Tuesday, February 23, 2010

The Validity of "Sexual Addiction": Chasing a Tiger

Nassir Ghaemi, MD, Psychiatry/Mental Health, 03:17PM Feb 6, 2010

Everyone is writing about Tiger Woods, and I am not at all inclined to join in - but I suppose I will. The casual use of the concept of "sexual addiction" in relation to his recent diagnosis and treatment may warrant some internal dialogue among psychiatrists. I write these notes not to persuade but to raise questions and see if other colleagues are not wondering similarly.

What is sex addiction all about? I understand hypersexuality, and I understand addiction, but I am not sure I understand sex addiction.

As a psychiatrist, I would first want to apply here the concept of a hierarchy of diagnoses. So a high amount of sexual activity could certainly occur with many conditions, and the concept of a sex addiction, if valid, would have to be the last thing one would diagnose - a diagnosis of exclusion since it could happen with so many other things. First on everyone's list of causes of high sexual activity, I would think, should be mania, or bipolar disorder. Next, or right with it, would be obsessive compulsive disorder (OCD), with sexual content; this is quite common. Then perhaps PTSD with sexual trauma (with later hypersexuality in some people), substance abuse (e.g., amphetamine, steroid, or testosterone abuse), and frontal lobe syndrome. Some depressed individuals also appear to engage in sexual activity, not because of aroused libido, but out of a wish to come out of their isolation and engage with others, even if only physically.

Sexual addiction, as a concept, though, would seem to represent nothing but sex: no mania, nor PTSD, nor substance use, nor other causes. Addiction, as a concept, implies an intense feeling of acute pleasure, followed by a wish to repeat, and, often, tolerance and withdrawal. In this context, tolerance would mean that the more one experienced sex, the less pleasurable it would be; and withdrawal would mean that when abstinence occurred, one experienced painful psychological or physical symptoms (perhaps depression and anxiety). Addiction also implies something that perhaps begins as an experiment, later becomes a habit, and then becomes autonomous. Neurobiologically, addictions tend to involve, we think, activation of the dopaminergic pleasure centers of the brain. Can lots of sex take on this pattern?

It seems difficult to me to distinguish OCD from so-called sexual addiction; perhaps the main difference would be that the individual is bothered by his behavior in one case (OCD) and not the other (addiction); yet this single minor subjective difference would seem to be a small feature upon which to base an entire diagnostic entity. Indeed, there appear to exist many cases of OCD without insight, that is, OCD in which the patient is not much bothered by his or her symptoms. OCD is not, traditional teaching notwithstanding, uniformly characterized by presence of insight (better phrasing than the old ego-dystonic term, in my view).
One reputable website defines sexual addiction as "a progressive intimacy disorder characterized by compulsive sexual thoughts and acts." DSM's definition, under paraphilias, as sexual disorders NOS includes the following ideas: "compulsive searching for multiple partners, compulsive fixation on an unattainable partner, compulsive masturbation, compulsive love relationships and compulsive sexuality in a relationship." This kind of definition seems quite hard to distinguish from OCD with sexual content.

The difference in terminology is important; the idea of sexual addiction would seem to imply analogies to substance abuse: 12 step programs, a limited role for medications, Malibu resorts. The OCD concept would put medications central to the treatment, and make the problem more biological in origin and pathogenesis, rather than simply habit gone awry.

Where we are uncertain, I would prefer the term sexual paraphilia, so as to remain neutral as to the addiction versus OCD dichotomy. Dr. Martin Kafka, a specialist in paraphilias, with whom I have shared patients and whose expertise is large, recently suggested a new DSM category of "Hypersexual disorder", which presumes carefully first ruling out other conditions like OCD and bipolar disorder hierarchically. Though I know he practices this way, I fear that the public at large, and the average clinician, will be too democratic, and too little hierarchical, and forget that such a diagnosis, though perhaps not useless, is one of exclusion, and last resort.

If individuals like Tiger Woods have a variety of OCD, it could be that enough serotonergic antidepressant would knock out their libido or their OCD, or both, to keep them from ruining their lives. But 12 step programs might be tenuously utile.

I don't know the right answer, but it seems to me that this is yet another part of psychiatry where the lapidary use of popular phrases hardly clarifies.

Monday, February 22, 2010

Definition of Hypertension in Youth

Assessment and Management of Hypertension in Children and Adolescents

The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents[12] provides systolic and diastolic blood pressure levels corresponding to the 50th, 90th, 95th, and 99th percentiles based on the child's sex, age, and height percentile.
The height percentile is plotted from normal growth charts. The blood pressure tables and instructions for using them are available in the report[12] and online.[14]

Blood pressure status can be classified on the basis of systolic and diastolic blood pressure percentiles ( Table 1 ).
Measurements below the 90th percentile are considered normal.
Prehypertension or hypertension are present when measurements of either systolic or diastolic pressure, or both, are at or above the 90th percentile.
Blood pressure should be measured at least twice during the same assessment, and confirmed over at least three separate occasions.

Prehypertension is present when the measurement is at or above the 90th percentile, but less than the 95th percentile, as well as when blood pressure reaches or exceeds 120/80 mmHg in an adolescent.
Hypertension is present when repeated measurements are at or above the 95th percentile.
Hypertension is further classified as either stage 1, in which blood pressure ranges from the 95th to the 99th percentile plus 5 mmHg, or stage 2, where blood pressure is above the 99th percentile plus 5 mmHg.

'White coat' hypertension occurs when the patient's blood pressure remains above the 95th percentile when measured in a clinical setting, but is normal when measured in a familiar setting.
If hypertension is confirmed, blood pressure should be measured in both arms and a leg.
The classification of blood pressure influences decisions on evaluation and management.

Table 1. Classification of Hypertension in Youth*
Category Systolic or diastolic blood pressure percentile
Normal < 90th
Prehypertension 90-95th, or if blood pressure exceeds 120/80 mmHg even if < 90th up to < 95th
Stage 1 hypertension 95-99th plus 5 mmHg
Stage 2 hypertension >99th plus 5 mmHg
*Percentiles are based on normative values related to sex, age, and height percentile. If systolic and diastolic categories are different, classify by the higher category.

Friday, February 19, 2010

10 Brain Tips To Teach and Learn

Jul 3, 2008
By: Laurie Bartels

If you agree that our brains are designed for learning, then as educators it is incumbent upon us to be looking for ways to maximize the learning process for each of our students, as well as for ourselves. Some of what follows is simply common sense, but I’ve learned that all of it has a scientific basis in our brains.

1. Review and 2. Reflection are two means for thinking about what is being learned. Review can be done in the moments after a question is posed, a comment is made, a passage is read, an activity is done, or directions are given, providing ample time to think about what has taken place, process the information and respond accordingly.
Review is also what should be done periodically over the course of the year, so that students have the opportunity to revisit, relearn, clarify and consolidate their learning to memory.
Marilee Sprenger, based upon research by Jeb Schenck, notes that “spacing reviews throughout the learning and increasing the time between them gradually allows long-term networks to be strengthened… the timing between repeated reviews can significantly affect how much information is retained.”

Reflection encompasses not only a response to actual material but also thinking about how one learns.

It is 3. Metacognition, and with each iteration you learn more about yourself as a learner. We empower our students and ourselves when we take the time for reflection, because the more we understand about how we each learn, the better we can become at learning. According to Sprenger, “Metacognition involves two phases. The first is knowledge about cognition or thinking about our thinking. The second is monitoring and regulating cognitive processes.”

For me, blogging has been a continual process of review and reflection. In the course of over 170 posts to date, I continually revisit topics, make connections, and write about my own course of learning. As teachers, ideally we should be reviewing and reflecting on lessons, course materials, and interactions with students, both as a means of improving them as well as learning from what worked or did not work.

4. Sleep is another way to consolidate learning, which is one reason getting a full night of uninterrupted sleep is important. Of course, doing so also helps us the next day to have more energy and patience, which then helps us with our attention control. In fact, couple sufficient sleep with waking up to a healthy breakfast, and you are prepared to tackle the day.

Proper 5. Nutrition keeps our systems functioning closer to their peak by stabilizing various levels of hormones and chemicals. All of this holds equally true for students as well as teachers!

We all have our own life stories, and being exposed to something new tends to stick better if we have something else to associate it with or if it is sufficiently unusual that it stands out on its own. Taking advantage of student

6. Prior Knowledge probably requires minimal effort on the part of the teacher, but yields big returns by engaging student interest as students consider new information as it pertains to them and their experiences.

This, in turn, can 7. Engage Emotions, which is the largest hook into learning. We all tend to remember things that get our blood boiling for better or for worse. The parts of the brain engaged in emotions include the small yet mighty amygdala, the hippocampus and the hypothalamus.

“The amygdala deals with our emotions, helps process our memories, and gets totally absorbed in managing our response to fear and stress. Combined, these are biggies, so the hippocampus and hypothalamus chime in with some assistance. The hippocampus handles factual information, while the hypothalamus monitors how your body is doing internally and directs the pituitary gland to release hormones on the basis of functions such as body temperature, appetite, and sexual functioning.”

8. Novelty is another big hook. As information presentation blends between teachers or stays the same by one teacher, it becomes difficult to see patterns and students may tune out the “sameness”. But change it up a bit, introduce something radically different or in a radically different manner, and all of a sudden it is like a quick-pick-me-up in the middle of a lesson, a “brain snack”. Students refocus their attention, and it can even enliven your presentation and wake you up! One way to incorporate novelty is to add some

9. Movement to reenergize the body and brain cells. Movement can shake the sillies out or wake up sluggish bodies and brains; it can be an antidote to the time of day or the climate. Movement is also a close relative of

10. Exercise, and it has been shown that exercise is especially helpful in keeping our adult brains healthy, so remember to participate in that movement with your students (and they will probably consider your participation a bit novel!).

Novelty and movement can also effectively be used to assist kids with sharpening control of their executive function, which is managed by the frontal lobes in the neocortex. Executive function is how we control our attention, create plans, and carry out those plans.
Too often in school, kids are required to “sit still” and “quiet down”, yet these are the very basics of being a kid! Consider harnessing that natural kid energy to help students manage their own functioning. Indeed, in a recent Newsweek article, Wray Herbert notes that an executive function curriculum has emerged to help students manage “effortful control and cognitive focus but also working memory and mental flexibility–the ability to adjust to change, to think outside the box

Laurie Bartels writes the Neurons Firing blog to create for herself the “the graduate course I’d love to take if it existed as a program”. She is the K-8 Computer Coordinator and Technology Training Coordinator at Rye Country Day School in Rye, New York. She is also the organizer of Digital Wave annual summer professional development, and a frequent attendee of Learning & The Brain conferences.

Physical Exercise and Brain Health

Jun 26, 2008

By: Dr. Pascale Michelon

Have you heard of or read John Ratey’s book “Spark: The Revolutionary New Science of Exercise and The Brain”?
According to Harvard Psychiatry Professor John Ratey nothing beats exercise for promoting brain heath.

I am sure you have also heard that exercising your mind promotes brain health.

What is the connection between physical and mental exercises? Do they have additive effects on brain health? Are they redundant?

Let’s start by reviewing what we know about the effects of physical exercise on the brain.

The effect of physical exercise on cognitive performance

Early studies compared groups of people who exercised to groups of people who did not exercise much. Results showed that people who exercised usually had better performance in a range of cognitive tasks compared to non-exercisers.

Laurin and colleagues (2001) even suggested that moderate and high levels of physical activity were associated with lower risk for Alzheimer’s disease and other dementias.

The problem with these studies is that the exercisers and the non-exercisers may differ on other factors than just exercise.
The advantage that exerciser show may not come from exercising but from other factors such as more resources, better brain health to start with, better diet, etc.

The solution to this problem is to randomly assigned people to either an aerobic training group or a control group. If the exerciser group and the non-exerciser group are very similar to start with and if the exerciser group shows less decline or better performance over time than the non-exerciser group, then one can conclude that physical exercise is beneficial for brain health.

In 2003, Colcombe and Kramer, analyzed the results of 18 scientific studies published between 2000 and 2001 that were conducted in the way described above.

The results of this meta-analysis clearly showed that fitness training increases cognitive performance in healthy adults between the ages of 55 and 80.

Another meta-analysis published in 2004 by Heyn and colleagues shows similar beneficial effects of fitness training on people over 65 years old who had cognitive impairment or dementia.

What is the effect of fitness training on the brain itself?

Research with animals has shown that in mice, increased aerobic fitness (running) can increase the number of new cells formed in the hippocampus (the hippocampus is crucial for learning and memory).
Increased exercise also has a beneficial effect on mice’s vascular system.

Only one study has used brain imaging to look at the effect of fitness on the human brain. In 2006, Colcombe and colleagues randomly assigned 59 older adults to either a cardiovascular exercise group, or a nonaerobic exercise control group (stretching and toning exercise). Participants exercised 3h per week for 6 months. Colcombe et al. scanned the participants’ brains before and after the training period.

After 6 months, the brain volume of the aerobic exercising group increased in several areas compared to the other group. Volume increase occurred principally in frontal and temporal areas of the brain involved in executive control and memory processes. The authors do not know what underlying cellular changes might have caused these volume changes. However they suspect, based on animal research, that volume changes may be due to an increased number of blood vessels and an increased number of connections between neurons.

How does physical exercise compare to mental exercise?

Very few studies have tried to compare the effect of physical exercise and mental exercise on cognitive performance.

When looking at each domain of research one notices the following differences:

- The effects of cognitive or mental exercise on performance seem to be very task specific, that is trained tasks benefit from training but the benefits do not transfer very well to tasks in which one was not trained.

- The effects of physical exercise on performance seem broader. However they do not generalize to all tasks. They benefit mostly tasks that involve executive-control components (that is, tasks that require planning, working memory, multitasking, resistance to distraction).

To my knowledge only one study tried to directly compare cognitive and fitness training:

Fabre and colleagues, in 1999, randomly assigned subjects to 4 groups: an aerobic training group (walking or running for 2 h per week for 2 months), a memory training group (one 90 min session a week for 2 months), a combined aerobic and mental training group, or a control group (no training).

Results showed that compared to the control group, the memory performance of all 3 groups increased. The combined group showed greater increase than the other 2 training groups.

This suggests that the effects of cognitive and fitness training may be additive… However this study involved only 8 participants per group! More research is clearly needed before anything can be safely concluded.

In the meantime let’s play it safe and combine fitness and cognitive training for better brain health…!

How can I improve my short term memory

Nov 6, 2006

Brain Coach Answers: By: Caroline Latham

Q: How can I improve my memory? Is there a daily exercise I can do to improve it?

A: The most important component of memory is attention.
By choosing to attend to something and focus on it, you create a personal interaction with it, which gives it personal meaning, making it easier to remember.

Elaboration and repetition are the most common ways of creating that personal interaction. Elaboration involves creating a rich context for the experience by adding together visual, auditory, and other information about the fact. By weaving a web of information around that fact, you create multiple access points to that piece of information. On the other hand, repetition drills in the same pathway over and over until it is a well-worn path that you can easily find.

One common technique used by students, is actually, not that helpful. Mnemonic techniques of using the first letter of each word in a series won’t help you remember the actual words. It will help you remember the order of words you already know. The phrase My Very Energetic Mother Just Screamed Utter Nonsense can help you remember the order the planets in our solar system, but it won’t help you recall the individual planet names: Mercury, Venus, Earth, Mars, Jupiter, Saturn, Uranus, Neptune.

These techniques do help you improve your memory on a behavioral level, but not on a fundamental brain structure level.
The main reason it gets harder for you to learn and remember new things as you age is that your brain’s processing speed slows down as you get older.
It becomes harder to do more than one thing at the same time, so it’s easier to get confused.
Your brain may also become less flexible, so it’s harder to change learning strategies in mid-stream.
All these things mean it becomes harder to focus.
So far, there’s nothing you can do to change your brain’s processing speed, but there are techniques you can use to increase your learning performance, even if your processing speed has slowed.

Alertness, focus, concentration, motivation, and heightened awareness are largely a matter of attitude. Focus takes effort.
In fact, most memory complaints have nothing to do with the actual ability of the brain to remember things.
They come from a failure to focus properly on the task at hand.

If you want to learn or remember something, concentrate on just that one thing.
Tune out everything else.
The harder the task, the more important it is to tune out distractions.
(If someone tells you they can do their homework better with the TV or radio on, don’t believe it. Any speech or speech-like sounds automatically use up part of your brain’s attention capacity, whether you are aware of it or not.)
In other words, it can be hard to do more than one thing at once, and it naturally gets harder as you get older.
The solution is to make more of an effort not to let yourself get distracted until you’ve finished what you have to do.

When you learn something new, take breaks so that the facts won’t interfere with one another as you study them. If you’ve ever been to a movie double feature, you know that you’ll have a hard time remembering the plot and details of the first movie immediately after seeing the second.
Interference also works the other way.
Sometimes when your friend gets a new telephone number, the old one will still be so familiar to you that it’s hard to remember the new one.

Your brain remembers things by their meaning.
If you spend a little effort extra up front to create meaning, you’ll need less effort later to recall it.
When you read or hear a word you don’t already know — for example, “phocine” — your brain has to work harder.
First, you have to remember how to spell it long enough to look it up in a dictionary. There, you’ll see it means “seal-like” and it’s pronounced “fo-sine.” Now picture a seal in your mind and repeat the word aloud. Even say “Fo! Fo! Fo!” aloud like a seal barking. The sound of the word, its spelling, the image of a seal, and the barking all work together to form memory links.
The more links the better to help you trigger the word later on, when you want to use it to describe, say, a sunbather in a black one-piece.

Say you’re on vacation in Maui, staying at a beachfront hotel in room #386. How do you remember that? Method number one: Pause for a minute to take a mental snapshot of your room door viewed from an outside vantage point. Then, when you return to that same vantage point, you’ll know which door is yours. Method number two: Stop and think for a minute. You’re on the third floor, which is the top floor of the hotel, so the number 3 is easy. Now for the 8 and the 6. The expression “to eighty-six” comes to mind — as in to get rid of, do away with, or throw out. As in what your boss will do to you if you decide to spend an extra week in Maui. Done.

The Ten Habits of Highly Effective Brains

Aug 22, 2007

By: Alvaro Fernandez

Let’s review some good lifestyle options we can follow to maintain, and improve, our vibrant brains.

1.Learn what is the “It” in “Use It or Lose It”.
A basic understanding will serve you well to appreciate your brain’s beauty as a living and constantly-developing dense forest with billions of neurons and synapses.

2.Take care of your nutrition. Did you know that the brain only weighs 2% of body mass but consumes over 20% of the oxygen and nutrients we intake?
As a general rule, you don’t need expensive ultra-sophisticated nutritional supplements, just make sure you don’t stuff yourself with the “bad stuff”.

3.Remember that the brain is part of the body. Things that exercise your body can also help sharpen your brain: physical exercise enhances neurogenesis.

4.Practice positive, future-oriented thoughts until they become your default mindset and you look forward to every new day in a constructive way.
Stress and anxiety, no matter whether induced by external events or by your own thoughts, actually kills neurons and prevent the creation of new ones.
You can think of chronic stress as the opposite of exercise: it prevents the creation of new neurons.

5.Thrive on Learning and Mental Challenges. The point of having a brain is precisely to learn and to adapt to challenging new environments. Once new neurons appear in your brain, where they stay in your brain and how long they survive depends on how you use them. “Use It or Lose It” does not mean “do crossword puzzle number 1,234,567″.
It means, “challenge your brain often with fundamentally new activities”.

6.We are (as far as we know) the only self-directed organisms in this planet. Aim high. Once you graduate from college, keep learning.
The brain keeps developing, no matter your age, and it reflects what you do with it.

7.Explore, travel. Adapting to new locations forces you to pay more attention to your environment. Make new decisions, use your brain.

8.Don’t Outsource Your Brain. Not to media personalities, not to politicians, not to your smart neighbour… Make your own decisions, and mistakes. And learn from them. That way, you are training your brain, not your neighbour’s.

9.Develop and maintain stimulating friendships. We are “social animals”, and need social interaction.
Which, by the way, is why ‘Baby Einstein’ has been shown not to be the panacea for children development.

10.Laugh. Often. Especially to cognitively complex humor, full of twists and surprises. Better, try to become the next Jon Stewart

Now, remember that what counts is not reading this article-or any other-, but practicing a bit every day until small steps snowball into unstoppable, internalized habits…so, pick your next battle and try to start improving at least one of these 10 habits today!

BMI Not as Effective as Waist-To-Height Ratio in Determining Heart Risks

From Reuters Health Information

NEW YORK (Reuters Health) Feb 12 - Body mass index (BMI) doesn't predict cardiovascular risk as well as waist-to-height ratio and other measures of obesity, new research suggests.

Asked whether physicians should replace BMI as a way of assessing a patient's cardiovascular risk, the study's lead author Dr. Harald J Schneider responded by email, "Probably, yes. However, I would still be cautious."
He pointed out that BMI might still be useful for assessing other risks, such as for orthopedic complications of being overweight or obese, which were not considered in the current study.

Dr. Schneider, of Ludwig-Maximilians University in Munich, Germany, and his colleagues analyzed data from two German cohort studies called DETECT and SHIP. DETECT followed 6,355 patients for more than 3 years, and SHIP followed 4,297 patients for more than 8 years. They reported their findings online February 3rd in the Journal of Clinical Endocrinology and Metabolism.

Overall, 620 people in both studies died, with 181 deaths attributed to cardiovascular causes, and 325 reached the composite endpoint of stroke, heart attack or cardiovascular death.

In both studies, the waist-to-height ratio was the best predictor of cardiovascular mortality, all-cause mortality and the combined endpoint.
The relative risk of cardiovascular mortality in the highest quartile of waist-to-height ratio compared to the lowest quartile was 2.75.
For BMI, the RR in the highest quartile versus the lowest quartile was 0.74.

Both waist-to-height ratio and waist circumference were significant predictors of all-cause mortality, and all measures except BMI were significantly correlated with the composite endpoint.

Results were comparable when subjects were stratified by age and gender.

"BMI does not distinguish between visceral fat, the 'bad' fat that accumulates in the belly, and subcutaneous fat, the 'good' fat that is under the skin," Dr. Schneider told Reuters Health.
He did point out that these studies involved mostly white, European populations, making it difficult to apply the same conclusions to other ethnic groups.

Dr. Cora E. Lewis, of the Division of Preventive Medicine at the University of Alabama at Birmingham, said other research has similarly indicated that it is more useful to know about abdominal fat than BMI when it comes to cardiovascular risk assessment. She was not involved in Dr. Schneider's research.

"There are some limitations to BMI, but it is easy to obtain," she said in an e-mail. "If you really want a measure to be widely used, the staff at the doctor's office needs to be able to do it quickly and reliably without a lot of fuss from the patients."

She added that the National Heart, Lung and Blood Institute's guidelines for assessing obesity and heart risks do advise the use of waist circumference as well as BMI.
In Dr. Schneider's study, waist circumference was not as successful at predicting risk as waist-to-height ratio, but it appeared to be better than BMI.

"Given that BMI does capture a lot of the information, I am not betting against BMI, at least in the near future," Dr. Lewis said.

J Clin Endocrinol Metab 2010.

Hormone Replacement Therapy With Estrogen Alone Increases Risk for Asthma Onset After Menopause

From Medscape Medical News
Fran Lowry

February 17, 2010 — Hormone replacement therapy (HRT) with estrogen has been linked to an increased risk for the development of asthma after menopause, according to new research published online February 7 in Thorax.

"Epidemiological studies have suggested that female hormones might play a role in asthma and that menopausal hormone therapy (MHT or ...HRT) might increase the risk of asthma in postmenopausal women," write Isabelle Romieu, MD, of the Instituto Nacional de Salud Publica, Cuernavaca, Morelos, Mexico, and colleagues. "The mechanisms underlying the link between hormonal factors and asthma risk are still not clearly understood. Knowing whether MHT affects this risk and if so, whether different preparations have a similar effect would provide a useful insight into the mechanisms by which the hormonal milieu acts on the airways."

The aim of the study was to learn more about the association between different types of hormone therapy and the risk for asthma onset after menopause.

The investigators used data from the E3N study, which is the French component of the European Prospective Investigation into Cancer and Nutrition (EPIC). The study observed a cohort of 98,995 French women born between 1925 and 1950 for more than 10 years, from 1990 to 2002.

The women completed a self-administered questionnaire every 2 years about their medical history, menopausal status, and various lifestyle characteristics. They were considered incident cases of asthma if they stated that they had never had an asthma attack before menopause and had a medical diagnosis of asthma after menopause.

Among 57,664 women who were free of asthma at the start of menopause and who had information about their use of HRT, there were 569 incident cases during 1990 and 2002, which corresponded to an incidence of 1.15/1000 per year, the study authors report.

An increased risk for asthma onset was associated with hormone use. After adjustment for age, smoking, body mass index, oral contraceptive use, parity, and total caloric intake, the hazard ratio (HR) of asthma onset among women who had ever used HRT was 1.21 (95% confidence interval [CI], 1.00 - 1.46) vs never-users.

In women who had recently used HRT, the HR of asthma onset was 1.20 (95% CI, 0.98 - 1.46), and among past users, it was 1.16 (95% CI, 0.86 - 1.57).

However, the increased risk for asthma was significant only in women who used estrogen alone, the study authors report. Compared with never-users, the HR for estrogen-only users was 1.54 (95% CI, 1.13 - 2.09). This risk increased in never-smokers (HR, 1.80; 95% CI, 1.15 - 2.80) and in women who reported allergic disease before asthma onset (HR, 1.86; 95% CI, 1.18 - 2.93).

A small increase in the risk for asthma was observed with combination estrogen-progestagen use in women who never smoked and who had prior allergic disease, the study authors write.

Use of combination hormone therapy with estrogen plus progestagen was also associated with a small increase in the risk for asthma in these 2 subgroups.

The study authors note that they did not measure pulmonary function; therefore, some women may have had chronic obstructive pulmonary disease vs asthma. Results of their study could also be biased if respondents who used hormone replacement "systematically" reported more asthma attacks or were diagnosed with asthma more often because of more frequent visits to the clinician.

This association between the unopposed estrogen and asthma onset needs to be evaluated in light of the beneficial effects of the therapy on the quality of life of menopausal women, the study authors conclude.

Thorax. Published online February 7, 2010.

Sunday, February 14, 2010

Dietary Supplement Causes Widespread Selenium Poisoning

From Medscape Medical News
Fran Lowry

February 8, 2010 — A dietary supplement containing toxic levels of selenium 200 times greater than the concentration listed on the label caused a widespread outbreak of acute selenium poisoning, affecting 201 people from 10 states, investigators report today in the February 8 issue of the Archives of Internal Medicine.

"Selenium is a naturally occurring mineral required for good health. It is obtained from food, and the recommended dietary allowance is 55 μg/d for persons 14 years or older, with a tolerable upper intake limit of 400 μg/d," write Jennifer K. MacFarquhar, RN, MPH, from the Centers for Disease Control and Prevention, Atlanta, Georgia, and colleagues. "The amount of selenium available in a diverse diet with meat, grains, vegetables, and nuts is typically sufficient to negate the necessity for supplementation."

Symptoms of selenium poisoning include nausea; vomiting; nail discoloration, brittleness, and loss; hair loss; fatigue; irritability; and foul breath odor.

The authors began to investigate an outbreak of acute selenium poisoning after reports of cases of toxicity started to surface in March 2008. They defined a case as the onset of symptoms of selenium toxicity within 2 weeks of ingesting a dietary supplement that was manufactured by a company (designated as "Company A") and purchased after January 1, 2008.

The search for cases was conducted nationally. The investigators administered a questionnaire to 227 affected persons from 9 states, including Florida, Georgia, Kentucky, Michigan, North Carolina, Pennsylvania, Tennessee, Texas, and Virginia. They administered a follow-up questionnaire 90 days after the first interview in Florida, Georgia, Michigan, North Carolina, and Tennessee.

The source of the outbreak was identified as a liquid dietary supplement. It was marketed as being suitable for the "entire family" to provide a balance of nutrients to "maintain energy and sustain health" and was labeled as containing 200 μg of selenium per fluid ounce in the form of sodium selenite, an inorganic form of selenium.

Selenium Concentration Was 200 Times Labeled Concentration

When the US Food and Drug Administration (FDA) tested the supplement, it found the selenium concentration to be 40,800 μg/ounce — approximately 200 times the labeled concentration.

The authors report that 201 cases of selenium poisoning were identified, 1 of which required hospitalization. The median estimated dose of selenium consumed was 41,749 μg/day.

The symptoms most frequently reported were diarrhea (78%), fatigue (75%), hair loss (72%), joint pain (70%), nail discoloration or brittleness (61%), and nausea (58%). Symptoms that persisted for 90 days or longer included fingernail discoloration and loss in 52% of cases, fatigue (35%), and hair loss (29%).

In 8 patients, the mean initial serum selenium concentration was 751 μg/L (reference range, ≤125 μg/L), and the mean initial urine selenium concentration in 7 patients was 166 μg/24 hours (reference range, ≤55 μg/24 hours).

Although 201 cases were identified, the actual number of affected persons was likely greater, the authors note. Because selenium toxicity is so rare, and because the wide array of associated symptoms can be nonspecific, making the diagnosis can be difficult.

When interviewed, patients stated that they had not suspected the supplement had made them ill and never mentioned the fact they were taking it to their physicians. Some increased the dose to try to ameliorate their symptoms. "This highlights the importance of patients informing their health care providers about all dietary supplements, herbal remedies, and over-the-counter medications, in addition to prescription medications," the authors write.

The investigation was limited by potential recall bias among patients and a limited number of clinical specimens available for laboratory testing. There were also substantial barriers to sharing proprietary or personally identifiable information among investigating agencies. Information from individuals calling MedWatch was not shared directly with health departments. Instead, the FDA staff had to ask the callers to contact the health department themselves, the authors comment.

"Had the manufacturers been held to standards used in the pharmaceutical industry, this outbreak may have been prevented," the authors conclude. "Gaps in existing regulations present a significant public health risk, and attention should be directed at correcting them to prevent recurring outbreaks such as this."

Reevaluation of Dietary Supplement Health and Education Act Needed

In an invited commentary, Bimal H. Ashar, MD, MBA, from Johns Hopkins School of Medicine, Baltimore, Maryland, writes that the time has come for lawmakers to reevaluate the Dietary Supplement Health and Education Act, passed in 1994, which allows manufacturers to market their products without submitting proof of efficacy or safety to the FDA.

Dr. Ashar notes that congressional support for the act centered on 4 main points: that it would allow consumers access to safe dietary supplements, that it would improve their health, that it would empower consumers to make choices about their preventive health, and that it would stimulate growth of the supplement industry.

However, patients have no way of distinguishing safe supplements from those that may be harmful, and the FDA is "ill equipped to expeditiously monitor, assess, and take action on potentially unsafe supplements," he writes.

The evidence that dietary supplements treat or prevent disease is lacking, but reports of adverse events continue to surface, Dr. Ashar said. "The fact that most patients do not experience adverse events from their supplement use should not be solely sufficient to justify their promotion without premarket evaluation."

Ms. MacFarquhar and Dr. Ashar have disclosed no relevant financial relationships.

Arch Intern Med. 2010;170:256-261, 262-263.

Caloric Restriction With or Without Exercise: The Fitness versus Fatness Debate

From Medicine and Science in Sports and Exercise®

D. Enette Larson-Meyer; Leanne Redman; Leonie K. Heilbronn; Corby K. Martin; Eric Ravussin

There is a debate over the independent effects of aerobic fitness and body fatness on mortality and disease risks.

Purpose: To determine whether a 25% energy deficit that produces equal change in body fatness leads to greater cardiometabolic benefits when aerobic exercise is included.

Methods: Thirty-six overweight participants (16 males/20 females) (39 ± 1 yr; 82 ± 2 kg; body mass index = 27.8 ± 0.3 kg·m2, mean ± SEM) were randomized to one of three groups (n = 12 for each) for a 6-month intervention: control (CO, weight-maintenance diet), caloric restriction (CR, 25% reduction in energy intake), or caloric restriction plus aerobic exercise (CR + EX, 12.5% reduction in energy intake plus 12.5% increase in exercise energy expenditure). Food was provided during weeks 1-12 and 22-24. Changes in fat mass, visceral fat, V·O2peak (graded treadmill test), muscular strength (isokinetic knee extension/flexion), blood lipids, blood pressure, and insulin sensitivity/secretion were compared.

Results: As expected, V·O2peak was significantly improved after 6 months of intervention in CR + EX only (22 ± 5% vs 7 ± 5% in CR and −5 ± 3% in CO), whereas isokinetic muscular strength did not change. There was no difference in the losses of weight, fat mass, or visceral fat and changes in systolic blood pressure (BP) between the intervention groups. However, only CR + EX had a significant decrease in diastolic BP (−5 ± 3% vs −2 ± 2% in CR and −1 ± 2% in CO), in low-density lipoprotein (LDL) cholesterol (−13 ± 4% vs −6 ± 3% in CR and 2 ± 4% in CO), and a significant increase in insulin sensitivity (66 ± 22% vs 40 ± 20% in CR and 1 ± 11% in CO).

Conclusions: Despite similar effect on fat losses, combining CR with exercise increased aerobic fitness in parallel with improved insulin sensitivity, LDL cholesterol, and diastolic BP. The results lend support for inclusion of an exercise component in weight loss programs to improve metabolic fitness.

Numerous studies have linked increased adiposity[17,32] and reduced physical activity[17] and/or fitness[32,35] to increased risk of cardiovascular disease (CVD) and overall mortality. However, because of the strong link between physical fitness-particularly of aerobic nature-and reduced prevalence of obesity,[35,38] there is debate about the potential independent effects of aerobic fitness and adiposity (i.e., fatness) on CVD and metabolic health risk factors. For example, it is generally recognized that the benefits of increased physical activity on CVD risks include decreased platelet aggregation, enhanced fibrinolysis, decreased susceptibility to malignant ventricular arrhythmias, improved endothelial function, and myocardial oxygen delivery, along with reduced obesity.[12] The detriments of increased fatness, on the other hand, include increased renin-angiotensin system activation,[10] low-grade inflammation,[2,39] and chronic oxidative stress[20] which result in reduced nitric oxide availability, increased vascular tone and arterial stiffening, and increased systolic and pulse pressures.[8,29] Furthermore, both fatness and poor fitness are linked with insulin resistance, elevated blood pressure, and elevated total and low-density lipoprotein (LDL) cholesterol concentrations,[12] all of which improve with weight loss and enhanced fitness. These links are of course complicated by the strong negative relation between fitness and fatness.

Although several large studies[18] including the Nurses Health Study[17] and the Lipid Research Clinic Study[32] have provided evidence supporting independent contributions of both decreased physical activity/fitness and increased fatness on mortality, there are several reports predominately from Blair's group[4,5,23,33,34] suggesting that aerobic fitness can negate the adverse effects of fatness on mortality.[4,33,34] Such results have often been interpreted that reducing fatness is not necessary in light of adequate fitness.[24] The majority of previous studies, however, have been criticized for inclusion of mostly relatively young healthy white individuals rather than a more ethnically representative sample of aging individuals.[38] In contrast, analysis from the Look AHEAD (Action for Health in Diabetes) Trial in a large ethnically diverse sample of overweight individuals with type 2 diabetes found that both fitness and fatness are related to CVD risk factors, but that the strength of the association for fitness versus fatness was different for different risk factors.[38] These results along with a few other trials[3,19] suggest that both fitness and reduced fatness are important for reducing overall morbidity and mortality.

An interesting question still up for debate is whether improvements in fitness or fatness independently alter risk factors for CVD and the metabolic syndrome, particularly during caloric restriction (CR). Prolonged CR increases life span in rodents and other shorter-lived animal species,[36] but the addition of exercise improves average life span but not maximal life span.[16] In humans, CR has been shown to impact several biomarkers of longevity including fasting insulin concentration, body core temperature,[14] DNA damage,[14] and markers of atherosclerosis.[9] It is, however, not known if in a prospective design, the addition of exercise training will yield extra health benefit in the face of similar weight and fat loss. In other words, does CR with or without exercise result in different improvements in cardiometabolic risk factors which could ultimately improve longevity? The purpose of this analysis was to determine whether a deficit by energy restriction or energy restriction plus aerobic exercise that produces equal change in fatness[26] leads to greater cardiometabolic benefits when exercise is included.


Gastric Banding May Allow Significant Weight Loss in Obese Teens

From Medscape Medical News
Laurie Barclay, MD

February 9, 2010 — Gastric banding may be more effective than lifestyle intervention in achieving weight loss in obese adolescents, according to the results of a prospective, randomized controlled trial reported in the February 10 issue of the Journal of the American Medical Association (JAMA).

"Adolescent obesity is a common and serious health problem affecting more than 5 million young people in the United States alone," write Paul E. O'Brien, MD, FRACS, and colleagues of Monash University and the Centre for Adolescent Health, Royal Children's Hospital, Melbourne, Australia, and colleagues.
"Bariatric surgery is being evaluated as a possible treatment option. Laparoscopic adjustable gastric banding (gastric banding) has the potential to provide a safe and effective treatment."

The goal of this study was to compare the outcomes on adolescent obesity of gastric banding vs an optimal lifestyle program. Between May 2005 and September 2008, a total of 50 adolescents aged 14 to 18 years with body mass index (BMI) of more than 35 kg/m2 were recruited from the Melbourne, Australia, community and randomly assigned to a supervised lifestyle intervention or to undergo gastric banding. During 2-year follow-up, the primary study endpoint was weight loss, and secondary endpoints were change in metabolic syndrome, insulin resistance, quality of life, and adverse outcomes.

In the gastric banding group, 24 of 25 patients completed the study vs 18 of 25 in the lifestyle group. Loss of more than 50% of excess weight, corrected for age, occurred in 21 patients (84%) in the gastric banding group and in 3 patients (12%) in the lifestyle group.

In the gastric banding group, mean weight loss was 34.6 kg (95% confidence interval [CI], 30.2 - 39.0 kg), representing an excess weight loss of 78.8% (95% CI, 66.6% - 91.0%), loss of 12.7 BMI units (95% CI, 11.3 - 14.2), and a BMI z score change from 2.39 (95% CI, 2.05 - 2.73) to 1.32 (95% CI, 0.98 - 1.66).
In the lifestyle group, mean weight loss was 3.0 kg (95% CI, 2.1 - 8.1), representing an excess weight loss of 13.2% (95% CI, 2.6% - 21.0%), 1.3 BMI units (95% CI, 0.4 - 2.9), and a BMI z score change from 2.41 (95% CI, 2.21 - 2.66) to 2.26 (95% CI, 1.91 - 2.43).

Metabolic syndrome was present at entry in 9 participants (36%) in the gastric banding group and in 10 participants (40%) in the lifestyle group, but at 24 months, none of the gastric banding group had the metabolic syndrome (P = .008) vs 4 (22%) of the 18 completers in the lifestyle group (P = .13).
Participants in the gastric banding group also reported improved quality of life. Although there were no perioperative adverse events, 8 surgical revisions (33%) were required in 7 patients either for proximal pouch dilatation or tubing injury during follow-up.

"Among obese adolescent participants, use of gastric banding compared with lifestyle intervention resulted in a greater percentage achieving a loss of 50% of excess weight, corrected for age," the study authors write. "There were associated benefits to health and quality of life."

Limitations of this study include lack of generalizability to the general obese adolescent population in the community, possible recruitment bias, study not powered to measure differences in adverse events or in health measures other than differences in weight outcomes, and follow-up limited to 2 years.
In addition, the investigators used an intent-to-treat analysis for the primary outcome of weight change but used the completer's analysis for secondary outcomes.

"In this study, gastric banding proved to be an effective intervention leading to a substantial and durable reduction in obesity and to better health," the study authors conclude. "The adolescent and parents must understand the importance of careful adherence to recommended eating behaviors and of seeking early consultation if symptoms of reflux, heartburn, or vomiting occur. As importantly, they should be in a setting in which they can maintain contact with health professionals who understand the process of care."

In an accompanying editorial, JAMA contributing editor Edward H. Livingston, MD, from the University of Texas Southwestern Medical Center in Dallas, notes that this study shows that randomized controlled trials can and should be performed to evaluate surgical technologies.

"The quality of evidence in support of bariatric surgery is poor, resulting in substantial controversy regarding its use for obesity treatment," Dr. Livingston writes. "Many insurance companies in the United States will not pay for bariatric surgeries, and their decision to not cover this treatment is based on the lack of compelling, universally accepted evidence in its favor. Studies such as the one by O'Brien et al go a long way toward providing the evidence necessary to evaluate the benefits and risks of bariatric surgery."

The National Health and Medical Research Council supported this study. Allergan provided the laparoscopic adjustable gastric bands used in the study and provided an unrestricted research support grant to the Centre for Obesity Research and Education. One of the study authors (Dr. Dixon) has disclosed various financial relationships with Allergan, Bariatric Advantage, Scientific Intake, SP Health Co, Optifast, Abbott Australasia, Eli Lilly Australia, Merck Sharp & Dohme Australia, Nestle Australia, and Roche Products Australia. Dr. Livingston has disclosed no relevant financial relationships.

JAMA. 2010;303:519-526, 559-560.

Soft Drink Consumption Linked to Pancreatic Cancer

From Medscape Medical News
Roxanne Nelson

February 10, 2010 — The regular consumption of sugar-laden soft drinks could boost a person's risk of developing pancreatic cancer. The results of a new study found that individuals who consumed 2 or more soft drinks per week had an 87% increased risk for pancreatic cancer, compared with those who did not.

Even after taking factors such as smoking, caloric intake, and type 2 diabetes mellitus into account, the authors found that consuming soft drinks might play an independent role in the development of pancreatic cancer.

The finding is reported in the February issue of Cancer Epidemiology, Biomarkers & Prevention.

Both soft drinks and fruit juices have a high glycemic load relative to other foods and drinks, and it has been hypothesized that both are risk factors for pancreatic cancer. The high levels of sugar can increase levels of insulin in the body, and this can contribute to pancreatic cancer cell growth, the researchers explain.

Association Not Seen With Fruit Juice

However, this study did not find an association between consumption of juice and an increased risk for pancreatic cancer.

"There are several plausible explanations why fruit juice was not significantly associated with pancreatic cancer," said first author Noel Mueller, MPH, a research associate at Georgetown University Medical Center in Washington, DC.

One reason is that the finding was based on a relatively small number of cases, so there might have been too few cases to detect an effect with fruit juice, he explained. Another is that there are differences between soft drinks and fruit juice — fruit juice is lower in sugar, includes many nutrients, and is typically served in smaller portion sizes.

A third explanation is that fruit juice intake is associated with healthier lifestyle characteristics than soft drink intake, he said.

The consumption of soft drinks coincided with a number of other unhealthy lifestyle characteristics, making it somewhat difficult to separate smoking, caloric intake, body weight, and type 2 diabetes mellitus from soft drink consumption. "But the findings from our study suggest that soft drinks may play an independent role in the development of pancreatic cancer," Mr. Mueller told Medscape Oncology.

"The influence of soft drink intake on the risk of pancreatic cancer remained virtually unchanged after adjustment for smoking status, energy intake, body weight, and type 2 diabetes mellitus," he added.

Results Statistically Significant for Soft Drinks

The current study examined the association between the consumption of soft drinks and juice and the risk for pancreatic cancer among Chinese people residing in Singapore.
The data came from the Singapore Chinese Health Study (n = 60,524), and information regarding the consumption of soft drinks, juice, and other dietary items, along with lifestyle factors and environmental exposures, was collected at recruitment to the study. The participants were followed for up to 14 years.

At the start of the study, 9.7% of the participants consumed at least 2 soft drinks per week and 10.2% consumed at least 2 servings of juice per week. The authors note that, compared with those who did not consume soft drinks, those who consumed 2 or more soft drinks per week were younger, were more likely to be men, and were more likely to smoke cigarettes.
They also had higher levels of education, alcohol consumption, and total energy intake; lower levels of physical activity; and consumed more total carbohydrates, fat, added sugar, and red meat.

Individuals who reported consuming 2 or more juice drinks a week had lifestyle and dietary habits that were similar to those who consumed soft drinks. However, there was no association between juice intake and cigarette smoking, and body mass index (BMI) was comparable across different categories of soft drink and juice consumption.

At 14 years and a cumulative 648,387 person-years of follow-up, 140 incident pancreatic cancers developed in people who were cancer free at baseline. After adjustment for confounders such as BMI, type 2 diabetes mellitus, and fruit juice intake, the authors found that those consuming 2 or more soft drinks per week experienced a statistically significant increased risk for pancreatic cancer (hazard ratio [HR], 1.87; 95% confidence interval [CI], 1.10 - 3.15).

Although people who consumed 2 or more juice drinks a week had an increased risk for pancreatic cancer of approximately 30%, elevated HR was not statistically significant after adjustment for variables.

However, in an age-adjusted analysis, smoking was also a risk factor. After excluding former smokers, the authors found that current smokers had a 49% increased risk for pancreatic cancer, compared with never smokers (HR, 1.49; 95% CI, 0.98 - 2.27). This risk factor remained unaffected after adjustment for diabetes and BMI.

Can Be Extrapolated to United States and Europe

Singapore is a highly industrialized nation with lifestyle and nutritional patterns reminiscent of many westernized countries. In that sense, these findings could be extrapolated to the United States and Europe, explained Mr. Mueller. Soft drinks are the leading source of added sugar in the American diet, the authors note.

"However, there are inherent differences between Singaporean Chinese and Caucasians, which is why one must be cautious when generalizing these results to the United States and Europe," he said. "But it is important to note that other studies in Caucasian populations have suggested that soft drink intake may increase risk for pancreatic cancer."

Because pancreatic cancer is a relatively rare disease, the number of cases in this study was relatively small, the authors point out. This limited the statistical power of the study. Another limitation was the inability to collect repeated dietary measurements during the course of the study; therefore, they could not account for changes in consumption of soft drinks and juices.

However, this study adds to the evidence that soft drink consumption plays a role in the development of pancreatic cancer, they conclude, and that "clinical studies examining biomarkers for glycemia and insulinemia and taking a mechanistic approach to the question of soft drink consumption and pancreatic cancer are warranted."

There is "still much to understand on the link between sugar-sweetened beverages and pancreatic cancer," the authors write.

The study was supported by a grant from the National Cancer Institute. The researchers have disclosed no relevant financial relationships.

Cancer Epidemiol Biomarkers Prev. 2010;19;447-455. Abstract

Superior Academic Performance Linked to Increased Risk for Bipolar Disorder

From Medscape Medical News
Pauline Anderson

February 11, 2010 — Students who at the age of 16 years excel at school, particularly in creative subjects, are almost 4 times more likely to develop bipolar disorder during the next decade than teenagers with average grades, a new study has found.

This finding supports the hypothesis that creative individuals are more susceptible to bipolar disorder, lead author James H. MacCabe, PhD, Senior Institute of Psychiatry, King’s College, London, United Kingdom, told Medscape Psychiatry. "This is an idea that a lot of people believe, although until this study, there hasn’t been very strong evidence," said Dr. MacCabe.

However, the investigators also found a relationship, albeit a weaker one, between students who do poorly in school and the later development of bipolar disorder.

The study is published in the February issue of the British Journal of Psychiatry.

Healthy Cohort at Baseline

For the study, researchers followed up 713,876 children who were in the Swedish national school register from 1988 to 1997. The researchers excluded students who developed a psychiatric disorder before or within 1 year after completion of their national examination, which all Swedish children must sit the year they turn 16 years old.

"We didn’t want to risk that we were capturing people who were already ill and whose school performance might have been affected by their illness," said Dr. MacCabe. "We wanted to get people when they were still well and then follow them up."

From the national examination, students receive grades ranging from A to E in each of 16 compulsory subjects, which are converted into grade point averages. In this study, grade point average scores ranged from 1.0 to 5.0, with means of 3.11 for boys and 3.39 for girls.

Researchers followed up the subjects until December 31, 2003. The mean follow-up period was 9.48 years, by which time the mean age of the study group was 26.48 years.

During the follow-up period, 280 young people developed bipolar disorder, with a mean age at onset of 20.79 years. There were roughly an equal number of men and women who developed the disorder. Information on bipolar disorder diagnoses came from the Swedish hospital discharge register that contains details of all psychiatric hospitalizations.

Association Stronger in Boys

Students in the highest academic category — with grades of 2 or more standard deviations above the mean — had a significantly higher risk for bipolar disorder (hazard ratio, 3.79) compared with those with average scores.

"Basically, these students who got mainly A grades and a few B's thrown in had a 4-fold increased risk of subsequently developing bipolar disorder,” said Dr. MacCabe.

At the other end of the academic scale, those in the lowest grade category were also more likely to develop bipolar disorder than those with average scores (hazard ratio, 1.86).

"The people who were 2 standard deviations below the mean, so mostly D and E grade students, were about twice as likely to get bipolar disorder," said Dr. MacCabe. Adjusting for parental education and socioeconomic status did not fully explain these relationships, he added.

Although there were more girls than boys in the top academic category, the relationship between scholastic achievement and bipolar disorder appeared to be stronger in boys than girls. The study authors noted, too, that most of the eminent creative historical figures with probable bipolar disorder were male.

"The men in this top category were a more extreme group in that they were doing much better [academically] than their peers," said Dr. MacCabe. "Perhaps the more extreme, the more different you are than your peers in terms of school performance, the higher your risk."

Striking Comparison to Schizophrenia

The study gives credence to the idea that creative people are more susceptible to bipolar disorder. Although scoring an A grade was associated with an increased risk for bipolar disorder for all 16 school subjects, the association was stronger for the humanities than for science and technical subjects.

In contrast to bipolar disorder, higher academic marks are associated with decreased risk for schizophrenia, the study authors noted. That’s "very striking" in light of a recent theory that schizophrenia and bipolar disorder are more closely genetically linked than previously believed, commented Dr. MacCabe. "This seems to suggest that we found something that distinguishes between schizophrenia and bipolar, at least in some cases."

The study compares the development of bipolar disorder with academic achievement not IQ. Intelligence is only 1 factor that influences academic success, with other factors including memory, attention, motivation, diligence, and organization skills. Recent research has shown that only about 60% of school performance is related to IQ, said Dr. MacCabe.

The study could have been biased toward more severe cases because it included only hospital-treated bipolar disorder. Other possible biases were that students with higher IQ might have been more likely to seek psychiatric treatment or psychiatrists may have been more apt to diagnose bipolar disorder in a student with a high IQ.

Although the study authors attempted to ensure that all students did not have bipolar disorder at the time of their examination, it is possible that some had subclinical symptoms of hypomania or depression, and this could have influenced their performance.

People who are genetically predisposed to bipolar disorder but have not become ill may have certain cognitive styles, for example, the ability to concentrate, that might enhance their academic performance, said Dr. MacCabe.

"We know that bipolar disorder is a strongly genetic disorder. Those people would have been carrying their genetic predisposition for the disorder, and it may have manifested itself in this way by actually improving their scores in school."

The study authors have disclosed no relevant financial relationships.

Br J Psychiatry. 2010;196:109-115.

Friday, February 12, 2010

Sneeze Reflex: Facts and Fiction

From Therapeutic Advances in Respiratory Disease

Murat Songul; Cemal Cingi

Sneezing is a protective reflex, and is sometimes a sign of various medical conditions. Sneezing has been a remarkable sign throughout the history. In Asia and Europe, superstitions regarding sneezing extend through a wide range of races and countries, and it has an ominous significance.
Although sneezing is a protective reflex response, little else is known about it. A sneeze (or sternutation) is expulsion of air from the lungs through the nose and mouth, most commonly caused by the irritation of the nasal mucosa.
Sneezing can further be triggered through sudden exposure to bright light, a particularly full stomach and physical stimulants of the trigeminal nerve, as a result of central nervous system pathologies such as epilepsy, posterior inferior cerebellar artery syndrome or as a symptom of psychogenic pathologies.
In this first comprehensive review of the sneeze reflex in the English literature, we aim to review the pathophysiology, etiology, diagnosis, treatment and complications of sneezing.


Mediterranean Diet, Physical Activity, Cognitive Function, and Dementia Risk

From Journal Watch > Journal Watch Neurology

Gad A. Marshall, MD

Two new studies addressed whether diet and physical activity in elders affect cognitive decline and dementia.

In two large, prospective, population-based studies, researchers examined whether better adherence to a Mediterranean-type diet, with or without greater physical activity, is associated with less global cognitive decline or lower incidence of Alzheimer disease.

Scarmeas and colleagues investigated the association between amount of physical activity, alone or in combination with adherence to a Mediterranean-type diet, and incidence of Alzheimer disease (AD). For a mean of 5.4 years, the investigators followed 1880 community-dwelling, nondemented elders in New York City. Approximately every 1.5 years, participants completed physical-activity and food-frequency questionnaires and underwent cognitive and clinical assessments to determine dementia onset. A total of 282 participants developed AD. After adjustments for multiple confounders (including age, education, sex, ethnic background, presence of apolipoprotein E ε4 gene, baseline cognitive function, body-mass index, caloric intake, leisure activities, medical comorbidities, and smoking), the risk for AD was lower in participants with a high diet score (hazard ratio, 0.60), high physical activity (HR, 0.67), or both (HR, 0.65).

Féart and colleagues investigated the associations of adherence to a Mediterranean-type diet with cognitive decline and with dementia incidence. The investigators followed 1410 community-dwelling, nondemented elders from Bordeaux, France. Participants completed a food-frequency questionnaire and underwent cognitive tests and clinical assessments at least twice during a 5-year period. A total of 99 participants developed dementia (66 AD). After adjustment for potential confounders (including age, education, sex, marital status, presence of apolipoprotein E ε4 gene, physical activity, energy intake, multiple medications intake, depression, stroke, and cardiovascular risk factors), less cognitive decline on the Mini-Mental State Examination (but not in individual cognitive domains) was associated with greater adherence to a Mediterranean-type diet (measured as a continuous variable), whereas reduction in dementia risk was not.

In the New York study, both the Mediterranean-style diet and physical activity reduced dementia risk, whereas in the Bordeaux study, the diet helped maintain global cognitive function but did not affect dementia risk. The Bordeaux study may have been underpowered. On the other hand, the New York study had a high percentage of Latino and black participants, and therefore the findings may not generalize well to the rest of the U.S. or the world. Moreover, as an editorial author notes, whether these late-life lifestyle modifications reflect midlife lifestyle changes is unclear, thus further confounding the results.

Most dementia prevention or treatment interventions being investigated consist of new investigational drugs or supplements. Too few large, prospective, carefully designed population studies have tested the extent to which common midlife and late-life lifestyle modifications affect cognitive function and dementia risk. We need larger, longer-duration, prospective population studies and clinical trials of such lifestyle modifications. Results of these studies can be used to better educate patients earlier in life and to reinforce such common-sense interventions

Friday, February 5, 2010

Exercise in Older Women May Improve BMD and Reduce Fall Risk

From Medscape Medical News
Laurie Barclay, MD

February 4, 2010 — An exercise program vs a general wellness intervention in older women may improve bone mineral density (BMD) and reduce fall risk, but not cardiovascular disease risk, according to the results of a randomized, single-blinded, controlled trial reported in the January 25 issue of Archives of Internal Medicine.

"Physical exercise affects many risk factors and diseases and therefore can play a vital role in general disease prevention and treatment of elderly individuals and may reduce costs, write Wolfgang Kemmler, PhD, from Freidrich-Alexander University of Erlangen-Nuremberg in Erlangen, Germany, and colleagues from the Randomized Controlled Senior Fitness and Prevention (SEFIP) Study.
"We sought to determine whether a single exercise program affects fracture risk (bone mineral density [BMD] and falls), coronary heart disease (CHD) risk factors, and health care costs in community dwelling elderly women."

From May 1, 2005, through July 31, 2008, a total of 246 women 65 years or older who were living independently in the area of Erlangen-Nuremberg, Germany, were recruited and randomly assigned 1:1 to an 18-month exercise program (exercise group) or to a wellness program (control group).
The exercise intervention consisted of a multipurpose exercise program emphasizing exercise intensity, whereas the control intervention emphasized well-being with a low-intensity, low-frequency program. Study endpoints included BMD, the number of falls, Framingham-based 10-year CHD risk, and direct healthcare costs.

Among 227 women who completed the 18-month study, there were significant effects of exercise for BMD of the lumbar spine (mean percentage of change in BMD from baseline to follow-up for the exercise group: 1.77% (95% confidence interval [CI], 1.26% - 2.28% vs control subjects: 0.33%; 95% CI, −0.24% to 0.91%; P < .001), femoral neck (exercise group: 1.01%; 95% CI, 0.37% - 1.65% vs control subjects: −1.05%; 95% CI, −1.70% to −0.40%; P < .001), and fall rate per person for 18 months (exercise group: 1.00; 95% CI, 0.76 - 1.24 vs control subjects: 1.66; 95% CI, 1.33 - 1.99; P = .002).

In both subgroups, there was a significantly effect on 10-year CHD risk, but this was not significantly different between the groups (absolute change for the exercise group: −1.96%; 95% CI, −2.69% to −1.23% vs control subjects: −1.15%; 95% CI, −1.69% to −0.62%; P = .22). During the 18-month intervention, direct healthcare costs per participant were not significantly different between the groups (exercise group: €2255; 95% CI, €1791 - €2718; vs control subjects : €2780; 95% CI, €2187 - €3372; P = .20).

"Compared with a general wellness program, our 18-month exercise program significantly improved BMD and fall risk, but not predicted CHD risk, in elderly women," the study authors write. "This benefit occurred at no increase in direct costs."

Limitations of this study include exercise in both groups, which may have prevented significant group differences for 10-year CHD risk; and possible crossover and inadequate blinding.

"This contribution extends the existing data in that a single multipurpose exercise program that is based on a low-volume, high-intensity philosophy and is designed for the elderly improves overall fitness, maintains bone health, and reduces fall risk," the study authors conclude. "Because this training regimen can be easily adopted by other institutions and health care providers, a broad implementation of this program is feasible."

The Siemens Betriebs Krankenkasse, Behinderten-undRehabilitations-Sportverband Bayern, Netzwerk Knochengesundheit e.V.,Opfermann Arzneimittel GmbH, Thera-Band, Institute of Sport Science, and Institute of Medical Physics supported this study. The study authors have disclosed no relevant financial relationships.

Arch Intern Med. 2010;170:179-185. Abstract

Tuesday, February 2, 2010

Transdermal Nicotine for 24 Weeks vs 8 Weeks May Improve Abstinence

From Medscape Medical News
Laurie Barclay, MD

February 2, 2010 — Transdermal nicotine for 24 weeks compared with 8 weeks is more effective in achieving and maintaining abstinence and reduces the risk for lapses in smoking, according to the results of a parallel randomized, double-blinded, placebo-controlled trial reported in the February 2 issue of Annals of Internal Medicine.

"Tobacco dependence is a chronic, relapsing condition that may require extended treatment," write Robert A. Schnoll, PhD, from the University of Pennsylvania in Philadelphia, and colleagues. "We evaluated the relative efficacy of extended (24 weeks) versus standard (8 weeks) transdermal nicotine therapy for promoting biochemically confirmed point-prevalence abstinence at weeks 24 and 52 among adult smokers."

From September 2004 to February 2008, a total of 568 adult smokers seen at an academic center were randomly assigned to standard therapy (Nicoderm CQ [GlaxoSmithKline, Research Triangle Park, North Carolina], 21 mg, for 8 weeks and placebo for 16 weeks) or extended therapy (Nicoderm CQ, 21 mg, for 24 weeks), with use of an unstratified small block–randomization scheme.

The main endpoint of the study was biochemically confirmed point-prevalence abstinence at weeks 24 and 52, and secondary endpoints were continuous and prolonged abstinence, lapse and recovery events, cost per additional quitter, adverse effects, and adherence.

Compared with standard therapy, extended therapy was associated with higher rates at week 24 of point-prevalence abstinence (31.6% vs 20.3%; odds ratio [OR], 1.81; 95% confidence interval [CI], 1.23 - 2.66; P = .002), prolonged abstinence (41.5% vs 26.9%; OR, 1.97; CI, 1.38 - 2.82; P = .001), and continuous abstinence (19.2% vs 12.6%; OR, 1.64; CI, 1.04 - 2.60; P = .032). The extended therapy group also had lower risk for lapse (hazard ratio [HR], 0.77; 95% CI, 0.63 - 0.95; P = .013), higher likelihood of recovery from lapses (HR, 1.47; 95% CI, 1.17 - 1.84; P = .001), and slower time to relapse (HR, 0.50; 95% CI, 0.35 - 0.73; P < .001).

However, at week 52, extended therapy was associated with higher quit rates only for prolonged abstinence (P = .027). The extended-treatment evaluation revealed no between-group differences in adverse effects and adverse events.

"Transdermal nicotine for 24 weeks increased biochemically confirmed point-prevalence abstinence and continuous abstinence at week 24, reduced the risk for smoking lapses, and increased the likelihood of recovery to abstinence after a lapse compared with 8 weeks of transdermal nicotine therapy," the study authors write.

"Additional research on the optimal duration of therapy and the possible addition of other treatment components (for example, more intensive counseling, precessation use of nicotine patches) from an efficacy, patient acceptance, and cost perspective should be a priority."

Limitations of this study include low generalizability because participants were smokers without medical comorbid conditions who were seeking treatment, and differences in adherence between treatment groups.

"Some participants did not provide complete abstinence data," the editors write. "Extended therapy with transdermal nicotine helps some adults quit smoking, but benefits may persist only while treatment is maintained."

The National Cancer Institute and the National Institute on Drug Abuse, National Institutes of Health, supported this study. The senior study author (Caryn Lerman, PhD) has disclosed various financial relationships with GlaxoSmithKline, AstraZeneca, Pfizer, and Novartis.

Ann Intern Med. 2010;152:144-151.

H1N1 Spreading in Some Areas but Declining Overall

From Reuters Health Information

GENEVA (Reuters) Jan 29 2010- The H1N1 flu is still spreading in North Africa, parts of eastern and southeastern Europe and areas of Asia, but is generally declining, the World Health Organization (WHO) said on Friday.

The pandemic virus is still the predominant influenza virus circulating worldwide, posing an increased risk to pregnant women and people with underlying medical conditions such as asthma, it said.

"Activity in general is decreasing," WHO spokesman Gregory Hartl told a news briefing.

Much of the temperate northern hemisphere passed a peak of influenza transmission between late October and late November, the WHO said in a weekly update.

But the H1N1 virus continues to transmit actively in North Africa, including Egypt, limited areas of eastern and southern Europe, and in parts of South and East Asia, including western India, according to the United Nations agency.

In China, the H1N1 pandemic virus has declined substantially since peaking last November, but other influenza viruses have been detected increasingly in recent weeks, the WHO said.

The virus has killed at least 14,711 people worldwide since emerging last April, it said.

The WHO has said it will take a year or two after the pandemic ends to establish the true number of fatalities.