Building Healthy Adults Starts in Childhood

From Medscape Medical News > Psychiatry Megan Brooks December 28, 2011 — Extensive evidence indicates that early childhood adversity and “toxic stress” have harmful effects on mental and physical health that can last a lifetime, warns a new technical report from the American Academy of Pediatrics (AAP). In an accompanying policy statement, the AAP advocates incorporating the growing scientific knowledge base that links childhood adversity to lifelong harm into the training of all current and future physicians. The report and policy statement were published online December 26 and will appear in the January 2012 print issue of Pediatrics. "Potentially Transformational" Drawing on multiple lines of investigation in biological, behavioral, and social sciences, the authors of the technical report present an ecobiodevelopmental (EBD) framework that illustrates how early childhood experiences and environmental influences can shape lifelong learning, behavior, and health. The authors summarize what they call “extensive evidence” linking early adversity to later impairments in learning, behavior, and physical and mental well-being. The implications of this EBD framework for the practice of medicine are “potentially transformational,” Jack P. Shonkoff, MD, director of the Center on the Developing Child at Harvard University, Boston, Massachusetts, and colleagues note in the report. It suggests that many adult diseases “should be viewed as developmental disorders that begin early in life and that persistent health disparities associated with poverty, discrimination, or maltreatment could be reduced by the alleviation of toxic stress in childhood,” they write. In the accompanying policy statement, the AAP says, “All health care professionals should adopt the proposed EBD framework as a means of understanding the social, behavioral, and economic determinants of lifelong disparities in physical and mental health.” Pediatrics. 2012;129: Published online December 26, 2011. Report, Policy Statement

Does the Cranberry Beat Antibiotics for Recurrent UTIs?

From Medscape Internal Medicine > Medicine Matters Medicine Matters , Medscape Sandra A. Fryhofer, MD Posted: 12/22/2011 Hello. I'm Dr. Sandra Fryhofer. Welcome to Medicine Matters. The topic? Relief for recurrent urinary tract infections (UTIs): cranberries or antibiotics? A new study in the Archives of Internal Medicine explores which approach is best. Urinary tract infections are common. About half of all women have had at least one. For those who have had at least 2 or more UTIs per year, low-dose antibiotics are often prescribed for prevention, but this can create strains -- usually Escherichia coli -- that are resistant to most antibiotics. So, is a more organic treatment, such as cranberries, preferable? Cranberries have been used as the alternative treatment of choice for UTI prevention for years. Exactly how they work isn't totally clear. Cranberries contain both fructose and Type A proanthocyanadins (PACs) that prevent bacteria from attaching to the urinary tract lining. A combined look at 2 randomized control trials found that cranberry products do work better than placebo. They reduced risk of UTI recurrence by 39%. However, unlike these studies, the one discussed in this commentary compared cranberries to an antibiotic -- trimethoprim sulfa (Bactrim®). This was a year-long, double-blind, double-dummy, randomized, noninferiority trial of more than 200 premenopausal women with recurrent UTIs. Patients received either trimethoprim sulfa, 480 mg once a day, or cranberry capsules, 500 mg twice a day. The PAC dose in the cranberries was 9.1 mg. Antibiotics were better at preventing urinary tract infections in the women. However, bacteria did become more resistant to trimethoprim sulfa as well as amoxicillin and ciprofloxacin. Increased resistance was not seen in the cranberry group. There is a caveat. Research published in the journal BMC Infectious Diseases finds that 72 mg of PACs prevent bacteria from adhering to the urinary tract lining. This is much higher than the 9.1 milligrams used in this study. Does more cranberry equal more prevention? It might be worth another study.

DHEA Hormone May Help Women Through Menopause

From Reuters Health Information By Kate Kelland LONDON (Reuters) Dec 20 - A hormone called DHEA and mostly secreted by the adrenal glands might be able to help women who are going through menopause and could also give them better sex lives, according to a preliminary study out Tuesday. Italian researchers writing in the journal of the International Menopause Society, Climacteric, said they had found the first robust evidence that low doses of DHEA can help sexual function and menopausal symptoms, suggesting it may one day become an alternative to hormone replacement therapy (HRT). But they stressed that the trial was small, so far larger studies are needed to confirm the results. "We must bear in mind that this is a pilot study with a small sample," Dr. Anna Fenton, co-editor of Climacteric, said in commentary on the work. "We can't yet say that this study means that DHEA is a viable alternative to HRT, but ... we should be looking to do larger studies to confirm these initial results." DHEA, or dehydroepiandrosterone, is a natural steroid hormone mostly made in the adrenal glands and has a variety of therapeutic uses. Sales of HRT drugs have fallen sharply since the Women's Health Initiative study in 2002 found higher rates of ovarian cancer, breast cancer and strokes in women who took the pills, and the search has since been on for alternatives. American researchers said in January that the antidepressant Lexapro, made by drugmaker Forest Laboratories, significantly cut the number and severity of hot flushes in menopausal women, and other antidepressants including GlaxoSmithKline's Paxil and the Pfizer drugs Prozac and Effexor also have been found to be effective. For this trial, a team of researchers led by Dr. Andrea Genazzani of the University of Pisa followed a group of 48 post-menopausal women with troubling symptoms. Over a year, 12 women took vitamin D and calcium, 12 took DHEA 10 mg daily, 12 took standard HRT (1 mg estradiol plus 5 mg dihydrogesterone daily), and 12 took a synthetic steroid called tibolone (2.5 mg daily) which is used to alleviate menopausal symptoms. The women's menopausal symptoms, sexual interest and activity were measured using a standard questionnaire that explores factors such as satisfaction with frequency of sex, vaginal lubrication, orgasm, and sexual partner. After 12 months, all the women on hormone replacements had improvements in menopausal symptoms, but those taking vitamin D and calcium did not show any significant improvement. At the start of the trial, all groups had similar sexual activity, but after the year, those taking calcium and vitamin D scored an average of 34.9 on the questionnaire scale, while those taking DHEA had a score of 48.6, showing that those on DHEA had more sexual interest and activity. The results for the HRT group were similar, and both the HRT and DHEA groups showed a higher level of sexual intercourse in comparison to the control group, the researchers said. Dr. Genazzani said the results showed DHEA has potential, especially for those women who may have problems in taking more conventional HRT. "But this is a small study, a proof of concept," she cautioned. "What we need to do now is to look at a larger study, to confirm that these initial results are valid," she added. SOURCE: http://bit.ly/vuMZnp

French Breast Implant Fears Spread Around World

From Reuters Health Information By Kate Kelland and Daniel Flynn LONDON/PARIS (Reuters) Dec 22 - Fears over the safety of silicone breast implants made by a now defunct French firm spread to Australia, South America and across Europe on Thursday as French officials prepared to decide if thousands of women should have their implants surgically removed. The silicone gel implants, made by a company called Poly Implant Prosthese (PIP) which was shut down in 2010, appear to have an unusually high rupture rate and have sparked an investigation in France into possible links to cancer. Some 300,000 PIP implants, which are used in cosmetic surgery to enhance breast size or replace lost breast tissue, were sold worldwide before PIP went bust last year. "It's not just France that's concerned. We're looking at 300,000 to 400,000 potential victims in the world," said Alexandra Blachere, the leader of a French PIP implant patient group. She said women from Italy and Spain had been in touch with her with worries about their implants, and she'd seen reports of problems in Venezuela, Brazil and elsewhere. Britain's drugs watchdog the Medicines and Healthcare products Regulatory Agency (MHRA) said, however, that there was no reason for patients to be alarmed and stressed as there is currently no scientific evidence to suggest increased health risks. MHRA officials said they had talked to other health or regulatory experts from France, the Netherlands, Portugal, Italy, Ireland, Hungary, Austria, Denmark and Malta. "They all agreed that there was no evidence of any increase in incidents of cancer associated with PIP breast implants and no evidence of any disproportionate rupture rates other than in France," it said in a statement. Founded in 1991, Poly Implants Prosthese was based in southern France and for a while ranked as the world's number three maker of implants, supplying around 100,000 a year. Some 80% were exported abroad, and health authorities around the world said they were watching closely for the results on Friday of an inquiry by France's National Cancer Institute into whether the implants can be linked to cancer. France has had reports of eight cases of cancer in women with breast implants made by PIP, which is accused of using industrial-grade silicone normally used in anything from computers to cookware. MHRA said there were also French reports of a woman with PIP implants who died from anaplastic large cell lymphoma (ALCL). France's drug and medical device regulatory authority, AFSSAPS, ruled last year that the state would pay for the removal of all the PIP implants but only fund replacements for victims of breast cancer, not those who used them for aesthetic purposes. A French victims association is pushing for the state to pay for replacements for all women with PIP implants. France's Health Ministry is expected to make an announcement on Friday following the National Cancer Institute's findings. BRITAIN MONITORING FRENCH DECISION Australia's healthcare watchdog, the Therapeutic Goods Administration (TGA), said around 8,900 of the PIP implants had been used in Australian women, some of whom had complained about the devices splitting and leaking. "The TGA has received 45 reports relating to PIP implants, 39 of which relate to rupture," it said in a statement. It has had no reports of ALCL in Australian women with the implants. The TGA said women with PIP implants should continue to monitor them and consult their surgeons if they have any concerns. Brain's MHRA said the same, adding that it would be "looking carefully at the French safety statement when it comes out as a matter of priority." PIP was placed into liquidation in March 2010 with losses of 9 million euros after AFSSAPS recalled its implants when surgeons reported abnormally high rupture rates. During a subsequent inspection of its manufacturing site, officials found PIP had started using a type of silicone gel that was not approved by health authorities, but was around 10 times cheaper. A subsequent investigation found that a majority of implants made by PIP since 2001 contained the unapproved gel. A solicitor acting for at least 250 British women taking legal action over their PIP implants said the liquidation of the French company had limited the scope for patients' legal action. "We're suing about half a dozen clinics that have been involved in implanting the PIP breast implants," Mark Harvey, a partner at legal firm Hugh James, told Reuters. "We would have preferred to sue PIP, obviously, but they are bankrupt so they have no money and no assets."

Acetaminophen: Repeated Use of Slightly Too Much Can Be Fatal

From Medscape Medical News Laurie Barclay, MD November 22, 2011 — Repeated doses of slightly too much acetaminophen (known as paracetamol in the United Kingdom and elsewhere in Europe) can be fatal, according to the results of a large, single-center cohort study published online November 22 in the British Journal of Clinical Pharmacology. "On admission, these staggered overdose patients were more likely to have liver and brain problems, require kidney dialysis or help with breathing and were at a greater risk of dying than people who had taken single overdoses," senior author Kenneth J. Simpson, MBChB (Hons), MD, FRCP (Edin), from the University of Edinburgh and Scottish Liver Transplant Unit in the United Kingdom, said in a news release. "They haven't taken the sort of single-moment, one-off massive overdoses taken by people who try to commit suicide, but over time the damage builds up, and the effect can be fatal," he adds. In the United Kingdom, acetaminophen hepatotoxicity is the leading cause of acute liver failure (ALF). However, the effect of a staggered overdose pattern or delayed hospital presentation on mortality or need for emergency liver transplantation was previously unknown. Of 663 patients admitted with acetaminophen-induced severe liver injury between 1992 and 2008, 161 (24.3%) had taken a staggered overdose. Compared with patients who took an overdose at a single time, patients with staggered overdose were significantly older and more likely to abuse alcohol. When asked why they repeatedly ingested more than the recommended dose of acetaminophen, patients with staggered overdose most often cited pain relief as their rationale (58.2%). Compared with patients who took an overdose at a single time, those who took staggered overdoses had lower total ingested doses and lower serum alanine aminotransferase (ALT) levels on admission. Nonetheless, they were more likely to be encephalopathic and to require renal replacement therapy or mechanical ventilation. Although mortality was higher in staggered overdoses than in single-time overdoses (37.3% vs 27.8%; P = .025), the staggered overdose pattern was not an independent predictor of mortality. For staggered overdoses, sensitivity of the King's College poor prognostic criteria was reduced (77.6%; 95% confidence interval [CI], 70.8% - 81.5%). Delayed presentation to medical services more than 24 hours after single-time overdose occurred in 44.9% of those in whom accurate timings could be determined, and was independently associated with death or liver transplantation (odds ratio [OR], 2.25; 95% CI, 1.23 - 4.12; P = .009). In their logistic regression analysis, the investigators controlled for signs and symptoms, such as hepatic encephalopathy and prothrombin time, as well as various demographic factors. "Staggered overdoses or patients presenting late after an overdose need to be closely monitored and considered for the paracetamol antidote, N-acetylcysteine [NAC], irrespective of the concentration of paracetamol in their blood," Dr. Simpson said. Because both these groups are at increased risk of developing multiorgan failure, they should be considered for early transfer to specialist liver centers. Limitations of this study include reliance on patient recall regarding the time of last ingestion, total paracetamol dose, and suicidal intent; limited data regarding the use of concomitant P450 enzyme inducers or recent fasting; and selection bias for the more severe cases of acetaminophen toxicity in Scotland. "[T]his large cohort study demonstrates the deleterious effects of delayed presentation and staggered overdose pattern upon outcome following paracetamol-induced acute liver injury," the study authors conclude. "Both delayed presentation > 24 hours and staggered overdoses are strongly associated with multiorgan injury and the need for [liver transplantation]. Patients presenting with these overdose patterns should be treated as high risk for progression to ALF, and should receive NAC in their presenting hospital whilst awaiting serial ALT and PT levels." This study received no external funding. The authors have disclosed no relevant financial relationships. Br J Clin Pharmacol. Published online November 22, 2011.

Pomegranate Juice Lowers Cardiovascular Risk Factors

From Medscape Medical News Daniel M. Keller, PhD November 12, 2011 (Philadelphia, Pennsylvania) — Patients on hemodialysis consuming a moderate amount of pomegranate juice for a year saw a continuous, cumulative, beneficial effect on their lipid profile, their blood pressure, and the number of antihypertensive medications they required, Batya Kristal, MD, MHA, from the Nephrology Department at the Western Galilee Hospital in Nahariya, Israel, reported here at Kidney Week 2011: American Society of Nephrology 44th Annual Meeting. In addition to water, sugars, and pectin, pomegranates contain the antioxidants ascorbic acid and polyphenolic flavonoids. Hemodialysis patients were randomized to receive 100 mL of pomegranate juice (n = 66) or an equivalent-tasting placebo (n = 35) 3 times a week for 12 months. End points of the trial were lipid profile, including triglycerides (TGs), low-density-lipoprotein cholesterol, high-density-lipoprotein cholesterol (HDL), systolic and diastolic blood pressure, and the number of antihypertensive drugs required. At 12 months, all components of the lipid profile improved in the pomegranate juice group but not in the placebo group. In the juice group, there were statistically significant decreases in TGs from baseline to 12 months (P = .01), especially in patients with a baseline TG level of at least 200 mg/dL (P < .001). Over the same time period, HDL rose significantly (P = .005) in the juice group. There was no significant change in any of these parameters in the placebo group. During the study period, there was a significant decrease in systolic blood pressure in the juice group overall (P < .006), especially in patients who had a baseline systolic pressure of at least 140 mm Hg (P < .005); this was not the case in the placebo group. At 12 months, those in the juice group were taking significantly fewer antihypertensive drugs than those in the placebo group (P < .05). In the juice group, 22% of the subjects were taking fewer and 12.2% were taking more antihypertensive drugs; in the placebo group, 7.7% were taking fewer and 34.6% were taking more antihypertensive drugs. Dr. Kristal speculated that the consumption of pomegranate juice might lower the risk for cardiovascular disease in patients on hemodialysis, and recommended that it be added to diets that improve cardiometabolic risks, including low-salt diets, Dietary Approaches to Stop Hypertension (DASH), and the Mediterranean diet. One safety concern is that pomegranate juice contains a high level of potassium, so potassium overload is a risk, especially in patients with chronic kidney disease and dietary potassium restrictions. Dr. Kristal recommended that such patients be monitored by a dietician and a nephrologist. In addition, pomegranate juice intake can interfere with the metabolism of certain drugs, raising their levels in the blood. However, no adverse effects were detected in the group taking pomegranate juice. Katherine Tuttle, MD, executive director for research at Providence Sacred Heart Medical Center and professor of medicine at the University of Washington School of Medicine in Spokane, who was not involved in the study, told Medscape Medical News that "it's an interesting preliminary study.... I think before we conclude that we should be giving our patients pomegranate juice, we need to do bigger studies in other settings [with] more diverse populations and, of course, look beyond just the risk factors that they measured." In light of the high levels of potassium in pomegranate juice, Dr. Tuttle advised that "if [patients] decide to use it, [they should] be sure to let their healthcare professionals know." The study had no commercial funding. Dr. Kristal and Dr. Tuttle have disclosed no relevant financial relationships. Kidney Week 2011: American Society of Nephrology 44th Annual Meeting. Abstract FR-PO1660. Presented November 11, 2011.

Statins Can Make Asthma Worse

From Medscape Medical News Fran Lowry November 14, 2011 (Boston, Massachusetts) — Statins are among the most widely prescribed drugs in the world and help to stave off cardiovascular disease, but results from a small study suggest that they might worsen asthma control, researchers said here at the American College of Allergy, Asthma & Immunology 2011 Annual Scientific Meeting. Statin drugs, which are 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, are effective at lowering cholesterol, but they also influence allergic inflammation with immunomodulatory activities, said lead author Safa Nsouli, MD, director of the Danville Asthma and Allergy Clinic in California. These include the downregulation of the T helper (TH)1 phenotype response and the upregulation of the TH2 phenotype response. Dr. Nsouli said he noticed that some of his patients with asthma had exacerbations and worsening control. When he investigated, he observed that they were using statins. The observation prompted him to conduct this small study. He compared 20 patients with asthma who were taking statins with 20 matched patients who were not taking statins. "The patients were very carefully selected and did not have any other medical factors that could interfere with asthma exacerbation," Dr. Nsouli told Medscape Medical News. The patients were seen at 3, 6, and 12 months. At each follow-up visit, measures of the following asthma factors were taken: forced expiratory volume in 1 second (FEV1), the use of beta agonists, nocturnal wakening, and daytime exacerbation symptoms. The investigators found that at 3 months, patients in the statin group had a 20% decrease in FEV1 from baseline, compared with patients in the nonstatin group, who had a 10% decrease. At 6 months, the decreases were 28% and 12%, respectively; at 12 months, the decreases were 35% and 14%. The use of beta-agonist rescue inhalers was also higher in the statin group than in the nonstatin group, Dr. Nsouli said. At 12 months, beta-agonist use was up by 72% in the statin group, compared with 9% in the nonstatin group. At 3 months, peak expiratory flow was decreased by 18% in the statin group, and by 4% in nonstatin group. At 6 months, it was decreased by 25% and 9%, respectively, and at 12 months, it was decreased by 39% and 11%. Finally, statin users had more nighttime wakening and a greater increase in daytime symptoms than nonusers. At 12 months, the increase in nighttime wakening was 31% and 3%, respectively, and the increase in daytime asthma symptoms was 35% and 3%. "More studies are needed to demonstrate that statins cause possible immune changes that promote allergic diseases such as asthma," Dr. Nsouli said. "Statins inhibit proinflammatory cytokines, which is good for the cardiovascular system, but they also suppress the major histocompatibility complex, class II, which is detrimental for patients with asthma," he explained. Physicians who notice that their patients' asthma is worsening should find out if they are taking statins. Dr. Nsouli suggested. He also said that patients with asthma who are prescribed statins should be informed that, because of the adverse immunomodulatory effects that statins produce, their asthma might get worse. "This does not mean that patients with asthma who need to take statins should stop taking these drugs. But it does mean that they should be treated more aggressively," Dr. Nsouli said. Chitra Dinakar, MD, from the University of Missouri School of Medicine in Kansas City, told Medscape Medical News that she thinks the observations from this study are interesting, but stressed their preliminary nature. "He had 20 patients in each group. The dose of statins wasn't clear, neither was the patient profile, but the study is thought provoking," said Dr. Dinakar, who was comoderator of the oral session. "It tells us that we need to be watching out for patients with asthma who are on statins to see if the statins do indeed affect their control. The data are preliminary at this point, but they do raise doubt. The subject merits further study." Dr. Nsouli has disclosed no relevant financial relationships. Dr. Dinakar reported financial relationships with AstraZeneca and GlaxoSmithKline. American College of Allergy, Asthma & Immunology (ACAAI) 2011 Annual Scientific Meeting: Abstract 30. Presented November 6, 2011.

Diabetes Epidemic on 'Relentlessly Upward Trajectory'

From Medscape Medical News Martha Kerr September 13, 2011(Lisbon, Portugal) — The number of people diagnosed with and dying from diabetes continues "on a relentlessly upward trajectory," with no signs of abating, according to officials from the International Diabetes Federation (IDF) and the European Association for the Study of Diabetes (EASD) 47th Annual Meeting. Data from international studies demonstrate that the number of people with diabetes in 2011 has reached 366 million. This year, 4.6 million deaths will be attributed to diabetes, with 1 person dying from diabetes every 7 seconds. Healthcare spending on diabetes has reached $465 billion. The warning comes a week before the United Nations Summit on Non-Communicable Diseases, to be held September 19 and 20 in New York City, where world leaders will meet to discuss the global issues posed by diabetes, cancer, heart, and respiratory diseases. IDF president Jean Claude Mbanya and EASD vice president Andrew Boulton state that "without urgent research into improved care and prevention models, we stand little chance of meeting any long-term targets that arise from the summit." "Implementation of current knowledge will bring some improvements to [noncommunicable disease] care and prevention, but further research is essential if we are to truly defeat these diseases," the officials say, adding that increased funding for research is critical. The findings will be published in the 5th edition of the Diabetes Atlas. The figure of 366 million people with diabetes in 2011 is up almost 30% from the 285 million cited for 2010 in the 4th edition of the Atlas. More information on the call for action can be obtained at www.idf.org or www.easd.org.

Neuromuscular Warm-Ups Reduce Injuries in Female Athletes

From Medscape Medical News Jennifer Garcia November 7, 2011 — Coach-led neuromuscular warm-up training (NMT) reduces lower-extremity injuries in female high school basketball and soccer players in a low-income, mixed-ethnicity, urban setting, according to data from a large, cluster-randomized, controlled trial published in the November issue of the Archives of Pediatric and Adolescent Medicine. To find out whether NMT training could reduce lower-extremity injuries in this setting, Cynthia R. LaBella, MD, from the Children's Memorial Hospital, Chicago, Illinois, and colleagues invited girls' soccer and basketball head coaches from all Chicago high schools to participate in the study during the 2006-2007 season. Of the 258 coaches invited, 95 enrolled, and 90 completed the study, representing 105 teams. The study was approved by the Chicago Public Schools research review board and the Children's Memorial Hospital review board. After learning how to implement a 20-minute neuromuscular warm-up before team practices and a shorter pregame version, the coaches in the intervention group used the prescribed warm-up before an average of 80% (standard deviation [SD], 21%) of practices, with a median of 87%. The control coaches stuck to their standard warm-up protocol, including no warm-up exercises and having athletes jog or warm up on their own. Overall, 96 lower-extremity injuries occurred (4.19/1000 athlete exposures; 95% confidence interval, 3.35 - 5.02 per 1000 athlete exposures) in the control group and 50 lower-extremity injuries (1.78/1000 athlete exposures; 95% confidence interval, 1.29 - 2.28 per 1000 athlete exposures) in the intervention group. Compared with athletes in the control group, Dr. LaBella and colleagues noted a 44% decrease in acute noncontact lower-extremity injuries and a 34% decrease in noncontact ankle sprains among players in the intervention group. Moreover, 7 athletes in the control group sustained anterior cruciate ligament (ACL) injuries during the study, and 6 of those required surgery. Two athletes in the intervention group sustained ACL injuries; neither required surgery. NMT combines progressive strengthening with plyometric, balance, and agility exercises. Coaches instructed the athletes to avoid dynamic knee valgus and to land jumps with flexed hips and knees. The investigators taught coaches how to distinguish proper from improper form and how to use verbal cues to promote proper form. The study authors calculated that 189 athletes would need to be trained to use neuromuscular warm-up exercises to prevent 1 noncontact lower-extremity injury. This would require training 11 soccer coaches or 16 basketball coaches, which, at $80 per coach per session, would be far less expensive than the estimated treatment cost for 1 surgically treated ACL injury. A potential limitation of the study, the researchers note, is that it encompassed only 1 season, so whether compliance can be maintained for several seasons is unknown. In addition, parental consent to include personal health and background information was available for only 855 of the 1492 participating athletes; therefore the data may not be representative of the entire sample. Despite the limitations, Dr. Labella and colleagues conclude: "[T]o our knowledge, this is the first randomized controlled study to demonstrate that (1) high school coaches in a mixed-ethnicity, predominantly low-income, urban population can implement a neuromuscular warm-up; (2) the warm-up reduces noncontact [lower-extremity] injuries, including ACL injuries, in female basketball and soccer athletes in this population; (3) the effect is likely dose related; and (4) coach training seems cost-effective." M. Alison Brooks, MD, MPH, from the Department of Orthopedics and Pediatrics, and Timothy A. McGuine, PhD, ATC, from the University of Wisconsin Health Sports Medicine Center, University of Wisconsin–Madison, write in an accompanying editorial: "This study is indeed novel for targeting a group that is often ignored and understudied because of logistical barriers and lack of resources." Although the study does confirm that neuromuscular training programs can reduce lower-extremity injuries, Dr. Brooks and Dr. McGuine point out that a longer follow-up would be needed to evaluate whether coaches continue to implement NMT consistently for several seasons, or whether retraining will be needed. The editorialists also note that many of the coaches in the control group did not include any type of warm-up routine in their training. Whether this behavior extends to the large percentage of coaches who declined to participate in the study could provide qualitative information that may help identify barriers to successful implementation of injury prevention strategies. Additionally, the authors of the editorial point out that including cost analysis of other, more common lower-extremity injuries beyond ACL would actually demonstrate an even greater cost-savings if coaches were trained in how to implement a neuromuscular warm-up as part of their training regimen. Both the study authors and the editorialists point out that physical activity has significant benefits in adolescent girls, including improved academic success and lower rates of obesity, diabetes, pregnancy, and depression. This association underscores the importance of sports injury prevention, particularly in girls from mixed-ethnicity, predominantly low-income, urban populations who are at higher risk for adolescent obesity, diabetes, and pregnancy. This study was supported by grants from Children's Memorial Research Center and Office of Child Advocacy. Dr. Brooks and Dr. McGuine have disclosed no relevant financial relationships. Arch Pediatr Adolesc Med. 2011;165:1033-1040. Abstract

Some Probiotics Effectively Reduce Common GI Symptoms

From Medscape Medical News Sandra Yin November 8, 2011 (National Harbor/Washington, DC) — Mounting evidence is building a strong case for the use of probiotics, or "good" bacteria, to alleviate common gastrointestinal (GI) symptoms, such as diarrhea, bloating, and inflammation, according to several studies highlighted during a press briefing here at the American College of Gastroenterology 2011 Annual Scientific Meeting and Postgraduate Course. In one meta-analysis, researchers from the Maimonides Medical Center in Brooklyn, New York, found that in 22 studies of more than 3000 patients, probiotic prophylaxis significantly reduced the odds of developing antibiotic-associated diarrhea and Clostridium difficile–associated diarrhea by about 60%. In another meta-analysis, researchers from Beth Israel Deaconess Medical Center and Harvard Medical School, in Boston, Massachusetts, analyzed 28 randomized controlled trials in which more than 3000 patients received a single or a combination of antibiotics for various indications. In adult and pediatric populations, the preventive effect of probiotic use was significant, regardless of the species used and regardless of the antibiotic administered. In the largest study to date on probiotics in a nonpatient population, researchers from the University of North Carolina at Chapel Hill evaluated the efficacy of Bifidobacterium infantis 35624, a probiotic that has relieved symptoms in patients with irritable bowel syndrome, to see how well it relieved abdominal discomfort and bloating in nonpatients. The double-blind randomized placebo controlled study involved a 2-week placebo phase followed by a 4-week intervention phase, and was conducted at 10 clinical centers in the United States. More than 300 nonpatients who had experienced abdominal discomfort and bloating more than twice weekly, on average, for at least 3 months were included in the study. They had not seen a physician or received prescribed medication for their symptoms in the previous 12 months. In contrast to previous clinical studies of irritable bowel syndrome patients, the researchers saw no statistically significant improvement in mean severity of abdominal discomfort or bloating after the nonpatient population took B infantis 35624. However, an Irish group found that a nonpatient population receiving B infantis 35624 experienced significantly more bloat-free days. The researchers hypothesized that microbial imbalance could explain the increased incidence of a wide range of inflammatory disorders. To test whether altering the balance between good and bad bacteria in the gut raises the immune regulatory response, which could lower inflammation, researchers from the Alimentary Pharmabiotic Centre at University College Cork, and Alimentary Health Ltd in Cork, Ireland, conducted a double-blind placebo controlled study. Their goal was to see if B infantis affects systemic proinflammatory biomarkers in patients with inflammatory disease. The results of their study suggest that probiotics exert antiinflammatory effects. "By giving a specific probiotic orally, we could actually reduce the levels of these proinflammatory cytokines and actually enhance the production of an anti-inflammatory cytokine, which is the exact replication of what we identified in animal models and more basic models," said principal investigator Eamonn Quigley, MD, FACG, professor of medicine at the National University of Ireland in Cork. Plasma levels of the anti-inflammatory cytokine interleukin (IL)-10 rose significantly in healthy volunteers and patients with psoriasis, but not in those who took the placebo for 8 weeks. Plasma levels of 2 proinflammatory cytokines — tumor necrosis factor-alpha and IL-6 — dropped in all patients who received B infantis. C-reactive protein levels were also significantly lower in patients with psoriasis, ulcerative colitis, and chronic fatigue after treatment with the bacterium than after treatment with placebo. Although not everybody who takes an antibiotic should also take a probiotic, the institutionalized elderly should, to minimize the chance of getting something like antibiotic-associated diarrhea or antibiotic-associated C difficile, said Fergus Shanahan, MD, FACG, a researcher involved in the Irish B infantis 35624 study, and professor and chair of the Department of Medicine at University College Cork. Certain subsets of patients, such as those with cystic fibrosis or chronic urinary infections, who must take recurring courses of antibiotics might benefit from taking probiotics to minimize antibiotic-associated diarrhea. "It's ironic that we would worry about taking an organism when we've got billions of organisms in the GI tract" and the amount is relatively small, Dr. Shanahan observed. Instead of worrying about drug toxicity in that population, "we're worried about something that has vanishingly low side effects. It can't be zero, but it is very, very low." "If we paid more attention to prescribing antibiotics, we wouldn't have a lot of these problems," added Dr. Quigley. According to Mark Mellow, MD, FACG, director of the Digestive Health Center at INTEGRIS Baptist Medical Center in Oklahoma City, Oklahoma, physicians aren't the only ones to blame for the indiscriminate use of antibiotics. Edicts from hospital compliance committees often establish rules that patients who come in with community-acquired pneumonia be placed on antibiotics soon after admission. These rules can have unintended consequences. "Someone comes in with a fever and a cough and because there's not enough time to sort it out, they get put on an antibiotic," he said, whether or not they have a bacterial infection. Dr. Quigley reports financial relationships with Alimentary Health, Norgine, Merck, Procter and Gamble, Movetis/Shire, Shire, Yakult, and Ironwood/Almirall. Dr. Shanahan reports a financial relationship with Alimentary Health Ltd. Dr. Mellow has disclosed no relevant financial relationships. American College of Gastroenterology (ACG) 2011 Annual Scientific Meeting and Postgraduate Course: Abstracts P650, P120, P60, P283. Presented November 1, 2011.

TNF Blockers and Cancer: FDA Requires Increased Surveillance

From Medscape Medical News > Alerts, Approvals and Safety Changes > Medscape Alerts Emma Hitt, PhD November 3, 2011 (UPDATED November 4, 2011) — The US Food and Drug Administration (FDA) announced today that it is requiring the manufacturers of tumor necrosis factor (TNF)-α blockers to perform enhanced safety surveillance of these drugs because of the potential risk for cancer in children and adults aged 30 years or younger. Manufacturers will be required to submit reports of all malignancies and, in the case of malignancy in pediatric and young adult patients, expedited reports (provided within 15 days). "This type of safety surveillance is important for our improved understanding of malignancies in pediatric and young adult patients treated with TNF blockers because it will allow FDA to more completely capture and analyze all reported malignancies based on more complete and consistent reports," the FDA states in an alert sent today from the Division of Drug Information of the FDA's Center for Drug Evaluation and Research'. The FDA recommends that healthcare professionals "remain vigilant" for TNF blocker–related malignancies and report them to the FDA's MedWatch program or to the manufacturer. They add that "healthcare professionals may be queried by FDA or the manufacturer for additional clinical and diagnostic information related to the malignancy cases." On November 4, 2011, MedWatch, the FDA's safety information and adverse event reporting program, sent out a new alert asking healthcare professionals to include specific information in its reports of malignancy in patients treated with TNF blockers. This information includes: patient characteristics (age, sex, no patient identifiers); risk factors for malignancy; exposure to other immune-suppressing products or products with risk for malignancy; indication for TNF blocker treatment; TNF blocker exposure (duration, dose); cancer diagnosis (date of diagnosis, stage); biopsy results; and outcomes of malignancy (treatments, event outcome) The FDA first warned of the increased risk for childhood and adolescent cancers associated with TNF blockers in 2008, and warnings were added to the product labels of these drugs in 2009. Today's announcement comes in the wake of several somewhat conflicting findings about TNF blockers and cancer risk. One report in the August 2010 issue of Arthritis & Rheumatism found that children treated with TNF-α blockers may have increased cancer risk but that cancer cases reported in these children were confounded by underlying illnesses and concomitant use of immunosuppressants. Likewise, another report found that TNF inhibitors used to treat rheumatoid arthritis (RA) may increase the risk for skin cancer (including melanoma) but did not appear to be associated with increased risk for other malignancies. The pooled analysis, published in the September 1, 2011, issue of the Annals of the Rheumatic Diseases, found negligible increase or no increase in overall risk of developing any cancer. However, several studies have demonstrated an increased risk with these agents. In the August 2011 issue of Rheumatology, a study including data from over 20,000 US military veterans showed that nonmelanoma skin cancer risk is about one third higher for patients with RA treated with TNF inhibitors than for similar patients treated with nonbiologic disease-modifying antirheumatic drugs. In addition, in April of this year, the FDA reported an association between hepatosplenic T-cell lymphoma in adolescents and young adults treated with TNF blockers, azathioprine, and/or mercaptopurine. Drugs included in the TNF blocker class include infliximab (Remicade, Centocor), etanercept (Enbrel, Amgen and Pfizer), adalimumab (Humira, Abbott Laboratories), certolizumab pegol (Cimzia, UCB), and golimumab (Simponi, Centocor Ortho Biotech Inc). Even in the absence of immunosuppressive drugs, a higher incidence of lymphomas has been found in patients being treated for RA, Crohn's disease, ankylosing spondylitis, psoriatic arthritis, and plaque psoriasis. More information about the announcement is available on the FDA Web site and on the MedWatch Web site. Adverse events related to use of TNF blockers should be communicated to the MedWatch by telephone at 1-800-FDA-1088, by fax at 1-800-FDA-0178, online at http://www.fda.gov/medwatch, or by mail to 5600 Fishers Lane, Rockville, Maryland 20852-9787.

Distinguishing Alzheimer Disease From Other Major Forms of Dementia

From Expert Review of Neurotherapeutics Stella Karantzoulis, PhD; James E. Galvin, MD, MPH 10/20/2011 http://www.medscape.org/viewarticle/751357?src=cmemp Abstract and Introduction Distinguishing AD Dementia From Other Major Forms of Dementia Memory Language Visuospatial Skills Attention & Executive Functions Lack of Insight/Unawareness/Anosognosia Behavior, Mood, Personality & Psychiatric Symptoms Personality Extrapyramidal Symptoms Expert Commentary & Five-year View Key Issues Abstract Alzheimer’s disease (AD) is the most common and most studied cause of dementia. Significant advances have been made since the first set of clinical criteria for AD were put forth in 1984 that are now captured in the new criteria for AD published in 2011. Key features include recognition of a broad AD spectrum (from preclinical to mild cognitive impairment to AD dementia) and requirement of AD biomarkers for diagnosis. Correctly diagnosing dementia type is increasingly important in an era when potential disease-modifying agents are soon to be marketed. The typical AD dementia syndrome has at its core, an amnestic syndrome of the hippocampal type, followed by associated deficits in word-finding, spatial cognition, executive functions and neuropsychiatric changes. Atypical presentations of AD have also been identified that are presumed to have a different disease course. It can be difficult to distinguish between the various dementia syndromes given the overlap in many common clinical features across the dementias. The clinical difficulty in diagnosis may reflect the underlying pathology, as AD often co-occurs with other pathologies at autopsy, such as cerebrovascular disease or Lewy bodies. Neuropsychological evaluation has provided clinicians and researchers with profiles of cognitive strengths and weaknesses that help to define the dementias. There is yet no single behavioral marker that can reliably discriminate AD from the other dementias. The combined investigation of cognitive and neurobehavioral symptoms coupled with imaging markers could provide a more accurate approach for differentiating between AD and other major dementia syndromes in the future. Key Issues Alzheimer’s disease (AD) is the most common form of dementia. There are 35 million individuals worldwide currently affected by the disease; and AD is projected to affect 115 million by 2050. Generally speaking, AD neuropathology initially involves medial temporal lobe structures (e.g., hippocampus and entorhinal cortex) and subsequently extends to temporal, parietal and frontal lobe association areas as the disease progresses. Neuropsychiatric symptoms are present throughout the course of AD. New diagnostic criteria for AD emphasize the importance of biomarker data in the definition of prodromal AD. The typical dementia syndrome continues to be described by prominent episodic memory impairment linked to early changes in the hippocampus and entorhinal cortex, with secondary deficits in word-finding skills, spatial cognition and executive functions. Atypical presentations of AD include posterior cortical atrophy, logopenic progressive aphasia and focal frontal variant AD. In posterior cortical atrophy, the onset is characterized by early, higher-order visual deficits and a higher density of neurofibrillary tangles in the occipital regions than in typical AD. Logopenic progressive aphasia is an atypical language variant defined as a primary phonological loop deficit leading to impaired memory, sentence repetition and comprehension, with sparse spontaneous speech and frequent prolonged word-finding pauses. Greater numbers of neurofibrillary tangles within the frontal lobes are seen in frontal variant AD, resulting in a more severe disease course. Episodic memory scores do not differ between behavioral variant frontotemporal dementia patients and AD patients, although the neural correlates of the memory impairment differs between the two patient groups. Lewy body dementia (LBD) tends to co-occur with AD in 80% of cases, with only 20% having pure LBD. Patients with pure Lewy body pathology have better verbal memory skills than those with pure AD or mixed LBD/AD. A fluctuating or step-wise course and history of strokes may help clinicians differentiate AD from mixed AD with cerebrovascular disease when their clinical profiles are otherwise indistinguishable. Subcortical vascular dementia is associated with primary deficits in information processing speed and executive functions, and secondary milder effects on memory. Personality changes are common among the dementias. They can occur in the very earliest stages of AD, prior to the onset of any obvious cognitive decline and can discriminate between AD and LBD (more passive traits in the LBD group). Personality changes appear to be more common in behavioral variant frontotemporal dementia than in AD. Current treatments for AD provide symptomatic relief either by improving symptoms or by delaying decline. Improving our understanding of the molecular mechanisms of AD has led to the identification of multiple potential targets for disease-modifying agents.

Pancreatic Cancer Possibly Detected by Salivary Bacteria

From Medscape Education Clinical Briefs News Author: Janis Kelly CME Author: Charles P. Vega, MD 10/20/2011 Clinical Context Pancreatic cancer is a solid tumor with particularly poor outcomes for patients, as reviewed by the authors of the current study. The 5-year survival rate of pancreatic cancer is only 5%, although this rate increases to approximately 20% among individuals with surgically resectable disease at the time of presentation. Cigarette smoking appears to be the most significant known risk factor for pancreatic cancer. Diabetes, insulin resistance, and obesity might also contribute to the risk for pancreatic cancer. The lack of biomarkers for early detection of pancreatic cancer contributes to its poor prognosis. The current study examines the value of changes in oral microbiota as an early warning sign for pancreatic cancer. Study Synopsis and Perspective A pair of bacteria in the saliva are associated with pancreatic cancer and chronic pancreatitis, according to a study published online October 12 in Gut. Although a press release from the journal attributes the suggestion that this finding "opens up the possibility of curbing the progress of one of the most difficult cancers to treat, by altering the balance of bacteria," to the researchers, they were, in fact, much more circumspect. According to lead author James J. Farrell, MD, MD, from the division of digestive diseases at the UCLA David Geffen School of Medicine in Los Angeles, California, the key finding is that the study provides proof of principle that differences in the microbiota in saliva can serve as noninvasive biomarkers for diagnosing and differentiating pancreatic cancer and chronic pancreatitis. Dr. Farrell told Medscape Medical News that "we need to validate the panel of salivary biomarkers, both bacterial and transcriptomic, in a larger prospective study, enrolling patients suspected of having pancreatic disease and cancer and following them over time. This is currently underway. The big unanswered question is: Are these bacteria causing or the result of the cancer? Most data from previous studies and studies in other disease suggest that the bacteria are directly or indirectly contributing to the development of pancreatic disease, likely through inflammation." Identifying Bacteria The researchers used the human oral microbe identification microarray (HOMIM) to examine salivary microbiota in 10 patients with resectable pancreatic cancer and 10 matched healthy control subjects. They then used real-time quantitative polymerase chain reaction (qPCR) to identify the bacterial species or clusters that were notably different in the saliva of patients with pancreatic cancer and that of control subjects. Finally, they validated the candidate marker bacteria with qPCR on saliva from 28 patients with pancreatic cancer, 27 with chronic pancreatitis, and 28 control subjects. The initial analysis identified 31 bacterial species or clusters that were higher in the saliva of patients with pancreatic cancer than in control subjects, and 25 that were lower. Two of the 6 candidate bacteria validated in the independent samples were present at significantly different levels in the patient and control groups: Neisseria elongata and Streptococcus mitis. Furthermore, 2 bacteria (Granulicatella adjacens and S mitis) were present at different levels in patients with chronic pancreatitis and in control subjects. Causative Rather Than Reactive? Dr. Farrell's group then combined N elongata and S mitis and determined that the pair distinguished patients with pancreatic cancer from control subjects with 96.4% sensitivity and 82.1% specificity. The authors write that "whether a variation in bacterial abundance is a causative factor for cancer carcinogenesis or a derivational reflection of cancer onset due to the change of oral niches needs to be further explored in longitudinal.... Taken together [with the association between chronic pancreatitis and pancreatic cancer], these data suggest that the association between variations in oral microbiota and pancreatic disease may likely be causative rather than reactive." The authors note that they were unable to test for possible changes in oral bacteria after pancreatic cancer resection. They also note that "none of the bacterial biomarkers validated in this study was significantly altered in the microflora profile of lung cancer." Limitations in Study Design However, Dominique Michaud, ScD, associate professor of community health at Brown University in Providence, Rhode Island, who reviewed the paper for Medscape Medical News, is more cautious. Dr. Michaud, whose research centers on causes of pancreatic and brain cancers, and who has studied periodontal disease and pancreatic cancer (J Natl Cancer Inst. 2007;99:171-175), said that although "this is an interesting preliminary study, it is far from conclusive. There are many limitations to the study design, including small numbers and lack of other diseased control subjects. These findings need to be replicated and cannot provide any information on causality. It is very possible that any immunocompromised patient would have the same profile of saliva bacteria, which means this would test would not be a useful clinical screening tool." Community Health Dr. Farrell told Medscape Medical News that his group is currently enrolling patients in a nested, case–control study to see how these biomarkers behave in a large general population to detect pancreatic disease, and that efforts are underway to convert the HOMIM, which is currently only a research tool, for patient and clinic-based salivary diagnostics. Dr. Farrell and Dr. Michaud have disclosed no relevant financial relationships. Coauthor David T.W. Wong, from the David Geffen School of Medicine, reports ownership of intellectual property related to the saliva diagnostics field. Gut. Published online October 12, 2011. Abstract

Thyroid Cancers Commonly Found Incidentally

From Medscape Medical News Nancy A. Melville October 31, 2011 (Indian Wells, California) — A significant increase in the incidence of thyroid cancer in recent decades might be largely attributable to cancers incidentally found with ultrasound and other types of imaging, according to research presented here at the American Thyroid Association 81st Annual Meeting. From 1975 to 2008, the incidence of thyroid cancer nearly tripled, increasing from 4.85 to 12.97 cases per 100,000. This increase is "more rapid than any other type of cancer," said coauthor Michael Malone, BS, a medical student at New York University Langone Medical Center in New York City. Recent studies have suggested that increasing diagnostic scrutiny largely explains the apparent rise in cancers. To evaluate the issue, Mr. Malone and his colleagues conducted a chart review of 404 patients who underwent initial surgery for well-differentiated thyroid cancer at the Langone Medical Center from January 2007 to August 2010. They found that of 307 (76%) patients with stage 1 or 2 thyroid cancer, 46% had their tumors initially detected with an imaging study; the rest were detected because the patient or physician felt a mass in the neck. Imaging studies were also the method of detection in 46 (47%) of the 97 (24%) patients with stage 3 or 4 well-differentiated thyroid cancer. Among the tumors detected with imaging, 58% were less than 1 cm, 53% were 1 to 2 cm, 31% were 2 to 4 cm, and 39% were greater than 4 cm, Mr. Malone noted. When tumors were detected with imaging, ultrasound was the leading modality, used in 104 (55%) patients, followed by computed tomography in 37 (20%) patients, magnetic resonance imaging in 19 (10%) patients, carotid duplex scan in 13 (7%) patients, and positron emission tomography or other imaging in 15 (8%) patients. "It is important to note that these were sonograms that were not performed to evaluate something that was palpated on physical exam, but instead were performed for a variety of reasons, some appropriate and some not." Patients whose tumors were detected with imaging were more likely to be male (32% vs 21%; P = .013) and were older (median age, 52 vs 46; P = .0004) than those whose tumors were detected without imaging. The findings support the argument that imaging studies indeed heavily influence the rise in thyroid cancer incidence rates, Mr. Malone concluded. "We feel that a substantial number of thyroid cancers are discovered by imaging rather than by palpation alone," he said. "This observation is true for small and large cancers, as well as early and advanced cancers." "As with small cancers, the increasing incidence of larger and more advanced thyroid cancers may be the result of increasing diagnostic scrutiny and may not necessarily represent a true increase in disease," he observed. Kenneth B. Ain, MD, professor of medicine and chair of cancer research at the University of Kentucky Medical Center, in Lexington, questioned whether the findings would hold true in a patient population outside of the New York City demographic. "I think before you attempt to generalize, you should take into account the evidence of geography and different populations," said Dr. Ain. "For example, the study deals with urban patients in population centers that have well-equipped medical centers, and many practitioners have unused ultrasound machines in their offices that have to generate money." "In that situation, I assure you that you'll have a huge number of case findings by ultrasound and not by palpation," he said. However, "if you take a rural population in eastern Kentucky, for instance, who have issues such as oxycontin use, smoking, and don't usually have ultrasound machines available, patients will generally present with palpable cancers and you will see the same increase in thyroid cancers among these patients as those in the big cities." He added that some of the data used for this study have also shown that thyroid cancer has the "second highest increasing cancer death rate among all ages and all sexes, and to merely state this increased case finding and not account for the fact that these cases are killing more people despite with our advanced therapeutics makes it a little curious." Kathryn G. Schuff, MD, of the Oregon Health & Science University in Portland, who moderated the session, said the study and the ensuing comments reflect a larger debate regarding the role of imaging in increasing thyroid cancer incidence rates. "There are thyroidologists arguing on both sides of the issue," noted Dr. Schuff. "Some say it's just imaging, others say it is a real increase, arguing that the increasing death rates indicate that this is not just an increase in 'small incidentally found' tumors. I don't think we have the answer to that particular question yet." Mr. Malone, Dr. Ain, and Dr. Schuff have disclosed no relevant financial relationships. American Thyroid Association (ATA) 81st Annual Meeting: Abstract 94. Presented October 28, 2011.

Yoga Improves Back Function in Patients With Low Back Pain

From Medscape Medical News > Neurology Megan Brooks October 31, 2011 — A study released today provides more evidence that yoga can help patients who suffer from chronic low back pain. Conducted in the United Kingdom, the study found that a 12-session, 3-month yoga program led to greater improvements in back function than usual care. However, yoga did not yield greater reductions in pain or improvements in overall health compared with usual care. "Although there was no evidence of pain reduction at 12 months, confidence in performing normal activities despite pain improved more in the yoga group than usual care group at 3 and 6 months," the study team notes. In terms of yoga studies for low back pain, this study is "the largest to date, with over 300 participants, and it has the longest follow-up of any trial," investigator David J. Torgerson, PhD, from the University of York's Department of Health Sciences, United Kingdom, told Medscape Medical News. "We followed them up for 12 months (9 months after they had finished the yoga), and found that the benefit of yoga was sustained for this length of time, probably because a proportion of participants continued to practice yoga after they had completed their formal course," he said. Based on the findings in this study, "yoga could be recommended as a therapy for chronic low back pain," Dr. Torgerson said. The study was published November 1 in the Annals of Internal Medicine. Benefit "Sustained" The study involved 313 adults with chronic or recurrent low back pain. All of them received a back pain education booklet and usual care. In addition, 156 were offered Iyengar yoga classes (12 classes total, once weekly). The yoga classes were given by 12 yoga teachers who had extra training in back care. Each class lasted 75 minutes. In a statement, Iyengar yoga teacher and study investigator Alison Trewhela, DBL, said: "Yoga aims to treat the whole person — not just the physical." The yoga program offers "poses for pain-relief and mental calming; mobilizing, stretching, strengthening and relaxation; improving awareness of posture; education about how a healthy back functions; and positive mental focus," she explained. Sixty percent of patients in the yoga group attended at least 3 of the first 6 sessions and at least 3 other sessions. In the first 3 months, 82% said they practiced yoga at home on their own, 65% were practicing yoga at home at 6 months, and 60% were practicing yoga at home at 12 months. The researchers report that the yoga group had better back function at 3 months (the primary outcome) and at 6 and 12 months (secondary outcomes) than the usual care group. "Although there is no consensus, a change of 1.1 to 2.5 on the RMDQ has been recommended as clinically important," the investigators note in their report. "In this trial, we found that individuals offered yoga benefited from, on average, 2.17 fewer limited activities at 3 months and by 1.57 fewer limited activities at 12 months." They note that they were missing data for the primary outcome for 21 yoga participants and 18 usual care participants, and differential missing data were observed (more so in the yoga group) for secondary outcomes. The yoga and the usual care groups had similar back pain and general health scores at 3, 6, and 12 months, and the yoga group had higher scores on the Pain Self-Efficacy Questionnaire at 3 and 6 months, but not at 12 months. Twelve (8%) of the 156 yoga patients reported adverse events; 1 adverse event was deemed as serious and possibly or probably related to yoga (the patient had experienced severe pain but had a history of severe pain after any physical activity). The other 11 adverse events in the yoga group were nonserious and were mostly related to increased pain. Adverse events were reported in 2 (1%) of the 157 patients in the usual care group (1 accident/injury, 1 death). Yoga Comparatively Effective Other interventions for low back pain that have been evaluated in randomized controlled trials include exercise and manipulation, the Alexander technique, and cognitive behavioral therapy, Dr. Torgerson and colleagues note in their report. Comparing the findings of their study with these other techniques, they say, "suggests that group yoga may improve back function (as measured by the RMDQ) more than exercise and manipulation, cognitive behavioral treatment, and 6 sessions of 1-on-1 Alexander technique but not as much as 24 sessions." They caution, however, against "overanalyzing these results because the comparisons are indirect." Further research is needed to compare yoga directly with these other treatments, they say. Additional support for yoga in chronic back pain comes from a study published online October 24 in the Archives of Internal Medicine. As reported by Medscape Medical News, the study found that stretching, regardless of whether it is achieved via yoga classes or conventional stretching exercises, has moderate benefits in adults with moderately impairing chronic low back pain. In a comparative effectiveness study, the researchers found that yoga classes were more effective than a self-help book, but not more effective than stretching classes, in improving function and reducing symptoms resulting from chronic low back pain, with benefits lasting at least several months. The author of a comment on the article in the Archives of Internal Medicine called the results from this trial "actionable" for practice because they reinforce the evidence that exercise is safe and moderately beneficial for chronic low back pain. "Health care providers should feel comfortable referring patients to either yoga or [physical therapy–]led classes; either seems to be helpful," writes Timothy S. Carey, MD, MPH, from the Sheps Center for Health Services Research, University of North Carolina, Chapel Hill. The current study was supported by Arthritis Research UK. Disclosures can be viewed on the journal's Web site. Ann Intern Med. 2011;155:569-578. Abstract

Explaining Gender Differences in Non-fatal Suicidal Behaviour Among Adolescents

From BMC Public Health Explaining Gender Differences in Non-fatal Suicidal Behaviour Among Adolescents A Population-based Study Michael Kaess; Peter Parzer; Johann Haffner; Rainer Steen; Jeanette Roos; Martin Klett; Romuald Brunner; Franz Resch Posted: 09/27/2011; BMC Public Health. 2011;11(597) © 2011 BioMed Central, Ltd. Background While suicide is the second leading cause of death among young people in most industrial countries, non-fatal suicidal behaviour is also a very important public health concern among adolescents. The aim of this study was to investigate gender differences in prevalence and emotional and behavioural correlates of suicidal behaviour in a representative school-based sample of adolescents. Methods A cross-sectional design was used to assess suicidal behaviour and various areas of emotional and behavioural problems by using a self-report booklet including the Youth Self-Report. One hundred sixteen schools in a region of Southern Germany agreed to participate. A representative sample of 5,512 ninth-grade students was studied. Mean age was 14.8 years (SD 0.73); 49.8% were female. Results Serious suicidal thoughts were reported by 19.8% of the female students and 10.8% of the females had ever attempted suicide. In the male group, 9.3% had a history of suicidal thoughts and 4.9% had previously attempted suicide. Internalizing emotional and behavioural problems were shown to be higher in the female group (difference of the group means 4.41) while externalizing emotional and behavioural problems slightly predominated in male students (difference of the group means -0.65). However, the total rate of emotional and behavioural problems was significantly higher in the adolescent female group (difference of the group means 4.98). Using logistic regression models with suicidal thoughts or attempted suicide as dependent variables, the pseudo-R2 of gender alone was only 2.7% or 2.3%, while it was 30% or 23.2% for emotional and behavioural problems measured by the YSR syndrome scales. By adding gender to the emotional and behavioural problems only an additional 0.3% of information could be explained. Conclusions The findings suggest that gender differences in non-fatal suicidal behaviour among adolescents can to a large extent be explained by the gender differences in emotional and behavioural problems during this age. Background Suicide and non-fatal suicidal behaviour are both well-recognized public health problems in young people.Whereas the prevalence of suicide and suicidal behaviour remains relatively low before puberty, adolescent suicide is one of the leading causes of death in the teenaged group.In Europe, suicide is the second leading cause of death in male and female adolescents. In the USA, suicide is reported to be the third leading cause of death after accidents and homicides.According to the findings of a WHO multi-centre study conducted in young people 15 to 24 years of age, the increase in suicide has been shown to be associated with an increase in suicide attempts. Results of a systematic review of 128 studies on the prevalence of suicidal phenomena in adolescents revealed that, on average, 9.7% (95% CI 8.5 to 10.9) of adolescents reported to have attempted suicide while even 29.9% (95% CI 26.1 to 33.8) of these adolescents indicated having thought about suicide at some point in their life. One of the strongest predictors of completed suicide or further suicide attempt has been found to be a previous suicide attempt. Therefore, suicide attempts and also suicidal thoughts in adolescents must always be taken seriously, in spite of the fact that for every death of a young person from suicide, many suicide attempts have already been undertaken, especially by girls. In most western countries, females are more likely to engage in suicidal behaviour, but are less likely to die as a result of a suicidal act than males. This "gender paradox" is known to be extremely distinctive in adolescents; during this period of life suicide attempts are 3–9 times more common in girls while completed suicides rates are 2–4 times higher in adolescent males. Many epidemiological studies so far have reported higher rates of non-fatal suicidal behaviour in females which could indicate a gender-specific predisposition for the experience of suicidal thoughts and suicide attempts during this life-period. As regards mental illness as one of the strongest risk factors for suicidal behaviour, depression and anxiety in particular seem to function as mediators of adolescent suicidal behaviour. But drug abuse, risk behaviours and other types of externalizing psychopathological behaviours are also associated with an increased risk of suicide among adolescents. There is only little empirical research which investigated the reasons underlying the correlation of being female and showing higher rates of suicidal thoughts and suicide attempts during adolescence. One theory is that gender differences in psychopathology could play an important role in this issue, suggesting that different types and characteristics of emotional and behavioural problems may primarily lead to unequal rates of suicidal behaviour in female and male individuals. Therefore, our hypothesis was that gender differences in non-fatal suicidal behaviour among adolescents could mainly be explained by the gender differences in emotional and behavioural problems.

Losing Weight by Midlife Reduces CVD Risk

From Heartwire Harvard alumni study of early and midlife coronary disease risk Reed Miller October 26, 2011 (Cambridge, Massachusetts) — A study of Harvard alumni shows that obesity early in life does not portend a coronary disease death in people who reach a healthier weight by their mid-40s. The National Institutes of Health–sponsored Harvard Alumni Health Study has followed nearly 19 000 men who began regular medical examinations during their undergraduate years at Harvard University between 1916 and 1950. The median follow-up period was 56.4 years and the maximum was 82.5 years. The authors report their findings in the October 24, 2011 issue of the Archives of Internal Medicine. Investigators Dr Linsay Gray (Medical Research Council, Glasgow, Scotland) and colleagues found that Harvard men who were obese in early adulthood had twice the risk of dying from coronary disease as men with a normal body-mass index as young men (18.5 to 28 years). The association between obesity as young men and cardiovascular mortality later on held even after adjustment for confounding variables in early adulthood such as smoking and physical activity and after adjustment for midlife risk factors including type 2 diabetes and hypertension. However, the link seen between early obesity (18.4 years) and later coronary disease death disappeared after taking into account midlife body-mass index (46.1 years), suggesting that men who were obese when they were young can reduce their risk by reaching a normal weight by middle age. The authors caution that their results should be replicated in more studies with a broader population. Commenting on the study, Archives editor Dr Rita Redberg (University of California, San Francisco) writes that this study "brings us some reason for hope that efforts to address childhood obesity are well worth it, [and] it is never too late to adopt healthy lifestyle changes."

Chest X-Ray Screening Does Not Reduce Lung Cancer Mortality

From Medscape Medical News Laird Harrison October 26, 2011 (Honolulu, Hawaii) — The largest study yet to examine the issue shows that screening with chest radiographs does not reduce mortality from lung cancer, researchers reported here at CHEST 2011: American College of Chest Physicians Annual Meeting. The results, which were also published online October 26 in JAMA, confirmed earlier research on the issue but still came as a disappointment. "We were hopeful the chest X-rays we did would make a difference," coauthor Paul A. Kvale, MD, told Medscape Medical News. Putting these findings together with a those of study published in August in the New England Journal of Medicine, health policy groups are likely to recommend screening with low-dose computed tomography (CT), but not chest X-ray, and only for patients at high risk for lung cancer, said Dr. Kvale, a pulmonologist at Henry Ford Hospital in Detroit, Michigan. For the current study, part of the Prostate, Lung, Colorectal and Ovarian Cancer Cancer Screening Trial, researchers enrolled 154,901 participants aged 55 through 74 years. "This was the biggest study of its kind ever done," said Dr. Kvale. The investigators randomly assigned 77,445 of the patients to receive annual screenings with chest X-rays, and 77,456 to receive usual care, at 1 of 10 centers across the United States between November 1993 and July 2001. They offered participants in the screening group annual posterio-anterior view chest radiographs for 4 years. The participants in the usual care group were not offered screenings as part of the study, although 11% undertook chest X-rays independent of the study. Between 79% and 87% of the participants in the screening group got the X-rays offered each year. Researchers followed-up the patients for a maximum of 13 years until December 31, 2009. They tallied a lung cancer incidence of 20.1 per 10,000 person-years in the screening group and 19.2 per 10,000 person-years in the usual care group, for a rate ratio (RR) of 1.05 (95% confidence interval, 0.98 - 1.12). They counted 1213 deaths from lung cancer in the screening group compared with 1230 in the usual care group, for an RR of 0.99 (95% confidence interval, 0.87 - 1.22). The study avoided problems of previous studies, such as a large number of screenings in the control group, but still came up with the same bottom line, said Dr. Kvale. Another important aspect of the study was its analysis of a subgroup of patients who were at high risk for lung cancer because of their age, smoking, and other factors. Just as in the study as a whole, researchers randomly assigned 15,183 members of this subgroup to screening, and the same number to usual care. After 6 years of follow-up, 518 members of the high-risk screening group got lung cancer, and 316 died of the disease. In the high-risk usual care group, 520 got lung cancer and 334 died of it, for an RR of 0.94 (95% confidence interval, 0.81 - 1.10). The high-risk group was intentionally selected to match a high-risk group in the National Lung Screening Trial, published in the New England Journal of Medicine. In that study, researchers compared high-risk participants screened with chest X-rays with high-risk patients screened with low-dose CT. They concluded that the low-dose CT screening reduced the mortality rate of these patients by 20%. If low-dose CT screening is 20% better than X-ray screening, and X-ray screening is the same as usual care, then it would be logical to assume that CT screening is 20% better than usual care. However, more statistical analysis should be done before reaching that conclusion, writes Harold C. Sox, MD, from Dartmouth Medical School in West Lebanon, New Hampshire, in an editorial published along with the study in JAMA. New studies should directly compare usual care to low-dose CT-screening, Dr. Sox writes. Still, the findings are already being taken into consideration by a coalition of groups working on new guidelines for lung cancer screening, said Frank C. Deterrbeck, MD, chief of thoracic surgery at Yale University, New Haven, Connecticut, and cochair of the coalition. The coalition, made up of the American College of Chest Physicians, the American Cancer Society, the American Society of Clinical Oncology, the National Comprehensive Cancer Network, and to a lesser extent, the American Thoracic Society, will publish new guidelines within a few months, Dr. Deterrbeck told Medscape Medical News. However, he would not confirm that the guidelines will call for low-dose CT screening for everyone who is at high risk for lung cancer. "I think there is a potential benefit, as well as a potential harm," he said. "Selection of the appropriate population is something we have to pay careful attention to." Although low-dose CT poses a low risk from radiation, it often leads to other diagnostic procedures, some of which may not be necessary. "Low-dose CT picks up a lot of stuff that's nothing," he said. On the basis of the low-dose scans, patients may be referred for regular CT, with its higher doses of radiation, and for biopsies, which can cause complications. The cost questions are complicated, too, Dr. Deterrbeck said, as the expense of the screening must be weighed against the costs that are saved in treatment costs if cancer is caught earlier. However, the short-term implications of the study are clear, he said. "We have not employed X-rays as a screening tool for lung cancer, and I guess we won't." Dr. Kvale and Dr. Detterrbeck have disclosed no relevant financial relationships. Dr. Sox has disclosed that he is an unpaid member of advisory boards for the Southwest Oncology Group and the Fred Hutchinson University of Washington Cancer Consortium. JAMA. Published online October 26, 2011. Full text, Editorial CHEST 2011: American College of Chest Physicians Annual Meeting: Session 7225. Presented October 26, 2011.

Physical Activity Cuts Risk for Invasive Breast Cancer

From Medscape Medical News > Oncology Roxanne Nelson October 26, 2011 (Boston, Massachusetts) — Data supporting the association between physical activity and a reduced risk for breast cancer are increasing. Adding to these data are the results of a large European study, presented here at the Tenth Annual American Association for Cancer Research International Conference on Frontiers in Cancer Prevention Research. When the researchers compared the highest and lowest quartiles of physical activity, the risk for invasive tumors was inversely associated with high levels of total physical activity (hazard ratio [HR], 0.85; P trend < .001), especially recreational activity (HR, 0.88; P < .001). However, no association was seen between in situ carcinoma and any of the physical activity variables. The researchers also looked at the effect of physical activity on breast cancer risk by receptor status, and note that this is the largest prospective study to do so. Previous studies investigating this issue have yielded inconsistent results, explained study author Karen Steindorf, PhD, from the German Cancer Research Center in Heidelberg. The researchers found a significant protection of physical activity only for the estrogen-receptor (ER)-positive and progesterone-receptor (PR)-positive tumor types, said Dr. Steindorf. "These findings strengthen the hypothesis that lowering breast cancer risk with physical activity is at least partly related to hormonal pathways." The association between breast cancer risk and physical activity also differed by menopausal status. "There were significant risk reductions in postmenopausal breast cancer," she said, adding that the risk reductions were a little lower in premenopausal women. Among postmenopausal women, the risk reduction was significant for both total physical activity (HR, 0.81; P = .002) and recreational activity (HR, 0.89, P = .005). These results were slightly less robust for premenopausal breast cancer for total physical activity (HR, 0.87; P = .082) and for recreational activity (HR, 0.84; P = .032). "I would say that this adds to the evidence of what we have already seen in other research — that physical activity may reduce the risk of breast cancer," said Karen T. Liby, PhD, research assistant professor of medicine at Dartmouth Medical School, Hanover, New Hampshire, who was not involved in the study. "But it seems to be effective only in receptor-positive cancers." Exercise Linked to Lower Risk As previously reported by Medscape Medical News, postmenopausal women who maintain a regular moderate to vigorous exercise program can reduce their risk for breast cancer by 20% to 40%. In addition, research has shown that physical activity can reduce the risk in premenopausal women; among the most active women, risk reduction can be as high as 23%. Other data have shown that obesity and lack of physical activity can increase the risk for triple-negative breast cancer. Protective Effects Confirmed Dr. Steindorf and colleagues used data from the European Prospective Investigation Into Cancer and Nutrition (EPIC), a large study designed to investigate the relation between diet, nutritional status, and lifestyle and environmental factors and the incidence of cancer and other chronic diseases. The trial has recruited 520,000 people from 10 European countries. Detailed information on recreational household physical activity, occupational physical activity, and other variables was assessed in a baseline examination conducted between 1992 and 2000. The cohort in this trial involved 283,680 women; within this group, at a median follow-up of 11.7 years, there were 9947 incident breast cancer cases, including 1060 cases of in situ carcinoma. Of the 8887 invasive breast cancer cases, it was possible to assess the ER status of the tumor in 6007 cases (67.6%), the PR status in 4814 cases (54.2%), and the combined status in 4798 cases (53.9%). When analyzed by hormone-receptor status, stronger effects of total physical activity were seen for ER-positive/PR-positive breast tumors than for other combinations (P = .043 for heterogeneity). A more detailed analysis revealed that it was primarily the PR status (P = .006 for heterogeneity), not the ER status (P = 0.235 for heterogeneity), that dominated this result. The protective effect of physical activity on breast cancer risk is confirmed with these results, note the researchers. "The results of this largest prospective study on physical activity and different hormone-receptor status indicate that physical activity primarily reduces the risk for PR-positive and ER-positive/PR-positive tumors," they conclude. Tenth Annual American Association for Cancer Research (AACR) International Conference on Frontiers in Cancer Prevention Research. Presented October 24, 2011.

PSA Screening: USPSTF Review

From Medscape Education Clinical Briefs Draft Guidelines Recommend Against PSA Screening: USPSTF Review CME/CE News Author: Zosia Chustecka CME Author: Charles P. Vega, MD Clinical Context Few topics in the field of preventive medicine are contentious as prostate cancer screening. Widespread screening for prostate cancer has had a remarkable effect on the epidemiology of this tumor, as demonstrated in a study by Welch and Albertsen published in the October 7, 2009, issue of the Journal of the National Cancer Institute. Their study found that the introduction of routine prostate cancer screening led to approximately 1.3 million more men being diagnosed with prostate cancer in the United States alone. Men younger than 60 years accounted for most of this surge in cases. The authors estimated that more than 20 additional men would have to be diagnosed with prostate cancer through screening to result in a single case of reduced mortality risk from prostate cancer. These findings are fairly pessimistic regarding the value of prostate cancer screening. The current study commissioned by the US Agency for Healthcare Research and Quality provides a more complete review of important issues in screening for prostate cancer. Study Synopsis and Perspective The US Preventive Services Task Force issue draft recommendations against routine screening for prostate cancer using the prostate-specific antigen (PSA) test in the United States, where it is currently used more than in any other country in the world. As a result, prostate cancer is the most commonly diagnosed cancer in American men. The USPSTF draft recommendation against routine screening with the PSA test was to have been published October 11 in the Annals of Internal Medicine, but the entire draft paper was leaked and posted October 6 on the Cancer Letter Web site, in "an egregious breach of our embargo and media policies," according to the journal. The news has since been widely disseminated on the Internet; as a result, the journal published the paper early. The USPSTF already recommends against routine PSA screening in men older than 75 years. In the new draft recommendation, it extends this to all men. It now recommends against routine screening in men younger than 75 years, giving this a "D" rating, which means "there is moderate or high certainty that the service has no benefit or that the harms outweigh the benefits." The news is likely to spark a furor in medical circles, not unlike the outcry that followed the USPSTF's recommendation in 2009 against routine mammography screening for breast cancer in women younger than 50 years. This provoked outrage from some breast cancer experts, patient advocates, and professional societies, with accusations that this was a move toward the "rationing" of healthcare. Angry reactions to the latest news have already begun. The "decision of no confidence on the PSA test by the US government condemns tens of thousands of men to die," said Skip Lockwood, CEO of ZERO, the Project to End Prostate Cancer. ZERO is sponsored by many organizations with a stake in prostate cancer, such as Abbott, Beckman Coulter, Accuray, CyberKnife, Dendreon, and the American Urological Association (AUA). Based on Reviews of Trials The recommended change is based on a review of 5 randomized trials of screening and 3 trials and 23 cohort studies of treatments. Included in the review were the 2 largest trials of PSA screening, which reported conflicting results, the USPSTF notes. The European study found a reduction in mortality after 9 years of screening, but the American trial, which had high crossover and contamination rates, found no reduction in mortality after 10 years of screening, as previously reported by Medscape Medical News. The review also noted that treatment for prostate cancer, such as prostatectomy and radiation, is associated with risks for problems such as erectile dysfunction, urinary incontinence, and bowel dysfunction. The USPTSF concludes that "after about 10 years, PSA-based screening results in small or no reduction in prostate-cancer-specific mortality and is associated with harms related to subsequent evaluation and treatments, some of which may be unnecessary." Delay in Announcement This recommendation has been a long time coming, according to reports in the October 7 issue of the Cancer Letter and in the New York Times magazine. They assert that the timing of the release of this recommendation was influenced by political considerations. According to these reports, the task force first voted to recommend against routine PSA screening back in November 2009, but this "caused a violent political firestorm," and subsequent follow-up meetings were cancelled. The final vote was taken in March. After this, a paper summarizing the recommendation was submitted to the Annals of Internal Medicine, where is it expected to appear next week. PSA Test is Not Specific The main problems with the PSA test are that it is not specific for prostate cancer and it cannot differentiate between aggressive and indolent forms of the disease. "It cannot distinguish cancer that will never make a difference in a man's lifetime from cancers that will make a difference," so might prompt men to undergo aggressive treatment unnecessarily, Virginia Moyer, MD, MPH, chair of the USPTSF panel that made the recommendation, stated in an interview yesterday with Bloomberg News. "So you go from being a guy who feels fine and who is potentially one of the majority who would never have known they had this disease, to being a guy who wears adult diapers," she said. Dr. Moyer is a professor of pediatrics at Baylor College of Medicine in Houston, Texas. The PSA test is "hardly more effective than a coin toss," said Richard Ablin, PhD, research professor of pathology at the University of Arizona College of Medicine in Tucson. Dr. Ablin discovered PSA in 1970. Using this test to screen for prostate cancer in the general population has been a "hugely expensive public health disaster," he wrote in an opinion piece in the New York Times last year. "Drug companies continue peddling the tests, and advocacy groups push 'prostate cancer awareness' by encouraging men to get screened," he wrote. "The medical community must confront reality and stop the inappropriate use of PSA screening," he stated. "Doing so would save billions of dollars and rescue millions of men from unnecessary, debilitating treatment." Although PSA testing is recognized as being imperfect, it is the only test for prostate cancer that is widely available, and it does provide information that can be useful, proponents point out. One of the professional bodies that has long supported the use of the test, the AUA, emphasizes that it should not be used on its own, but needs to be combined with other information (such as family history). The AUA issued a statement in reaction to the new USPSTF recommendations: "We are concerned that the Task Force's recommendation will ultimately do more harm than good to the many men at risk for prostate cancer, both here in the United States and around the world." "The AUA's current clinical recommendations support use of the PSA test, and it is our feeling that, when interpreted appropriately, the PSA test provides important information in the diagnosis, pretreatment staging or risk assessment, and posttreatment monitoring of prostate cancer patients," according to the statement. "Not all prostate cancers require active treatment and not all prostate cancers are life-threatening," the statement points out, and the decision of whether to proceed to active treatment or whether surveillance is an option needs to be discussed in detail with the patient. The Agency for Healthcare Research and Quality supported this study. Author disclosure information is available on the Annals of Internal Medicine Web site. Ann Intern Med. Published online October 7, 2011.

Testosterone May Not Treat ED

From WebMD Health News Study: Testosterone May Not Treat ED Denise Mann October 24, 2011 — Many men may be taking supplements of the male sex hormone testosterone to boost their sex drive, but it may not be that helpful after all. A new study of men 60 and older who had low or borderline low levels of testosterone showed that testosterone replacement therapy did not improve erectile dysfunction (ED) or their ability to achieve and maintain an erection, compared to a placebo gel. Men who used either a low dose or a conventional dose of testosterone gel showed no improvements in their sexual function during the course of the year-long study, compared with men who used placebo gel. The findings were presented at the annual meeting of the American Society for Reproductive Medicine in Orlando, Fla. "It appears that testosterone supplementation will not improve ED, though it may have other benefits on sexual function that were not evaluated with this data," says study researcher Lauren W. Roth, MD, an obstetrician/gynecologist at the University of Colorado in Denver, in an email. Sexual function is one of many reasons that many men are turning to testosterone therapy. With a laundry list of promises from a boost in sex drive and more energy to an increase in muscle mass and mental acuity, testosterone therapy can be tempting for many men who want to feel and look younger than they do. But, according to some experts, the hormone may be more harmful than helpful for some men. "I am quite concerned about the rampant use of testosterone replacement therapy for very soft indications," says Rebecca Sokol, MD. She is a professor of medicine and obstetrics and gynecology and the director of the andrology program at the Keck School of Medicine of the University of Southern California in Los Angeles. "It is very much a buyer beware situation." "We have to be very cautious about who we do and do not start on testosterone," Sokol says. Risks of Testosterone Supplements There are risks attached to the use of testosterone, Sokol says. "This hormone may cause the prostate gland to increase in size, and there is also the theoretic risk that we can stimulate the growth of cancer cells in the prostate. We have been looking carefully to see if testosterone initiates prostate cancer and there is no data to indicate that it does at this point." Testosterone may also increase levels of LDL "bad" cholesterol while decreasing levels of HDL "good" cholesterol, she says. Men who are considering taking testosterone need to weigh the pros and cons carefully with their doctor. "The patient really needs to be evaluated by a physician who is an expert in hormones and male reproduction," Sokol says. "The indication for treatment needs to be very clear and verified by evaluation and physical exam." Checking for Low Levels of Testosterone Part of the problem is that men are getting their testosterone from non-expert sources, including their buddies in the gym and online, says Joseph P. Alukal, MD. He is an assistant professor of urology and the director of male reproductive health at New York University's Langone Medical Center in New York City. Testosterone replacement does have a role in treating some men with erectile dysfunction who also have low levels of the hormone, he says. "Testosterone is one of the treatments we have, but it's not the only one." The first step is to measure a man's testosterone levels to see if they are low. This needs to be done on more than one occasion to make sure the results are accurate, he says. If levels are low, and there are no other health problems that may be causing the problems with sexual functioning, testosterone replacement therapy is an option, Alukal tells WebMD. In some men, ED can be a red flag for heart problems. In these cases, men will likely need to see a cardiologist, he says. "Hormones are powerful," Alukal says. "They have tremendous benefits and significant risks, so to go on them requires proper monitoring by a physician who understands their risks and benefits and knows how to monitor men." Doctors who prescribe testosterone should monitor the prostate gland closely, he says. "We know that there is some relationship between testosterone and the growth of the prostate and the development of prostate cancer, but we don't fully understand the relationship," Alukal tells WebMD. SOURCES: Lauren W. Roth, MD, ob-gyn, University of Colorado, Denver. Joseph P. Alukal, MD, assistant professor of urology; director of male reproductive health, New York University Langone Medical Center. Annual Meeting of American Society for Reproductive Medicine, Orlando, Fla. Oct. 15-19, 2011. Rebecca Sokol, MD, professor of medicine and obstetrics and gynecology; director of andrology program, Keck School of Medicine, University of Southern California, Los Angeles.

Chronic Inflammation May Mean Early Menopause

From Medscape Medical News Megan Brooks October 21, 2011 (Orlando, Florida) — Women with psoriasis, rheumatoid arthritis, inflammatory bowel disease, or systemic lupus erythematosus have an increased risk for both early menopause (before 45 years of age) and premature ovarian failure, new research confirms. "Our findings support and add to existing studies," Janet F. McLaren, MD, from the division of reproductive endocrinology and infertility, University of Alabama, Birmingham, told Medscape Medical News. She presented the research here at the American Society for Reproductive Medicine 67th Annual Meeting. Dr. McLaren and colleagues from the University of Pennsylvania School of Medicine in Philadelphia reviewed the records of more than 1.7 million women of reproductive age (15 to 45 years). They accomplished this using The Health Improvement Network, an electronic medical records database. The researchers looked for diagnostic codes for psoriasis, rheumatoid arthritis, inflammatory bowel disease, and systemic lupus erythematosus. "These are the 4 most prevalent conditions in women of reproductive age," Dr. McLaren noted. Women without these conditions comprised the comparator group. Results of unadjusted analyses point to a 2- to 5-fold increased risk for both early menopause and premature ovarian failure in women with these common chronic inflammatory diseases, Dr. McLaren reported. IBD Finding Novel? "It's known that women with lupus have antiovarian antibodies and that they have premature ovarian failure," Dr. McLaren said. "Some studies have suggested that there is an earlier age at menopause in women with rheumatoid arthritis, and there are some older publications that show that the number of children they have is slightly lower than other women," she added. However, she said she has not been able to find any studies showing an increased risk for menopause in women with inflammatory bowel disease. The researchers controlled for smoking, body mass index, previous pelvic surgery, socioeconomic status, and drug therapy. After adjustment for these factors, psoriasis, rheumatoid arthritis, and inflammatory bowel disease were no longer associated with premature ovarian failure; lupus, however, remained associated, with an odds ratio of 2.5. "It is still likely," Dr. McLaren said, "that all of these diseases are associated with premature ovarian failure. It's just when you control for the medications, you control for the severity of the disease; so it's 'confounding by indication' — the more severe patients are getting the more aggressive medications." "Further research is needed to [determine] if the effect is due to the underlying illness or treatment," the study team notes in a meeting abstract. Dr. McLaren said adjusted analyses for early menopause have not been completed yet. "The next step of the project is to look more specifically at the different disease exposures and see which of these exposures are highly associated with early menopause," Dr. McLaren said. The study was supported by grants from the National Institutes of Health. The authors have disclosed no relevant financial relationships. American Society for Reproductive Medicine (ASRM) 67th Annual Meeting: Abstract 10. Presented October 17, 2011.

Exercise a Viable Treatment Option for Mental Illness

Medscape Medical News from the: Canadian Psychiatric Association (CPA) 61st Annual Conference Exercise a Viable Treatment Option for Mental Illness Absence of Guidelines Should Not Be a Barrier Caroline Cassels October 21, 2011 (Vancouver, British Columbia) — Exercise is an effective, but potentially underused, treatment option for mental illness, experts say. In a symposium presented here at the Canadian Psychiatric Association (CPA) 61st Annual Conference, Christopher Willer, MD, a senior psychiatry resident at the University of Toronto, Ontario, Canada, made the case for exercise as an adjunctive therapy. Emerging research, he said, strongly suggests that exercise can improve patients' physical and mental health and may help offset some of the metabolic effects associated with older antidepressants and newer atypical antipsychotics. "It's not too soon to talk to patients about exercise as another treatment option, especially if they are asking about it or if they have a history of sport being important in their lives. "There's often a time lag between the time research comes out and when treatment guidelines are published. Based on the quality of the research that has been published [on exercise and mental illness] in the last 5 years, I think it would be irresponsible to wait," Dr. Willer told Medscape Medical News. In his presentation, Dr. Willer reviewed the existing literature for aerobic exercise as a treatment for mental illness, some of which suggests it can be as effective as pharmacotherapy and/or talk therapies. However, potential mental health benefits aside, Dr. Willer noted that the physical benefits of exercise are clear and include reducing cardiovascular risk factors that are often associated with mental illness and the medications used to treat psychiatric disorders. "Exercise mitigates certain illnesses; it protects against obesity, which certainly is a big problem with much of our patient population; and it has been shown to help with cognition and affective problems in well people. "As psychiatrists, we have to remember that we're not just concerned with our patients' psychiatric symptoms but also their physical health. It is important that we promote an active lifestyle to our clients as part and parcel of good psychiatric treatment," he said. Antianxiety Properties Early research examining exercise and depressive symptoms has been relatively simple, relying on case reports or short-term intervention studies. However, said Dr. Willer, in the past 5 years it has become more sophisticated. "We've come a long way, and now there are randomized trials that are attempting to compare exercise to a sham version of exercise that include larger numbers of patients, so the studies are higher quality," he said. Most of the evidence to date supports the use of aerobic exercise in unipolar depression, he added. However, a Cochrane review published in 2010 and reported by Medscape Medical News at that time showed that regular physical exercise in individuals with schizophrenia and schizophrenia-like illnesses is feasible and may help improve the mental and physical well-being of these patients. Nevertheless, although the overall results were positive, the review included only 3 small studies, prompting the authors to point out that larger randomized trials are needed "before any definitive conclusions can be drawn." Dr. Willer also noted that physical activity has been shown to have antianxiolytic properties. In patients with anxiety, sometimes there is a concern that the somatic expression of exercise — elevated heart rate, sweating, and heavy breathing — may invoke a panic response, but the literature does not bear this out, said Dr. Willer. "There are studies that suggest that in the moment, anxiety can be moderated by physical activity, and there are also studies showing 20 minutes of exercise a day for 10 weeks can modify on trait anxiety," he added. Worthwhile Endeavor Dr. Willer pointed out that only about 30% of North Americans get the recommended amount of 150 minutes of exercise per week, and that the therapeutic dose for the treatment of mental illness is unclear. However, he noted, as the research becomes more refined, this will be elucidated. In the meantime, he said, encouraging psychiatric patients to become more physically active is a worthwhile endeavor. "It is not expensive, and it can be independent of the healthcare system. It doesn't require [the psychiatrist] to be involved, other than to mentor patients and to check in with them," he said. Asked by Medscape Medical News to comment on Dr. Willer's presentation and assertion that psychiatrists should consider exercise as a viable treatment option, Saul Marks, MD, a practicing sports psychiatrist at North York General Hospital in Toronto, said it is a routine part of his practice. "Exercise confers a definite benefit. I have a patient myself who was able to come off antidepressant medication by taking up running, and she is doing extremely well now. There is a growing body of literature that psychiatric patients are at particular risk of metabolic syndrome, especially if they are taking atypical antipsychotics, suggesting psychiatrists need to promote exercise as a treatment," said Dr. Marks. Dr. Marks added that he routinely talks to his patients about the importance of being physically active every day. "Even if they do something as simple as walking for 45 minutes a day, that will keep them physically fit and also help their mental health," he said. Dr. Willer and Dr. Marks have disclosed no relevant financial relationships. Canadian Psychiatric Association (CPA) 61st Annual Conference: Abstract S11b Presented October 13, 2011.