My Health

Smoking heightens aortic rupture risk for women

November 17, 2008 on 1:14 pm | In Uncategorized | Comments Off Washington -- Add another strong incentive to the list of reasons for women smokers to quit: abdominal aortic aneurysms.

A study posted online Oct. 14 in the British Medical Journal found that women who smoke were four times more likely to have an abdominal aortic aneurysm repair or rupture than women who had stopped. Women smokers also were eight times more likely to have the serious medical emergency occur than were women who had never smoked.

Most studies of AAA have focused on men. This study is believed to be the largest conducted on women.

"We've known that smoking confers a very high risk of AAA," said the study's lead author, Frank Lederle, MD, professor of medicine at the University of Minnesota and an internist at the Minneapolis VA Medical Center. The study's aim was to reach a better understanding of factors associated with AAA in women, the authors write.

"This study does provide another reason to quit smoking," he said.

Aortic aneurysms cause 15,000 deaths a year in the U.S.

The ballooning of the artery wall is more common in men older than 60 but may be more deadly for women, possibly rupturing at a smaller diameter. Aortic aneurysms cause about 15,000 deaths a year in the United States, with most originating in the abdomen. About 40% of the deaths occur in women.

"Women may not be getting the attention they should, especially women with a family history for AAA and who are smokers. They should be considered for screening," said David Neschis, MD, a vascular surgeon and associate professor of surgery at the University of Maryland's School of Medicine. Dr. Neschis was not involved with the study.

AAA has a high risk of mortality. Only a small number of people make it to the hospital alive, and those who do have about a 50-50 chance of death, Dr. Neschis said. "So the best way to treat these patients is to identify them before rupture and fix them." The bulging arteries are difficult to detect in a physical exam, so ultrasound scans of the abdomen are recommended.

"A screening ultrasound of the belly takes minutes, has no risk, is inexpensive in medical terms and is available at even the smallest community hospital," Dr. Neschis said.

The Agency for Healthcare Research and Quality recommends against routine screening in women but does recommend a one-time screening for men ages 65 to 75 who have ever smoked.

Reinforcing old warnings

The study's authors used data collected on 161,808 postmenopausal women enrolled in the Women's Health Initiative, a clinical trial that studied the effects of estrogen therapy, diet and vitamin D on heart disease, fractures, breast and cervical cancer. The main study ended in 2005.

During 7.8 years of follow-up, Dr. Lederle and colleagues found that 184 abdominal aneurysm repairs or ruptures were reported. The AAA's were strongly linked to age and smoking. Women in their late 60s were more likely to have been affected than were younger women.

Women smokers are 8 times more likely to have an abdominal aortic aneurysm than those who never smoked.

The principal messages for physicians are not new, said Janet Powell, MD, PhD, a professor of vascular surgery at the Imperial College in London and an author of an accompanying editorial. "More efforts must be made to stop women from smoking, and AAA must be high on the list of differential diagnoses in older women smokers who present with collapse and abdominal or back pain."

The connection between smoking and the entire world of heart disease isn't a surprise, said Vincent Bufalino, MD, an American Heart Assn. spokesman and president and CEO of Midwest Heart Specialists in Naperville, Ill. "Of the women I see with heart disease, far and away the majority are smokers. Either diabetes or smoking are the two biggest predictors of coronary heart disease."

Joel Dunnington, MD, a consultant on smoking issues for the Texas Medical Assn., would like physicians to counsel patients about the many risks of smoking, including AAA. And patients should be told that if they quit smoking at age 40, 50 or even 60, their risk levels quickly decline, he said. Dr. Dunnington is also an associate professor of radiology at the M.D. Anderson Cancer Center at the University of Texas in Houston.

The study also turned up a couple of other findings, Dr. Lederle said. For example, it was determined that hormone therapy provided protection from AAA events. This conclusion was in contrast to previous smaller studies, which found that estrogen alone may increase risk.

"That was a surprise," Dr. Lederle said. "It hadn't been shown before and needs to be confirmed. We certainly aren't suggesting that people go out and take hormones, but it does suggest there is a role for female hormones in providing protection from AAA, which might explain why there are fewer in women."

In another finding, diabetes also conveyed protection to women. Although this has been seen in previous studies among men, whether it occurred among women had been uncertain, the researchers write. But why this negative association occurs has yet to be explained.

XDR-TB prevention starts with TB treatment

November 17, 2008 on 1:14 pm | In Uncategorized | Comments Off Washington -- The outlook for treating extensively drug-resistant tuberculosis turned gloomier with a new study that confirms earlier reports of the poor prognosis associated with the disease.

The study, the largest to date on the most lethal form of TB, determined that patients with XDR-TB are four times more likely to fail treatment and three times more likely to die than are patients with other strains of multidrug-resistant TB. The study was in the Nov. 15 American Journal of Respiratory and Critical Care Medicine, a journal of the American Thoracic Society.

Despite efforts to control all forms of TB, the disease remains the worldwide leading cause of death from an infectious agent. An estimated 8 million to 9 million new cases develop annually and 2 million patients die, the study authors noted.

As drug-resistant cases increase, physicians find treatment options limited. An editorial in the same journal issue raised a related concern. Does the rise of XDR-TB portend the reversal of progress made at combating TB? The high mortality rate for XDR-TB mirrors TB deaths of decades ago, before there were any drugs, said editorial co-author D'Arcy Richardson, RN, technical director for TB programs at PATH, a nonprofit, international global health organization. "We are looking at, more or less, the natural history of TB."

For their study, "Treatment Outcomes and Long-term Survival in Patients with Extensively Drug-resistant Tuberculosis," researchers reviewed medical records of 1,407 patients in South Korea who were diagnosed with resistant forms of TB between 2000 and 2002, and 75 patients who had XDR strains.

Researchers monitored patients for up to seven years after treatment began. Among the findings: XDR-TB patients were older than MDR-TB patients, more likely to have a history of treatment with second-line TB drugs and more likely to have a history of being treated for TB two or more times.

"One of the most important take-away messages ... is to treat TB carefully the first time around so you don't end up with multidrug-resistant or extensively drug-resistant TB," Richardson said.

Steps to a nimble mind: Physical and mental exercise help keep the brain fit

November 10, 2008 on 1:07 pm | In Uncategorized | Comments Off The brain -- containing 100 billion neurons, 900 billion glial cells, 100 trillion branches and 1,000 trillion receptors -- reacts to stimuli in a series of electrical bursts, spanning a complex map of connections. Whether calculating an algorithmic equation or learning the tango, our brain continuously changes in response to our ideas, actions and activities.

Each time a dance step is learned, for instance, new pathways are formed. "Dancing is excellent for the brain and body," says Vincent Fortanasce, MD, clinical professor of neurology at the University of Southern California in Los Angeles. He wrote the Anti-Alzheimer's Prescription. "Not only are you moving around more, your brain is in constant motion as it recalls steps and movements."

It's an example that highlights a wave of new thinking about the importance of brain fitness.

Until recently, conventional wisdom held that our brains were intractable, hard-wired computers. What we were born with was all we got. Age wore down memory and the ability to understand, and few interventions could reverse this process. But increasingly, evidence suggests that physical and mental exercise can alter specific brain regions, making radical improvements in cognitive function. "When you challenge the brain with new skills and new ways of doing things, it increases connections in the brain," says Ericka P. Simpson, MD, a neurologist who co-directs the MDA Neuromuscular Clinics and directs the ALS clinical research division at the Methodist Hospital System Neurological Institute in Houston. "It increases synaptic density."

With nearly 72 million Americans turning 65 over the next two decades, physicians need the tools to handle growing patient concerns about how to best maintain brain health. Armed with this new brand of science, frontline physicians will be better equipped to address the needs of aging baby boomers, already in the throes of the brain fitness revolution. "They are the gatekeepers of information, and people listen," says Eduardo Locatelli, MD, MPH, a neurologist and medical director of the Florida Neuroscience Center in Fort Lauderdale. Dr. Locatelli implements brain fitness techniques for his postsurgery epilepsy patients as well as patients who present with mild- to moderate-stage Alzheimer's and dementia. "Encourage new experiences. ... Use it or lose it. Challenge it and gain."

The plastic brain

Within the brain, the pathways and regions that are most utilized generally grow and become stronger while other parts shrink. "The brain is very Darwinian, it's survival of the fittest," says Edward Taub, PhD, a behavioral neuroscientist at the University of Alabama at Birmingham, who has researched neuroplasticity since the 1970s. "At one time it was believed we did not use 90% of our brain. That is false. The brain is a zero sum game. Every part of the brain is used. It has enormous plasticity."

Thus, by challenging the brain and forcing the use of different pathways, brain maps can be altered. And such changes offer young and old -- even brain-injured individuals -- an opportunity to learn or re-learn things. "Vocabulary can increase into age 90," says Gary J. Kennedy, MD, a professor in the Dept. of Psychiatry and Behavioral Sciences at Albert Einstein College of Medicine. He also directs the geriatric psychiatry division at Montefiore Medical Center in the Bronx, N.Y. "As people age they may be slower, but they are capable of more and more complex projects."

Brain volume shrinks up to 1% every year after age 65.

To best illustrate neuroplasticity, consider stroke patients with damaged limbs. Contrary to traditional therapy, which works to strengthen the good limb, Taub restrains the uncompromised limb, forcing patients to use the damaged arm or leg. The therapy, constraint-induced movement therapy, also known as CI therapy, helps to rewire the brain.

"The more you use it, more neurons are available ... the more demand for cortical space and the more the patient is able to use the [damaged] arm," Taub said. Over time, small steps lead to improvements in activities of daily living. Ultimately, the damaged limb, at least in part, recovers because, although the brain does not regrow damaged areas, it re-routes around them.

When the brains of CI patients were examined, a tremendous increase in grey matter was detected, and interestingly, Taub says, the healthy part of the brain was recruited for the task. Some of Taub's research was published in the Nov. 1, 2006, Journal of the American Medical Association.

CI applications are now being explored for other forms of brain injury.

Young brains, old brains?

Mental agility begins declining around age 24, says Dr. Fortanasce. But there is a big difference between agility and capacity. "I may be slower, but what I know now far outweighs what I knew at 24," he says. "Some individuals perform their greatest creative work in late life. Verdi, for example, composed Othello at 73 and Falstaff at 79."

Greg Jicha, MD, PhD, assistant professor of neurology at the University of Kentucky College of Medicine, shares related stories, such as that of an 82-year-old who learned to play the trumpet. "I've heard people say, 'You can't teach an old dog new tricks.' That can't be further from the truth," says Dr. Jicha, who also heads the healthy brain aging research group at the university's Sanders-Brown Center on Aging. "When you look at the plasticity of the adult brain, it is amazing."

Mental agility, but not capacity, begins declining around age 24.

But age also brings anatomic changes. Brain weight and blood flow to the brain decrease by 20%. The number of fibers and nerves decrease by 37%. And brain volume shrinks up to 1% every year after age 65. Dr. Fortanasce also points to hormonal shifts, with the presence of dopamine and serotonin diminishing as cortisol, an aging hormone, increases. "Between age 20 and 70, we lose nearly 90% of youth hormones."

So what keeps some brains younger than their chronology? Experts point to a prescription of neurobics. This concept includes life-long learning, trying new things, a healthy diet, social interactions, sleep and physical activity. "Exercise can actually increase neurogenesis and increase the size of the hippocampus," says Dr. Fortanasce, who promotes isometrics and weight-bearing exercise. "Exercise also increases youth hormones. And novelty, doing new things, builds branches."

In a 2006 study in the Journal of Aging and Physical Activity, Brandeis University researchers found that strength training increased the participants' working memory span. The higher the level of resistance, the more memory improved, suggesting that strength training benefits not only the muscles but also the mind.

Dr. Locatelli suggests reversing daily patterns. People who take the same route to work every day need to push themselves beyond their comfort zones. A person can try to eat using his or her weaker hand, for instance. Or someone could listen to another type of music than the type usually favored. Activate unfamiliar areas of the brain, Dr. Locatelli says. The key is new places, socializing with different people, and reading new things.

And primary care physicians can help communicate this message.

"When a patient expresses concern about memory loss, never cast it off as associated with age," says Tom Perls, MD, MPH, associate professor of medicine at Boston University Medical Center. Dr. Perls also heads the New England Centenarian Study. "This is an incredibly serious issue. Losing brain function is devastating." Ask about memory. And rule out other conditions like depression or low thyroid first. "Encourage them to exercise the brain in novel and complex ways," he says.

Exercising new connections

So what about dance steps? At McGill University in Montreal, researchers found that the tango may be better than walking for improving execution of complex tasks because it incorporates elements found in standard neurological rehabilitation programs. It's also fun and social.

Participants, ages 62 to 90, were randomly assigned to a walking group or a tango dancing group, meeting two hours twice a week for 10 weeks. The tango group improved in balance, posture and motor coordination, as well as cognition.

Physical and mental exercise improve cognitive function.

According to new research published in the October issue of the journal Nature Neuroscience, University College London scientists say complex brain processes that enable the memorization and replication of activities such as playing the piano or riding a bicycle require the execution of complicated sequences of movements involving dozens of muscles. According to their research, pianists who learned and practiced their art from an early age had elevated amounts of myelin. This finding suggests that when people learn new skills, myelination might occur. Earlier studies indicated that brains of patients diagnosed with senile dementia had lowered amounts of myelin.

The emphasis, though, is the importance of embracing the complex and novel. And Joe Hardy, PhD, a cognition neuroscientist who develops brain plasticity training programs, says some common-sense advice from physicians is not based on good evidence. "They often recommend doing crossword puzzles," he says. "But evidence suggests that crossword puzzles are not helpful."

Hardy has been developing brain games for the San Francisco-based company Posit Science. The games -- the Brain Fitness Program and Insight -- have been tested in several randomized clinical trials funded by the National Institutes of Health. The results indicate that the brain age clock can roll back 10 years. "The key thing in terms of exercise for the brain: You need to do new things, thus forming new paths," he says.

Some have even compared this new era in brain health to the 1950s, when heart health came to the fore. "New things are coming out all the time, and we are going to see a revolution in brain health," Hardy says. "I think this is going to change the way people age."

FDA launches drug safety information Web site

November 10, 2008 on 1:07 pm | In Uncategorized | Comments Off Washington -- The Food and Drug Administration has a new Web page intended to provide one-stop shopping for postmarket drug safety information. Many physicians say the agency has, to a large extent, succeeded in its mission.

The site provides links to an array of data, including information on drug labels; medications that have risk evaluation and mitigation strategies; postmarket studies; information from MedWatch; and quarterly reports on drugs being evaluated for safety issues.

The development of the Web site (www.fda.gov/cder/drugsafety.htm) is one of the many requirements of the Food and Drug Administration Amendments Act of 2007. The measure was enacted last fall to help correct numerous drug safety problems that have plagued the agency over the past few years.

"By placing Web links to these up-to-date resources on a single page, we're helping consumers and health care professionals find drug safety information faster and easier," said Paul Seligman, MD, MPH, associate director of safety policy and communication in the agency's Center for Drug Evaluation and Research. "This type of communication is aimed at helping consumers and health care professionals make well-informed decisions about medication use."

The AMA has advocated for improved risk communication between the FDA and physicians for several years, and provided numerous comments leading up to passage of the drug safety law.

A round of applause

Curt Furberg, MD, PhD, professor of public health sciences at Wake Forest University Baptist Medical Center in Winston-Salem, N.C., praised the site. "It's a wonderful compilation of very relevant information," he said. Dr. Furberg, a close observer of the drug safety scene, served for several years on the FDA's Drug Safety and Risk Management Advisory Committee.

"You can get drug-specific information, including warning letters, which I try to monitor, but it's a pain to remember to go in there and see what's new," he said. "This [site] has everything in it."

The FDA has launched a new drug safety Web site mandated by a 2007 law.

However, after exploring the site further, he did find a flaw.

"The only communications are those of the FDA," he said. "I wish they had a section on other safety communication.

For example, the FDA had not posted a recent study by Dr. Furberg and others that concluded that inhaled anticholinergics were associated with a significantly increased risk of cardiovascular death or stroke among patients with chronic obstructive pulmonary disease.

Dr. Furberg sent the FDA a copy of the paper, which was published in the Sept. 24 Journal of the American Medical Association.

Overall, though, the site appears to be "a reasonable starting point, which will hopefully get better with time, experience and feedback from physicians and the general public," said David Fassler, MD, clinical professor of psychiatry at the University of Vermont in Burlington.

After reviewing the information on antidepressants, Dr. Fassler found "the site isn't terribly user-friendly. A simple search returns more information than most people want or need."

Keith Roach, MD, associate professor of clinical medicine and public health and epidemiology at New York-Presbyterian Hospital/Weill Cornell Medical Center in New York City, was an enthusiastic reviewer. "I like it," he said. "It's nicely organized. It has all the package inserts in one spot, which is great, so you don't need to have your PDR handy.

"It's definitely going to be a bookmark on my screen." Dr. Roach also favored the site's link to the National Institute of Health's MedlinePlus, which he called "my preferred place to get unbiased patient care information."

If he had to fault the drug safety site, it would be for providing "almost too much information."

All seem to agree that the unknown element is, now that the site has been built, will physicians and others come?

Intensive approaches advised for obese youth

November 3, 2008 on 1:00 pm | In Uncategorized | Comments Off Children and adolescents who are obese are able to lose weight through concentrated behavioral modification programs, according to a pair of recent reports.

But experts say these programs can be hard to access because of the money and time required. Evidence does not support any particular lower-intensity intervention, but experts also say efforts that can be effective in a primary care setting must be found to make a real impact on the pediatric obesity epidemic.

"Accessibility of these kinds of programs is a real issue. The cost is extremely high, but the public health impact is pretty limited," said Dr. Goutham Rao, director of the weight management and wellness center at Children's Hospital of Pittsburgh. "Unless we find a practical and financially sound solution for primary care, we're never going to solve the problem of childhood obesity."

Some 17% of children ages 2-19 are defined as obese, and this statistic has been the focus of significant medical society and public health initiatives. For instance, the American Medical Association, in collaboration with the Health Resources and Services Administration and the Centers for Disease Control and Prevention, convened representatives from 15 health organizations to form the Expert Committee on the Assessment, Prevention and Treatment of Child and Adolescent Overweight and Obesity. Its recommendations were published in the December 2007 Pediatrics.

"The challenge is how to help families actually make changes," said Sarah Barlow, MD, MPH, lead author on that paper and associate professor of pediatrics at Baylor College of Medicine in Houston.

17% of children are obese.

In September, the Agency for Healthcare Research and Quality issued a data review. Increasing acknowledgement of this problem has led to more research on the subject, and the authors believe that more evidence proving which approaches work will translate to more patients being able to access these services.

"The literature has burgeoned as people recognize this public health problem," said Evelyn Whitlock, MD, MPH, lead author and a senior investigator at the Kaiser Permanente Center for Health Research in Portland, Ore. "And we're hoping that this kind of evidence will allow insurers and health care organizations to make effective programs more available."

Researchers found that children and teens would weigh an average of three to 23 pounds less after a medium- to high-intensity weight-loss program that involved meeting for at least 25 hours over six to 12 months compared with those who did not take part. The more intensive the program, and the more overweight the child, the greater the weight loss. These changes were maintained for at least a year.

"It's such a difficult condition that you need consistent therapy," said Dr. Sonia Caprio, professor of pediatrics at Yale University School of Medicine in Connecticut, who studies this topic.

These programs also boosted physical fitness and improved markers of cardiovascular and diabetes risk. Efforts in health care settings worked better than those at schools. They all included organized physical activity, parental involvement for younger children and behavioral management principles. Prescription medications or bariatric surgery were found useful for extremely obese teens.

"Effective prevention is the best way to stem the childhood obesity epidemic, but we also have to find effective and healthy ways of helping our children and teens who already are obese get to a healthier weight," said AHRQ Director Carolyn M. Clancy, MD. "AHRQ's new evidence report helps identify possible solutions."

Accenting prevention

This report also reaffirmed the importance of prevention, and much of it was in line with new guidelines to be published by the Endocrine Society in December issue of the Journal of Clinical Endocrinology & Metabolism.

"The most important take-home message is prevention," said Gilbert P. August, MD, lead author and professor emeritus of pediatrics at George Washington University School of Medicine in Washington, D.C. "We want to introduce lifestyle changes before the patient is obese. Once the patient becomes obese, it's much more difficult to do these things. Bad habits become ingrained, and patients become frustrated by the slow pace of healthy weight loss."

The Endocrine Society document recommended evaluating possible comorbidities in any child with a body mass index over the 85th percentile, although routine evaluation for endocrine causes of excess weight was unnecessary. Physicians also should attempt to prevent obesity by advocating that schools allow for an hour of physical activity a day for all students. Mothers also should be encouraged to breastfeed infants.

In a related development, the U.S. Preventive Services Task Force published an evidence review in the Oct. 21 Annals of Internal Medicine. It found that primary care interventions before and during pregnancy and after a woman gives birth are effective at increasing breastfeeding, which has a range of health benefits, including preventing obesity.