularization.
Secondary end points were all vascular events, which included a composite of initial fatal or nonfatal coronary event, stroke, or revascularization, angina, intermittent claudication, transient ischemic attack, and all-cause mortality.
Patients in both groups were matched for age (mean age 62 years), gender (roughly 30% were men), and comorbidities. One-third of the study population consisted of smokers.
Aspirin had no effect in terms of reducing cardiovascular and cerebrovascular events. In all, there were 357 events, 181 (10.8%) in the aspirin group and 176 (10.5%) in the placebo group (hazard ratio 1.03, 95% CI 0.84–1.27).
Interestingly, cancer mortality was higher in the placebo group than in the aspirin group, Fowkes noted.
Adverse events, including major hemorrhage, were greater in the aspirin group (HR 1.71, 95% CI 0.99–2.97).
Fowkes pointed out that 40% of patients were noncompliant and did not take their aspirin as prescribed over the duration of the trial. Such a low compliance rate could have affected the results. "The 60% compliance rate is the typical level of compliance that you will find in the primary-prevention setting, and obviously there are many reasons that people stop taking aspirin. So whether aspirin is beneficial in clinical practice among patients who have a low ankle-brachial index and who are fully compliant with aspirin is unknown, and so our results cannot be extrapolated to that situation," he said.
heartwire asked Fowkes what he thinks may work for primary prevention in people with asymptomatic atherosclerosis, now that aspirin appears to be ineffective. "We don't have any strong evidence about what would work, but I think that given that these are high-risk individuals, it is probably reasonable to give them a statin. I think it would prove to be cost-effective to give a statin," he said. "Obviously, there is the possibility of giving a stronger antiplatelet such as clopidogrel or some of these new drugs that are being developed, but one would have to trial those properly."
AAA Underpowered
Patrono said the AAA study may have been underpowered and suggested that was one reason for its negative findings. "The sample size would have to be about four times larger to achieve the power to show a 12% relative risk reduction," he said.
Other reasons: "The presence of peripheral arterial disease, whether symptomatic or asymptomatic, may render platelet activation more critically dependent on ATP than thromboxane release, and there is some experimental as well as clinical evidence supporting this possibility."
An accelerated platelet turnover associated with peripheral arterial disease--at least in some patients--may also be a cause for the discrepancy, Patrono said.
To try to dissect out potential explanations, Fowkes and Dr Colin Baigent (Oxford University, UK), lead author of the ATT trial, have agreed to see how the AAA study would fit into the ATT meta-analysis. When available, the results will be posted by the Clinical Trial Service Unit, Patrono said.
Fowkes told heartwire that there is no reason to think that the relative reduction in cardiovascular events created by aspirin should be different in the primary or secondary setting.
It's just that the benefits in the secondary setting far outweigh the risks. "The absolute reduction is much higher in secondary prevention than in primary prevention, but the level of bleeding is the same.
So in secondary prevention, you've got a big reduction in events and a small amount of bleeding. In primary prevention, you have a smaller amount of reduction of events, and the same amount of bleeding. These two have got to be counterbalanced in the primary-prevention situation, and that is where the concern is at the moment."
Wednesday, January 13, 2010
Office-Based Childhood Measures May Help Predict Future Type 2 Diabetes
From Medscape Medical News
Laurie Barclay, MD
January 6, 2010 — Office-based childhood measures may help predict future long-term risk for type 2 diabetes mellitus (T2DM), according to the results of a study reported in the January 2010 issue of Archives of Pediatric & Adolescent Medicine.
"In the past 25 years, the prevalences of obesity and...T2DM have increased concomitantly, and the age at onset of T2DM has dropped precipitously, especially in black females," write John A. Morrison, PhD, from Cincinnati Children's Hospital Medical Center in Cincinnati, Ohio, and colleagues. "Models to identify children at increased and very low risk for young-adult T2DM could provide diagnostic and therapeutic insights into etiologic relationships of hyperinsulinemia, insulin resistance, and obesity with the development of T2DM and could provide targeted avenues for prevention."
The goal of the study was to assess whether pediatric office measures (waist circumference, body mass index [BMI], systolic and diastolic blood pressure, and parental diabetes) and laboratory measures (glucose, triglyceride, high-density lipoprotein cholesterol, and insulin levels) could help predict T2DM risk at ages 19 and 39 years.
At urban and suburban schools, 1067 girls enrolled in the National Growth and Health Study at age 10 years and 822 schoolchildren aged 6 to 18 years at entry in the Princeton Follow-up Study had follow-up evaluations at 9 and 26 years. The primary endpoint was development of T2DM.
In the Princeton Follow-up Study, predictors of T2DM at age 39 years were childhood systolic blood pressure and BMI in the top fifth percentile and black race (area under the receiver-operator curve [AUC], 0.698). When childhood glucose levels of 100 mg/dL or more and high-density lipoprotein cholesterol in the bottom fifth percentile and triglyceride concentration in the top fifth percentile were added as explanatory variables, AUC increased to 0.717 and 0.709, respectively. The likelihood of T2DM at age 39 years was 2% if childhood BMI, systolic blood pressure, and diastolic blood pressure were all lower than the 75th percentile, and this decreased further to 1% if the parents had no diabetes.
Systolic blood pressure in the top fifth percentile and parental diabetes predicted T2DM at age 19 years among children enrolled in the National Growth and Heath Study (AUC, 0.699). When insulin in the top fifth percentile was added, AUC was increased to 0.764, with insulin being a significant variable. The likelihood of T2DM at age 19 years was 0.2% if childhood BMI, systolic blood pressure, and diastolic blood pressure were all lower than the 75th percentile; 0.2% if the parents also did not have diabetes; and 0.3% if childhood insulin level was also below the 75th percentile.
"Office-based childhood measures predict the presence and absence of future T2DM 9 and 26 years after baseline," the study authors write. "Childhood insulin measurement improves prediction, facilitating approaches to primary prevention of T2DM."
Limitations of this study include childhood insulin measured only in the National Growth and Health Study and not in the Princeton Follow-up Study, length of follow-up 22 to 30 years in the Princeton Follow-up Study vs 9 years in the National Growth and Health Study, inability to differentiate type 1 from T2DM in insulin users at follow-up, and lack of certain laboratory tests.
"Our data have practical clinical value in assessment of preteen-aged and teenaged children, since children with SBP [systolic blood pressure], triglyceride, BMI, and insulin in the top fifth percentile, a glucose concentration of at least 100 mg/dL, and a parent with diabetes could be targeted for primary prevention of T2DM through diet, exercise, and possibly insulin-sensitizing drug intervention, with special focus on overweight children with a positive family history of DM," the study authors conclude.
The National Institutes of Health, the American Heart Association, the Taft Research Fund, and the Lipoprotein Research Fund of the Jewish Hospital of Cincinnati helped support this study. The study authors have disclosed no relevant financial relationships.
Arch Pediatr Adolesc Med. 2010;164:53-60. Abstract
Laurie Barclay, MD
January 6, 2010 — Office-based childhood measures may help predict future long-term risk for type 2 diabetes mellitus (T2DM), according to the results of a study reported in the January 2010 issue of Archives of Pediatric & Adolescent Medicine.
"In the past 25 years, the prevalences of obesity and...T2DM have increased concomitantly, and the age at onset of T2DM has dropped precipitously, especially in black females," write John A. Morrison, PhD, from Cincinnati Children's Hospital Medical Center in Cincinnati, Ohio, and colleagues. "Models to identify children at increased and very low risk for young-adult T2DM could provide diagnostic and therapeutic insights into etiologic relationships of hyperinsulinemia, insulin resistance, and obesity with the development of T2DM and could provide targeted avenues for prevention."
The goal of the study was to assess whether pediatric office measures (waist circumference, body mass index [BMI], systolic and diastolic blood pressure, and parental diabetes) and laboratory measures (glucose, triglyceride, high-density lipoprotein cholesterol, and insulin levels) could help predict T2DM risk at ages 19 and 39 years.
At urban and suburban schools, 1067 girls enrolled in the National Growth and Health Study at age 10 years and 822 schoolchildren aged 6 to 18 years at entry in the Princeton Follow-up Study had follow-up evaluations at 9 and 26 years. The primary endpoint was development of T2DM.
In the Princeton Follow-up Study, predictors of T2DM at age 39 years were childhood systolic blood pressure and BMI in the top fifth percentile and black race (area under the receiver-operator curve [AUC], 0.698). When childhood glucose levels of 100 mg/dL or more and high-density lipoprotein cholesterol in the bottom fifth percentile and triglyceride concentration in the top fifth percentile were added as explanatory variables, AUC increased to 0.717 and 0.709, respectively. The likelihood of T2DM at age 39 years was 2% if childhood BMI, systolic blood pressure, and diastolic blood pressure were all lower than the 75th percentile, and this decreased further to 1% if the parents had no diabetes.
Systolic blood pressure in the top fifth percentile and parental diabetes predicted T2DM at age 19 years among children enrolled in the National Growth and Heath Study (AUC, 0.699). When insulin in the top fifth percentile was added, AUC was increased to 0.764, with insulin being a significant variable. The likelihood of T2DM at age 19 years was 0.2% if childhood BMI, systolic blood pressure, and diastolic blood pressure were all lower than the 75th percentile; 0.2% if the parents also did not have diabetes; and 0.3% if childhood insulin level was also below the 75th percentile.
"Office-based childhood measures predict the presence and absence of future T2DM 9 and 26 years after baseline," the study authors write. "Childhood insulin measurement improves prediction, facilitating approaches to primary prevention of T2DM."
Limitations of this study include childhood insulin measured only in the National Growth and Health Study and not in the Princeton Follow-up Study, length of follow-up 22 to 30 years in the Princeton Follow-up Study vs 9 years in the National Growth and Health Study, inability to differentiate type 1 from T2DM in insulin users at follow-up, and lack of certain laboratory tests.
"Our data have practical clinical value in assessment of preteen-aged and teenaged children, since children with SBP [systolic blood pressure], triglyceride, BMI, and insulin in the top fifth percentile, a glucose concentration of at least 100 mg/dL, and a parent with diabetes could be targeted for primary prevention of T2DM through diet, exercise, and possibly insulin-sensitizing drug intervention, with special focus on overweight children with a positive family history of DM," the study authors conclude.
The National Institutes of Health, the American Heart Association, the Taft Research Fund, and the Lipoprotein Research Fund of the Jewish Hospital of Cincinnati helped support this study. The study authors have disclosed no relevant financial relationships.
Arch Pediatr Adolesc Med. 2010;164:53-60. Abstract
Tuesday, January 12, 2010
Nausea and Vomiting in Acute MI Don't Predict Infarct Site
From Reuters Health Information
NEW YORK (Reuters Health) Jan 08 - Nausea and vomiting in a patient with acute myocardial infarction (AMI) do not predict the site of the infarct, new research shows.
The investigators note in their paper that some studies say nausea and vomiting are more common when the inferior portion of the left ventricle is involved, but "other studies have found just the opposite."
In email to Reuters Health, senior researcher Dr. Mark Feldman from Texas Health, Presbyterian Hospital, Dallas, pointed out that knowing the location of the infarct can be "important because anterior AMI has a worse prognosis than inferior AMI."
Therefore, he and his colleagues re-examined the relationship between infarct location and nausea and vomiting in 180 patients with either acute ST-segment elevation AMI or AMI associated with left bundle branch block.
Forty percent of the infarctions were in the anterior wall.
Nearly two thirds of the patients (64%) presented with nausea and almost one third (31%) presented with vomiting, the investigators report in the December 15th issue of the American Journal of Cardiology.
Although there was a trend toward higher rates of nausea and vomiting with inferior AMI, the difference was not statistically significant.
Rates of nausea and vomiting, respectively, were 69% and 33% in patients with inferior AMI, and 57% and 26% in patients with anterior AMI.
Dr. Feldman said he was not surprised at the lack of association between nausea and vomiting and infarct location, "but a study was needed to confirm or refute my impressions."
Am J Cardiol 2009;104:1638-1640.
NEW YORK (Reuters Health) Jan 08 - Nausea and vomiting in a patient with acute myocardial infarction (AMI) do not predict the site of the infarct, new research shows.
The investigators note in their paper that some studies say nausea and vomiting are more common when the inferior portion of the left ventricle is involved, but "other studies have found just the opposite."
In email to Reuters Health, senior researcher Dr. Mark Feldman from Texas Health, Presbyterian Hospital, Dallas, pointed out that knowing the location of the infarct can be "important because anterior AMI has a worse prognosis than inferior AMI."
Therefore, he and his colleagues re-examined the relationship between infarct location and nausea and vomiting in 180 patients with either acute ST-segment elevation AMI or AMI associated with left bundle branch block.
Forty percent of the infarctions were in the anterior wall.
Nearly two thirds of the patients (64%) presented with nausea and almost one third (31%) presented with vomiting, the investigators report in the December 15th issue of the American Journal of Cardiology.
Although there was a trend toward higher rates of nausea and vomiting with inferior AMI, the difference was not statistically significant.
Rates of nausea and vomiting, respectively, were 69% and 33% in patients with inferior AMI, and 57% and 26% in patients with anterior AMI.
Dr. Feldman said he was not surprised at the lack of association between nausea and vomiting and infarct location, "but a study was needed to confirm or refute my impressions."
Am J Cardiol 2009;104:1638-1640.
First Look at Effects of Resting Heart Rate and Exercise on Heart-Disease Deaths
From Heartwire
Lisa Nainggolan
January 12, 2010 (Trondheim, Norway) — A high resting heart rate (HR) is associated with a higher risk of death from ischemic heart disease (IHD), particularly in younger women, new research shows [1]. While women were able to temper this adverse effect to some extent by exercising, the same did not seem to be true in men, the researchers report.
The risk of dying from IHD rose 18% for every 10-beats-per-minute (bpm) increase in resting HR in women up to the age of 70, report Dr Javaid Nauman (Norwegian University of Science and Technology, Trondheim, Norway) and colleagues in a study published online January 11, 2010 in the Journal of Epidemiology & Community Health. In men, there was around a 10% higher risk of IHD mortality for every 10 bpm increase in resting HR, regardless of age.
This is the first study to account for the combined effect of resting heart rate and physical activity on deaths from ischemic heart disease in a population that was reported to be free from cardiovascular disease at baseline, say Nauman et al.
Nauman told heartwire that in apparently healthy individuals, "clinicians are reluctant to prescribe heart-rate–lowering drugs," so an important message from this study is that there are nonpharmacological means to modulate heart rate. "By engaging in physical activity of moderate or high intensity, you can keep your heart rate in check and get the benefits. Do some workout and you will get the reward."
Men in Highest Quintile of Resting HR 73% More Likely to Die From IHD
In their prospective cohort study, the researchers enrolled and followed 25 000 men and 25 000 women from a county in Norway who were free from cardiovascular disease at baseline, from 1984 to 1986, in the HUNT study.
Information was collected on general health and lifestyle, including the frequency and intensity of exercise performed in a week, with five response options: 0, <1, 1, 2–3, and >4 times. Those who reported exercising at least once a week were also asked about the average duration (<15, 15–30, 30–60, >60 minutes) and intensity (light, moderate, or vigorous) of exercise. To assess the effect of total exercise volume, a summary score was constructed combining information on frequency, duration, and intensity.
During a mean of 18.2 years of follow-up, 2566 men and 1814 women died from cardiovascular causes. Resting HR was positively associated with the risk of cardiovascular disease, in particular IHD, in men, showing a gradual increase in mortality with increasing HR.
In men whose HR was 101 bpm or more (the highest quintile), the adjusted hazard ratio for IHD mortality was 1.73 compared with those in the reference group, whose resting HR was considered to be in the "normal" range of 61 to 72 bpm.
Among men, this association did not substantially differ by age. For each increment of 10 resting heart beats per minute among men, there was a 10% higher risk of death from IHD in those under 70 (p=0.004) and an 11% higher risk of death in the older age group (p=0.01).
Effects in Women Appear Age-Dependent
In women, the adjusted hazard ratio was 1.42 for IHD mortality in the highest quintile of women compared with those in the reference group.
In contrast to the men, the effects of resting HR were strongly dependent on age in women. Younger women (under 70) in the highest quintile for resting HR were twice as likely to die from IHD as those in the reference group (adjusted hazard ratio 2.11). But in those aged 70 and over, the corresponding hazard ratio was 0.95.
For each increment of 10 resting heart beats per minute, the risk of death from IHD was 18% higher in women less than 70 (p<0.001); no such association was observed among women 70 years and older.
"This effect could be caused by deaths at a relatively young age in women who were particularly vulnerable to a high resting HR," the researchers speculate.
"The present results contribute to extend the literature on the epidemiology of cardiovascular disease among women, as previously, data among women have been sparse, except for one large cohort study of postmenopausal women that showed that resting HR is an independent predictor of coronary events," say Nauman et al.
Physical Activity Protective, Particularly in Women
People who reported no physical activity were at consistently higher risk of CVD than those who reported any level of physical activity.
The findings with regard to exercise in women suggest that by being physically active, women with a high resting heart rate could avoid cardiovascular complications, say the Norwegian doctors.
Why exercise did not seem to attenuate the association of high resting HR with deaths from IHD among men remains unclear, they add, although it could be that men, "more so than women, tend to overestimate their levels of physical activity, and this in turn could have influenced the results.
"Future studies are warranted to investigate the association of resting HR and physical activity to assess the combination of intensity and volumes to have an optimal influence on IHD mortality," they conclude.
http://www.medscape.com/viewarticle/714974?sssdmh=dm1.580257&src=nldne&uac=71630FV
Lisa Nainggolan
January 12, 2010 (Trondheim, Norway) — A high resting heart rate (HR) is associated with a higher risk of death from ischemic heart disease (IHD), particularly in younger women, new research shows [1]. While women were able to temper this adverse effect to some extent by exercising, the same did not seem to be true in men, the researchers report.
The risk of dying from IHD rose 18% for every 10-beats-per-minute (bpm) increase in resting HR in women up to the age of 70, report Dr Javaid Nauman (Norwegian University of Science and Technology, Trondheim, Norway) and colleagues in a study published online January 11, 2010 in the Journal of Epidemiology & Community Health. In men, there was around a 10% higher risk of IHD mortality for every 10 bpm increase in resting HR, regardless of age.
This is the first study to account for the combined effect of resting heart rate and physical activity on deaths from ischemic heart disease in a population that was reported to be free from cardiovascular disease at baseline, say Nauman et al.
Nauman told heartwire that in apparently healthy individuals, "clinicians are reluctant to prescribe heart-rate–lowering drugs," so an important message from this study is that there are nonpharmacological means to modulate heart rate. "By engaging in physical activity of moderate or high intensity, you can keep your heart rate in check and get the benefits. Do some workout and you will get the reward."
Men in Highest Quintile of Resting HR 73% More Likely to Die From IHD
In their prospective cohort study, the researchers enrolled and followed 25 000 men and 25 000 women from a county in Norway who were free from cardiovascular disease at baseline, from 1984 to 1986, in the HUNT study.
Information was collected on general health and lifestyle, including the frequency and intensity of exercise performed in a week, with five response options: 0, <1, 1, 2–3, and >4 times. Those who reported exercising at least once a week were also asked about the average duration (<15, 15–30, 30–60, >60 minutes) and intensity (light, moderate, or vigorous) of exercise. To assess the effect of total exercise volume, a summary score was constructed combining information on frequency, duration, and intensity.
During a mean of 18.2 years of follow-up, 2566 men and 1814 women died from cardiovascular causes. Resting HR was positively associated with the risk of cardiovascular disease, in particular IHD, in men, showing a gradual increase in mortality with increasing HR.
In men whose HR was 101 bpm or more (the highest quintile), the adjusted hazard ratio for IHD mortality was 1.73 compared with those in the reference group, whose resting HR was considered to be in the "normal" range of 61 to 72 bpm.
Among men, this association did not substantially differ by age. For each increment of 10 resting heart beats per minute among men, there was a 10% higher risk of death from IHD in those under 70 (p=0.004) and an 11% higher risk of death in the older age group (p=0.01).
Effects in Women Appear Age-Dependent
In women, the adjusted hazard ratio was 1.42 for IHD mortality in the highest quintile of women compared with those in the reference group.
In contrast to the men, the effects of resting HR were strongly dependent on age in women. Younger women (under 70) in the highest quintile for resting HR were twice as likely to die from IHD as those in the reference group (adjusted hazard ratio 2.11). But in those aged 70 and over, the corresponding hazard ratio was 0.95.
For each increment of 10 resting heart beats per minute, the risk of death from IHD was 18% higher in women less than 70 (p<0.001); no such association was observed among women 70 years and older.
"This effect could be caused by deaths at a relatively young age in women who were particularly vulnerable to a high resting HR," the researchers speculate.
"The present results contribute to extend the literature on the epidemiology of cardiovascular disease among women, as previously, data among women have been sparse, except for one large cohort study of postmenopausal women that showed that resting HR is an independent predictor of coronary events," say Nauman et al.
Physical Activity Protective, Particularly in Women
People who reported no physical activity were at consistently higher risk of CVD than those who reported any level of physical activity.
The findings with regard to exercise in women suggest that by being physically active, women with a high resting heart rate could avoid cardiovascular complications, say the Norwegian doctors.
Why exercise did not seem to attenuate the association of high resting HR with deaths from IHD among men remains unclear, they add, although it could be that men, "more so than women, tend to overestimate their levels of physical activity, and this in turn could have influenced the results.
"Future studies are warranted to investigate the association of resting HR and physical activity to assess the combination of intensity and volumes to have an optimal influence on IHD mortality," they conclude.
http://www.medscape.com/viewarticle/714974?sssdmh=dm1.580257&src=nldne&uac=71630FV
Friday, January 1, 2010
CRP Screening, and Aggressive Statin Therapy-implications for the Primary Prevention of Cardiovascular Disease
From Therapeutic Advances in Cardiovascular Disease
The Jupiter Study,
Richard Kones
Abstract
CRP levels are strong, independent predictors of cardiovascular risk and can enhance risk stratification.
Jupiter enrolled 17 802 apparently healthy middle-aged men and women with CRP levels over 2.0 mg/l, and LDL less than 130 mg/dl.
They were randomized to receive rosuvastatin 20mg daily or placebo, and followed for a primary endpoint of nonfatal myocardial infarction, stroke, arterial revascularization, hospitalization for unstable angina, or cardiovascular death for 1.9 years.
Rosuvastatin lowered CRP (37%), LDL (50%), nonfatal myocardial infarction (55%), nonfatal stroke (48%), hospitalization and revascularization (47%), all-cause mortality (20%), and benefited women and minority subgroups. Rosuvastatin was tolerated relatively well, with a small rise in physician-reported diabetes.
Jupiter data suggest that patients with high levels of CRP should receive statins. Approximately 4.3% of the population satisfies Jupiter inclusion criteria. A review of the assessment of cardiovascular risk is under way at the National Institutes of Health to guide practitioners.
Introduction
Controversy about the clinical role of inflammatory biomarkers has heightened over the past decade [Ware, 2008; Wang et al. 2006; Greenland et al. 2001; Koenig, 2001; Rifai and Ridker, 2001; Kannel et al. 1961].
In addition, there has been growing concern about the shortcomings of current risk assessment point scores designed to stratify cardiovascular risk [Wilson, 2008; Ridker et al. 2004; Pearson et al. 2003].
C-reactive protein is an inflammatory marker which has been proposed for inclusion in risk factor assessment grids [Everett and Ridker, 2008; Capuzzi and Freeman, 2007; Ridker, 2001], and new data about its value now appear compelling.
The plenary session of the American Heart Association Annual Scientific Session last year began with a landmark report, The JUPITER Trial—Rosuvastatin in the Prevention of Cardiovascular Events Among 17 802 Men and Women with Elevated Levels of C-Reactive Protein, showing a surprisingly high reduction in cardiovascular events among healthy individuals with elevated C-reactive protein (CRP) as a result of rosuvastatin therapy.
The study, simultaneously published online in the New England Journal of Medicine [Ridker et al. 2008a], generated data which were remarkable in several ways, and will surely impact both the thinking and practice of primary prevention.
The characteristics of the Jupiter study, an acronym for Justification for the Use of statins in Primary prevention: an Intervention Trial Evaluating Rosuvastatin, have been previously described [Ridker et al. 2007a; Ridker, 2003]. Debate about Jupiter and its implications has continued unabated through 2009 as well, which only attests to its potential significance.
Jupiter enrolled 17 802 apparently healthy middle-aged men (≥50 years) and women (≥60 years) from 1315 sites in 26 countries.
Patients were free of diabetes and heart disease, with normal low-density lipoprotein levels (LDL < 130 mg/dl), but high hs-C reactive protein (CRP) levels (≥2.0 mg/l, median, 4.2 mg/l).
Participants were randomly assigned into two groups: either treated with rosuvastatin, 20mg daily, or placebo. Salient baseline patient data are summarized in Table 1. Enrollees were followed for a primary composite end point of myocardial infarction, hospitalization for unstable angina, heart-related death, arterial revascularization or stroke. Although planned as a 4-year study, the trial was stopped after a median follow-up time of 1.9 years based upon advice from an independent monitoring board and study steering committee.
Rosuvastatin lowered CRP levels by 37% (down to a 12-month mean, in the treated group, of 2.2; lowered LDL by 50% (down to a 12-month mean, in the treated group, of 55) and sharply decreased the number of cardiovascular events and all-cause mortality.
At the end of 1.9 years, rosuvastatin therapy significantly lowered the primary composite end point by 44% compared with placebo.
In particular, there was a 55% lowering of nonfatal MI, 48% fall in the risk of non-fatal stroke, and a 47% fall in the risk of serious cardiac events (Table 2).
The reduction in vascular risk was greater in Jupiter than in previous statin trials.
The number of physician-reported new cases of diabetes was 270 in the rosuvastatin group and 216 in the untreated group, with a small rise in median glycosylated hemoglobin (A1c), previously noted in statin studies. Ten instances of myopathy, and one case of rhabdomyolysis were reported in the treatment group, with nine and none, respectively, in the untreated group.
At the end of the trial, 75% of participants were taking rosuvastatin. The number needed to treat for 2 years to prevent one primary event was 95; treatment for 4 years lowered it to 31, and for 5 years, the number to treat fell to 25.
The Jupiter Study,
Richard Kones
Abstract
CRP levels are strong, independent predictors of cardiovascular risk and can enhance risk stratification.
Jupiter enrolled 17 802 apparently healthy middle-aged men and women with CRP levels over 2.0 mg/l, and LDL less than 130 mg/dl.
They were randomized to receive rosuvastatin 20mg daily or placebo, and followed for a primary endpoint of nonfatal myocardial infarction, stroke, arterial revascularization, hospitalization for unstable angina, or cardiovascular death for 1.9 years.
Rosuvastatin lowered CRP (37%), LDL (50%), nonfatal myocardial infarction (55%), nonfatal stroke (48%), hospitalization and revascularization (47%), all-cause mortality (20%), and benefited women and minority subgroups. Rosuvastatin was tolerated relatively well, with a small rise in physician-reported diabetes.
Jupiter data suggest that patients with high levels of CRP should receive statins. Approximately 4.3% of the population satisfies Jupiter inclusion criteria. A review of the assessment of cardiovascular risk is under way at the National Institutes of Health to guide practitioners.
Introduction
Controversy about the clinical role of inflammatory biomarkers has heightened over the past decade [Ware, 2008; Wang et al. 2006; Greenland et al. 2001; Koenig, 2001; Rifai and Ridker, 2001; Kannel et al. 1961].
In addition, there has been growing concern about the shortcomings of current risk assessment point scores designed to stratify cardiovascular risk [Wilson, 2008; Ridker et al. 2004; Pearson et al. 2003].
C-reactive protein is an inflammatory marker which has been proposed for inclusion in risk factor assessment grids [Everett and Ridker, 2008; Capuzzi and Freeman, 2007; Ridker, 2001], and new data about its value now appear compelling.
The plenary session of the American Heart Association Annual Scientific Session last year began with a landmark report, The JUPITER Trial—Rosuvastatin in the Prevention of Cardiovascular Events Among 17 802 Men and Women with Elevated Levels of C-Reactive Protein, showing a surprisingly high reduction in cardiovascular events among healthy individuals with elevated C-reactive protein (CRP) as a result of rosuvastatin therapy.
The study, simultaneously published online in the New England Journal of Medicine [Ridker et al. 2008a], generated data which were remarkable in several ways, and will surely impact both the thinking and practice of primary prevention.
The characteristics of the Jupiter study, an acronym for Justification for the Use of statins in Primary prevention: an Intervention Trial Evaluating Rosuvastatin, have been previously described [Ridker et al. 2007a; Ridker, 2003]. Debate about Jupiter and its implications has continued unabated through 2009 as well, which only attests to its potential significance.
Jupiter enrolled 17 802 apparently healthy middle-aged men (≥50 years) and women (≥60 years) from 1315 sites in 26 countries.
Patients were free of diabetes and heart disease, with normal low-density lipoprotein levels (LDL < 130 mg/dl), but high hs-C reactive protein (CRP) levels (≥2.0 mg/l, median, 4.2 mg/l).
Participants were randomly assigned into two groups: either treated with rosuvastatin, 20mg daily, or placebo. Salient baseline patient data are summarized in Table 1. Enrollees were followed for a primary composite end point of myocardial infarction, hospitalization for unstable angina, heart-related death, arterial revascularization or stroke. Although planned as a 4-year study, the trial was stopped after a median follow-up time of 1.9 years based upon advice from an independent monitoring board and study steering committee.
Rosuvastatin lowered CRP levels by 37% (down to a 12-month mean, in the treated group, of 2.2; lowered LDL by 50% (down to a 12-month mean, in the treated group, of 55) and sharply decreased the number of cardiovascular events and all-cause mortality.
At the end of 1.9 years, rosuvastatin therapy significantly lowered the primary composite end point by 44% compared with placebo.
In particular, there was a 55% lowering of nonfatal MI, 48% fall in the risk of non-fatal stroke, and a 47% fall in the risk of serious cardiac events (Table 2).
The reduction in vascular risk was greater in Jupiter than in previous statin trials.
The number of physician-reported new cases of diabetes was 270 in the rosuvastatin group and 216 in the untreated group, with a small rise in median glycosylated hemoglobin (A1c), previously noted in statin studies. Ten instances of myopathy, and one case of rhabdomyolysis were reported in the treatment group, with nine and none, respectively, in the untreated group.
At the end of the trial, 75% of participants were taking rosuvastatin. The number needed to treat for 2 years to prevent one primary event was 95; treatment for 4 years lowered it to 31, and for 5 years, the number to treat fell to 25.
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