Tuesday, August 31, 2010

New Mechanism for Berries' Potential Brain Benefits Uncovered

From Medscape Medical News
Megan Brooks

August 31, 2010 — US scientists say they have uncovered a new mechanism by which berries may protect the aging brain.

In cultured mouse hippocampal cells, they found that extracts of blueberries, strawberries, and acai berries induce autophagy, a mechanism by which toxic debris are sequestered in the brain. Studies have shown that this "housekeeping" function in the brain declines considerably with age, which can lead to the buildup of proteins linked to age-related mental decline and memory loss.

Shibu Poulose, PhD, from the US Department of Agriculture–Agricultural Research Service Human Nutrition Research Center on Aging at Tufts University in Boston, Massachusetts, presented the preliminary findings at the 240th National Meeting of the American Chemical Society in Boston.

Berries and Walnuts

Natural polyphenols in berries and other fruits, vegetables, and nuts are known to enhance brain health via their antioxidant and anti-inflammatory properties. "There are many publications using animal models both from our lab and elsewhere reporting effects of berries and walnuts on memory, motor skills, and other behavior," Dr. Poulose noted in an email to Medscape Medical News.

For example, in a prior study, Dr. Poulose and Dr. Joseph showed that aging laboratory rats maintained for 2 months on diets containing 2% high-antioxidant strawberry, blueberry, or blackberry extract showed a reversal of age-related deficits in nerve function and behavior involving learning and memory.

"We have reported berries and walnuts exert powerful antioxidant and anti-inflammatory effects on the brain cells as well as regions of the brain in rats," Dr. Poulose noted.

The new research suggests that the benefits of berries on the aging brain extend beyond the antioxidant and anti-inflammatory effects to cellular toxic clearance through induction of autophagy in the brain.

They found that a blueberry, strawberry, and acai berry extract added to cultured HT22 hippocampal neuronal cells and BV2 microglial cells inhibited mammalian target of rapamycin, a protein that negatively regulates autophagy, and increased levels of proteins that facilitate the autophagic process to clear toxic proteins.

"Our research suggests that the polyphenolics in berries have a rescuing effect," Dr. Poulose noted in a written statement from the meeting. "They seem to restore the normal housekeeping function. These findings are the first to show these effects of berries."

A New Mechanism

Reached for outside comment, Joseph A. Vinson, PhD, professor of chemistry at the University of Scranton in Pennsylvania, who was not involved in the study, noted that this is "a mechanistic study and it uncovers a new mechanism."

The study, he said, provides "a hint as to how berries can be good for you," but much more study is needed. "It's possible that this mechanism operates when you consume berries but until such a mechanism is found in vivo, I wouldn't get too excited," Dr. Vinson noted in a telephone interview with Medscape Medical News.

On the other hand, Dr. Vinson added, "I do think that berries have a biological effect." He cautioned, however, that the concentration used in the study is "incredibly high, so the question is: if the concentration were diluted a lot, would it have an effect?"

The study was funded in part by the Wild Blueberry Association of North America, US Highbush Blueberry Council, California Strawberry Commission, California Walnut Commission, and American Institute for Biosocial and Medical Research Life Sciences Inc. The study authors and Dr. Vinson have disclosed no relevant financial relationships.

240th National Meeting of the American Chemical Society. Presented August 23, 2010.

Water May Be Secret Weapon in Weight Loss

From WebMD Health News
Bill Hendrick

August 26, 2010 — Drinking water before each meal has been shown to help promote weight loss, according to a new study.

Brenda Davy, PhD, an associate professor of nutrition at Virginia Tech and senior author of a new study, says that drinking just two 8-ounce glasses of water before meals helps people melt pounds away.

The study is being presented at the 2010 National Meeting of the American Chemical Society in Boston.

"We are presenting results of the first randomized controlled intervention trial demonstrating that increased water consumption is an effective weight loss strategy," Davy says in a news release.
"We found in earlier studies that middle aged and older people who drank two cups of water right before eating a meal ate between 75 and 90 fewer calories during the meal."

She tells WebMD that many people substitute sweet-tasting calorie-containing beverages for water.

"If you look at research on beverage consumption trends, our average intake of sugar-sweetened beverages has increased dramatically in the past three or four decades," Davy tells WebMD in an email. "So, likely we are drinking other beverages in place of water."

Drinking Water and Weight Loss

Her study included 48 adults between age 55 and 75 who were divided into two groups.

One group drank two cups of water before meals and the other didn't. All participants ate a low-calorie diet throughout the study.

After 12 weeks, water drinkers lost about 15.5 pounds, compared to non-water-drinking dieters, who lost only 11 pounds.

Davy tells WebMD that the study participants drank about 1.5 cups of water per day prior to joining in the study.

Not only were those who drank water before meals more successful after 12 weeks, but they also kept "the weight off for a full year after the weight loss study."

Even better, most water drinkers, followed for an additional 12 months, not only kept weight off but "even lost another 1 to 2 pounds," she tells WebMD.

The message, she says, is clear: "People should drink more water and less sugary, high-calorie drinks."

How Water Aids Weight Loss

She points out that folklore and everyday experience both have suggested that water promotes weight loss, but little scientific information has been offered on the topic.

This doesn't mean that good old H2O is a magic potion, but that drinking water may help people shed pounds for the simple reason that it has no calories and fills up the stomach, making people less hungry.

Davy says water makes people feel fuller, inducing them to eat less food. She also offers good news for those who prefer diet sodas and other drinks with artificial sweeteners, saying such liquid refreshment fills people up, too. But she advises against drinking beverages made tasty with sugar and high fructose corn syrup, which are high in calories.

Davy says no one knows how much water people should drink daily, and that the federal Institute of Medicine says healthy people can let thirst be their guide.

However, she recommends that women drink about nine cups of fluids every day, including water and other beverages, and men about 13 cups.

It is possible, she adds, to drink too much water, which can lead to a rare but serious condition known as water intoxication.

The study was funded by the Institute for Public Health and Water Research, a nonprofit, independent science and education organization.

This study was presented at a medical conference. The findings should be considered preliminary as they have not yet undergone the "peer review" process, in which outside experts scrutinize the data prior to publication in a medical journal.


News release, American Chemical Society.

Youth Tobacco Use: Downward Trend Is Slowing

From WebMD Health News
Bill Hendrick

August 27, 2010 — Current tobacco use by middle and high school students has declined over the past decade, but this trend has slowed in recent years and more work is needed to combat the problem, the CDC says.

The CDC, reporting in its Morbidity and Mortality Weekly Report, says comprehensive anti-tobacco programs need more funding and that the federal government should enforce legislation that requires larger, graphic health warnings on cigarette packages and in advertisements.

Further, broader tobacco-free policies, tobacco tax increases, and advertisement restrictions would help further reduce both youth and adult tobacco use, the report says.

The analysis was based on data from the National Youth Tobacco Survey, a school-based study that collects information on tobacco use and related behaviors. In this study, 22,679 young people participated; they were asked to complete self-administered questionnaires each year from 2000 to 2009.

Besides cigarettes, youths were asked about use in the past month of cigars, smokeless tobacco, pipes, small brown cigarettes wrapped in leaves, called bidis, and clove cigarettes, or kreteks.

Current use was defined as use on at least one occasion in the past 30 days. Experimentation was defined as ever having smoked a cigarette, even a puff or two, but fewer than 100 cigarettes.

Pattern of Tobacco Use Decline

Among other things, the report says that, from 2000 to 2009:

•Prevalence of current tobacco use reported by high school kids declined from 34.5% to 23.9%.
•Prevalence of current cigarette use dropped from 28% to 17.2%.
•Experimentation with tobacco dropped from 39.4% to 30.1%.
•Prevalence of current tobacco use among middle school students declined from 15.1% to 8.2%.
•Prevalence of current cigarette use among middle school kids dropped from 11% to 5.2%.
•Among middle school kids, experimentation with cigarettes declined from 29.8% to 15%.
The report notes that in 2009, some 8.2% of middle school students and 23.9% of those in high school reported they used tobacco in some form.

Decreases from 2006 to 2009 were found only among middle school students for current cigarette use in girls, dropping from 6.4% to 4.7%, and in non-Hispanic whites, from 6.5% to 4.3% in the same years.

Among high school kids, declines were only in girls for current tobacco use, dropping from 21.3% to 18.2%, and in current cigarette use, declining from 18.4% to 14.8%, and in non-Hispanic whites for use of bidis, from 2.6% to 1.7%.

"The general lack of significant change during the shorter period indicates that the current rate of decline in tobacco use is relatively slow," the researchers write.

Cigarette use and overall tobacco use among high school students both remain above target levels, the CDC says.

"The findings from this report suggest further efforts are needed to counter tobacco industry influences on youths," the CDC report says.
"New Food and Drug Administration regulations which prohibit the distribution of free samples of smokeless tobacco to youths and prohibit tobacco brand name sponsorship of any athletic, musical or other social or cultural events are designed to help prevent tobacco use among youths."

Sunday, August 29, 2010

Processed Meat Linked to Increased Risk for Bladder Cancer

From Medscape Medical News

Laurie Barclay, MD

August 2, 2010 — Intake of processed meat and its components is linked to increased risk for bladder cancer, according to the results of the large, prospective National Institutes of Health–AARP Diet and Health Study reported online August 2 in Cancer.

"Meat could be involved in bladder carcinogenesis via multiple potentially carcinogenic meat-related compounds related to cooking and processing, including nitrate, nitrite, heterocyclic amines (HCAs), and polycyclic aromatic hydrocarbons (PAHs)," write Leah M. Ferrucci, PhD, from the National Cancer Institute in Rockville, Maryland, and colleagues. "The authors comprehensively investigated the association between meat and meat components and bladder cancer."

Among 300,933 men and women who completed a validated food-frequency questionnaire, there were 854 cases of transitional cell bladder cancer identified during 7 years of follow-up. Using quantitative databases of measured values, the investigators estimated intake of nitrate and nitrite from processed meat and HCAs and PAHs from cooked meat, and they calculated total dietary nitrate and nitrite based on literature values.

For the fifth quintile vs the first quintile of red meat consumption, hazard ratio (HR) for bladder cancer was 1.22 (95% confidence interval [CI], 0.96 - 1.54; P for trend = .07). For the fifth vs first quintile of the HCA 2-amino-1 methyl-6-phenylimidazo(4,5-b)pyridine (PhIP), HR was 1.19 (95% CI, 0.95 - 1.48; P for trend = .06). These HRs showed a borderline statistically significant increased risk for bladder cancer. There were also positive associations in the top quintile for total dietary nitrite (HR, 1.28; 95% CI, 1.02 - 1.61; P for trend = .06) and nitrate plus nitrite intake from processed meat (HR, 1.29; 95% CI, 1.00 - 1.67; P for trend = .11).

"These findings provided modest support for an increased risk of bladder cancer with total dietary nitrite and nitrate plus nitrite from processed meat," the study authors write. "Results also suggested a positive association between red meat and PhIP and bladder carcinogenesis."

Limitations of this study include lack of data on urination frequency and bladder infections and only limited data on beverage intake.

"Our findings highlight the importance of studying meat-related compounds to better understand the association between meat and cancer risk," senior author Amanda J. Cross, PhD, also from the National Cancer Institute, said in a news release. "Comprehensive epidemiologic data on meat-related exposures and bladder cancer are lacking; our findings should be followed up in other prospective studies."

The Intramural Research Program of the National Cancer Institute, National Institutes of Health, Department of Health and Human Services, supported this study in part.

Cancer. Published online August 2, 2010.

University of Colorado Halts Live Liver Transplants After Donor Dies

From Reuters Health Information

DENVER (Reuters) Aug 16 - The University of Colorado has suspended living donor liver transplants following the death of a donor.

"We are conducting an internal review and will also have outside experts in the field do an external review," University of Colorado Hospital spokeswoman Erika Matich said on Friday. "We will make any changes or improvements if needed."

Ryan Arnold, 34, died on Aug. 2 at the Colorado hospital days after donating a portion of his liver to his older brother, Chad, 38, who was suffering from liver failure.

Rod Arnold, another brother, told Reuters that Ryan went into cardiac arrest two days after the surgery, was resuscitated by medical personnel and placed on life support. Testing revealed he had no brain activity and he died two days later.

The University of Colorado has long been at the forefront of liver transplants. Surgeons there conducted the world's first successful cadaver transplant in the early 1960s.

Arnold is the fourth donor to die in the United States following a live liver transplant operation and the second this year.

In May, a donor died at the Lahey Clinic in Massachusetts after undergoing the operation.

Rod Arnold said Chad Arnold is still recovering from the transplant, and that the family wanted people to know that it was a "natural decision" by Ryan to try and save his brother's life.

"Ryan took care of people his whole life," Rod Arnold said of his brother, who leaves behind a wife and three young sons.

Saturday, August 28, 2010

Signs Of Cheating - How To Detect An Affair

By: Stefan Kov Signs Of Cheating.

Are the one you love cheating on you? What are some signs of cheating that correlate with a cheater?

I have listed a few of the main and minor signs of cheating that cheaters generally show whether or not they realize it or not. Regardless of how hard a cheater might try to cover up their cheating actions some things just cannot be held back.

1. Once they no longer need sex or makes excuses to not have sex.

2. When they will not enable you access to their computer or they immediately shut down the pc when you walk into the room.

3. Once they suddenly need to work late and have all kinds of new obligations that take them away from home repeatedly or for lengthy durations of time.

4. After they arrive home smelling faintly of perfume/cologne or another particular person's body.

5. Once they arrive home and head straight into the shower or bath.

6. After they suddenly start to deal with you extraordinarily good; more so than usual.

7. After they start to make "kinky" requests or recommend wildly erotic play throughout sex including things you have never completed before. They may additionally present an increased interest in sex or sexual things, including porn.

8. Her: When she gets spiffed up and clothes provocative to "go grocery buying" or to "get her hair done." She may also present up with a sudden change of hair style. Him: When he showers, shaves (cologne, deodorant, etc.) and dresses up more than standard to "go out with his buddies" or to "go fishing."

9. When they break their established routine at work and home for no obvious or logical reason.

10. After they change into suddenly forgetful and you need to inform him/her every thing several times; their thoughts are clearly elsewhere.

11. When they are at all times drained or demonstrate a noticeable lack of power or interest in the relationship.

12. Once they start to intentionally look at or flirt with the other sex when up to now, that is something they'd not have done.

13. If you discover that they're reluctant to kiss you or accept your affection.

14. When they ignore or criticize your affections and considerate ways. Instance : "Why are you so luvy duvy? I am simply not like that."

15. When the passenger seat in the car has been changed and isn't in the typical position or the mileage on the car is greater than usual. Also increased gas purchases which are inconsistent with the amount of miles on the car.

16. Whenever you notice a rise in ATM withdrawals. Signs of cheating costs money! To play you need to pay!

17. If you discover an increased attention to shedding weight or paying more consideration to their appearance.

18. After they start to volunteer to go to the post office, rushes to check the mail earlier than you do.

19. When they get mysterious phone calls or when they hurry to reply the telephone, leave the room to talk on the phone and whenever you ask who called, they say, "No one", "Incorrect number", or "Why do you care?"

20. Simple trips, such as to the grocery store or financial institution, take hours rather than the time it should take.

21. Your beloved appears to pick fights or finds causes to fight only to stomp out of the home and away from you.

While this list gives a couple of warning signs of cheating be sure to proceed with caution. Simply because your loved one might show a couple of or many of the signs of cheating does NOT imply they're cheating on you. It could be any variety of causes outside of cheating be it an issue at work, with household, and so forth that possibly they have just not wanted to share with you yet.

These signs of cheating are only meant to give you an idea of how cheaters act after and during the cheating process. The very last thing you must do is accuse your beloved because of this list alone.

To discover how to detect an affair in 48 hrs visit the Cheat Spouse Or How To Detect An Affair official website.

Smart Articles @ http://www.articlebrain.com

Johnson & Johnson Recalling Contact Lenses in Japan, Europe

From Reuters Health Information

NEW YORK (Reuters) Aug 23 - Johnson & Johnson, which has been beset with recalls of its over-the-counter medicines, is voluntarily recalling contact lenses in Japan and elsewhere in Asia and Europe following customer complaints.

Johnson & Johnson Vision Care is recalling an estimated 100,000 boxes of its 1 Day Acuvue TruEye lenses manufactured in Ireland, the company said on Monday. It said customers had complained of an unusual stinging or pain upon inserting the lenses.

The company said that upon investigating, it found an isolated failure of one piece of equipment used during the lens-rinsing process in a select number of lots.

Long-term health consequences from the lenses are "unlikely," the company said.

Besides the recall, Johnson & Johnson suspended shipments of affected lots still in its control. Most of the affected product is in Japan, where authorities were formally notified last week, Johnson & Johnson said.

Some countries in Asia and Europe also may have a limited number of affected lenses, Johnson & Johnson said, and the company was working with regulators.

No other markets are affected, including the United States, where a version of the lens is made with a different material, the company said.

Friday, August 27, 2010

Alcoholism Can Damage Episodic Memory, Awareness of Memory Deficits

From Medscape Medical News

Deborah Brauser

August 26, 2010 — Alcohol dependence (AD) can negatively affect episodic memory, metamemory, and executive function, according to a small trial from France.

In addition, alcohol-dependent patients in this "first of its kind study" were relatively unaware of their memory deficits and overestimated their memory capacity, report the investigators.

"This overestimation of episodic memory abilities in alcoholics has unquestionable clinical implications," corresponding study author Anne-Pascale Le Berre, clinician and PhD student in neuropsychology at Inserm-EPHE at the University of Caen/Basse-Normandie in France, told Medscape Medical News.

She explained that after being physically weaned off alcohol, patients with chronic alcoholism often undergo cognitive behavioral treatments during which they are taught to anticipate risky situations or those with a high risk for relapse.

"If patients are unaware of memory deficits, and especially overestimate their memory abilities, they will benefit only partially from their clinical treatment, since they will labor under the illusion that they have sufficiently consolidated this important clinical information for everyday life, whereas the reality is actually very different," she said.

Neuropsychological screening for cognitive deficits would also be "really useful at alcohol treatment entry, allowing clinicians to ascertain whether alcoholic patients are capable of undergoing standard therapy or whether it needs to be adjusted to take [into] account these impairments," added Dr. Le Berre.

The study was published online August 24 in Alcoholism: Clinical & Experimental Research.

First Time Metamemory Links Found

Dr. Le Berre and her team evaluated 28 patients with chronic AD (75% male; mean age, 47.9 years; average years of alcoholism, 11.49) early in their abstinence from alcohol (average days of abstinence before inclusion, 12.79) at an alcohol treatment facility and 28 non-AD matched healthy controls (50% male; mean age, 47.8 years).

All patients underwent an objective "feeling-of-knowing" (FOK) measure, which compared predictions about future memory performance during an episodic memory task with actual memory performance, and filled out the subjective Metamemory in Adulthood (MIA) questionnaire.

Additional evaluations of episodic memory and executive functioning were also conducted. None of the participants were taking any psychotropic medications or displayed any psychiatric conditions.

Results showed that the AD patients performed worse on the episodic memory and executive tasks than did the healthy controls.

"On episodic memory more particularly, conscience recollection in chronic alcoholics [was] significantly reduced, while familiarity [was] not," the investigators write.

The AD patients were also less accurate than the control group in the episodic memory task, as seen with the FOK measure, and overestimated their recognition performance, as seen with the MIA questionnaire.

The researchers write that "this study revealed for the first time" that metamemory decline in chronic alcoholism "appears to be influenced by the joint deficit in episodic memory and executive functions that is characteristic of this clinical population.

"In view of our results and the growing interest in the brain substrates of metamemory, it would be useful to study links between metamemory dysfunction and brain lesions consecutive to chronic alcohol consumption," they add.

Dr. Le Berre reported her team is continuing to explore metamemory in alcoholism using other measures than the [FOK], as well as conducting clinical and imaging studies on whether frontal activity underlies metamemory abilities. In fact, assessing "chronic alcohol consumption leading to frontal damage [is] the next step of this study."

Useful in Therapeutic Efforts

"The present study went a step further [than past studies], adding to the traditional memory test battery an assessment of the FOK phenomenon," Edith V. Sullivan, PhD, professor in the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine in California, said in a release.

"While it is striking that the alcoholic group had deficits in memory for new information, FOK analysis indicated that they were fundamentally unaware of their deficit," added Dr.Sullivan, who was not involved with the study.

"The over-estimation...of their memory ability was related to low performance on tests of executive function, which could either inhibit awareness or impair ability to retrieve information. In either case, there was a disconnection between feeling of knowing and accuracy of this knowledge."

She noted recognizing the impairment of overestimating episodic memory by those with AD "could be quite useful in therapeutic and rehabilitation efforts.

"Whether this FOK over-estimation generalizes to other cognitive abilities has yet to be determined but has the patina of being analogous to denial of problems with alcohol consumption that so often characterize recovering alcoholics and impede treatment success," concluded Dr. Sullivan.

This study was funded by Inserm, region Basse-Normandie. The study authors and Dr. Sullivan have disclosed no relevant financial relationships.

Alcohol Clin Exp Res. Published online August 24, 2010.

Wednesday, August 18, 2010

Long-Term Benefits Seen With Minimally Invasive Facial Rejuvenation

Medscape Medical News from the:
International Society of Aesthetic Plastic Surgery (ISAPS) 20th Biennial Congress

James Brice

August 17, 2010 (San Francisco, California) — Positive long-term results from a unique percutaneous approach to rejuvenating face-lift surgery had plastic surgeons buzzing here at the International Society of Aesthetic Plastic Surgery (ISAPS) 20th Biennial Congress about the growing impact of minimally invasive procedures.

Aesthetic plastic surgeons are adapting to growing consumer demands for botulinum toxin (Botox) injections, soft tissue fillers, and chemical peels as relatively inexpensive and less painful alternatives to open surgery. "The specialty is really transitioning from surgery 100% of the time," said Renato Saltz, MD, scientific program director of the 1700-member society, in an interview with Medscape Medical News. He practices at Saltz Plastic Surgery in Park City, Utah.

Injections of botulinum toxin to treat facial crow's feet, a symptom of normal aging or sun overexposure, for example, are leading to the obsolescence of sophisticated surgical procedures that took years to perfect, Dr. Saltz said.

The long-thread lift technique developed in 2002 by Woffles Wu, MD, at his surgical clinic in Singapore, proposes moving invasive face-lift surgery in the same direction.

Treatment begins with a minimally invasive procedure to lift sagging facial structures. It continues with follow-up sessions to apply several nonsurgical strategies to maintain the cosmetic effect over time.

A medical-grade nylon thread, studded with nearly microscopic barbs, is a key component to the initial intervention, Dr. Wu explained. With the patient under local aesthesia, Dr. Wu uses needle guidance to stretch 6 to 8 filaments through subcutaneous fat from the neck and jowl (above the jaw) to the temple (above the hairline). The tension of the threads is adjusted to lift skin, facial fat, and some muscle to a more physically attractive position. The filaments are left after surgery and become a permanent fixture under the skin.

Pre (left) and post (right) procedure. Higher cheeks and jowls create a more youthful appearance in women who undergo a minimally invasive long-thread face lift and long-term nonsurgical follow-up. (Courtesy of Dr. Wu)

"As we age, the ligaments that attach skin to the face become relaxed and less efficient at sticking skin to the underlying muscle," Dr. Wu told Medscape Medical News in a phone interview after his presentation. "So when you put these threads in, you create almost artificial ligaments between the skin and deeper layers of the face."

Dr. Saltz noted that Dr. Wu's approach doesn't replace conventional face lifts, but it is a short-term solution for adults who want to counter the effects of aging without undergoing a highly invasive procedure.

During conventional surgery, facial skin is stripped back from a long incision extending from below the ear lobe to above the hairline, which enables the surgeon to excise fatty deposits and suture sagging tissue. The procedure leads to substantial bruising and swelling. Recovery can take several weeks.

With the long-needle approach, patient trauma is limited to a few small skin punctures and bruising around needle entry and exit points, Dr. Wu said. Short-term patient discomfort can be controlled with nonprescription analgesics. Recovery typically takes 3 days.

The technique is completely scarless, Dr. Wu pointed out. Minor facial swelling and skin tightness are common in the first few days after the procedure. Adverse events have been rare in the approximately 1100 procedures he has performed. Problems with local skin infections along the hairline following the first few hundred surgeries were solved after Dr. Wu stopped knotting the thread at the temple and began looping it through the temple and stringing it back to the jowl, he explained.

Thread spitting — where the thread spontaneously breaks through the skin — is reported in about 2% of cases. The incidents are treated by simply trimming the filament flush with the skin, Dr. Wu said.

Follow-up treatments involving more thread placements and nonsurgical medication are performed about every 18 months to address the ongoing effects of aging.

Dr. Wu coined the term "the 4Rs" to signify the restoration of tissue volume with synthetic fillers, the relaxation of muscles with botulinum toxin, the resurfacing of skin with nonablative techniques (such as intense pulse light and chemical peels), and the redraping or relifting of skin.

Case histories described during Dr. Wu's presentation at the ISAPS meeting showed the fresh faces of older adults who appear to have aged little from the initial procedure and follow-up treatments at the lab.

"I showed a 68-year-old male after 8 years of treatment, and he actually looked younger than he did at age 60." Wu said.

The study did not receive commercial support. Dr. Wu invented the long-needle lift technique and is the owner and lead plastic surgeon at the Aesthetic Surgery & Laser Center in Singapore, where the research was performed. Dr. Saltz was not involved in the research and has disclosed no relevant financial relationships.

International Society of Aesthetic Plastic Surgery (ISAPS) 20th Biennial Congress: Session 2. Presented August 15, 2010.

Friday, August 13, 2010

Similar Weight Loss, HDL Edge for Low-Carb vs Low-Fat In Randomized Diet Study

From Heartwire

Fran Lowry

August 12, 2010 (Philadelphia, Pennsylvania) — Low-carbohydrate and low-fat diets coupled with comprehensive behavioral coaching in a randomized trial were similarly effective for weight reduction, while HDL-cholesterol levels ended up higher with the low-carb approach, researchers report in the August 3, 2010 issue of the Annals of Internal Medicine [1].

Lead author Dr Gary D Foster (Temple University, Philadelphia, PA) told heartwire that for him, the weight-control message "is that patients should probably be less concerned about whether the diet is high in this or low in that and more concerned with using behavioral strategies, like keeping track of what they eat, to help them adhere to healthy eating habits."

In the multicenter study that randomized 307 persons to follow one or the other diet, both groups achieved about 11% weight loss at six months and a total of 7% at 24 months; both changes were significant.
Both diets were also associated with increased HDL-cholesterol, but the increase was significantly higher for those on the low-carb diet.

Because weight loss itself affects HDL concentrations but was the same in both groups, Foster and his colleagues write, "we were able to determine that a low-carbohydrate diet has greater beneficial long-term effects on HDL-cholesterol concentrations than a low-fat diet."

Behavioral Training Allowed for Better Comparisons

It had been unclear whether low-carb or low-fat diets were better for weight loss, with only some studies finding in favor of the low-carb approach, at least in the short term. The problem was, these studies were of short duration, with only one lasting a year, and none included a comprehensive behavioral-treatment program. These studies also had very limited assessments of other health factors, such as the effect on bone-mineral density, muscle mass, cardiovascular risk factors, and general symptoms, Foster explained.

"We wanted to first of all do a long-term study of low-carbohydrate diets and examine these other factors. We also wanted to include a fair amount of behavioral support. The idea was that we would produce the largest possible weight loss with both diets because we would facilitate adherence, and that way we could better test any positive or adverse consequences of both diets," he said.

The 153 participants in the low-carb group followed guidelines set out in Dr Atkins' New Diet Revolution [2]. For the first 12 weeks, they were told to limit carbohydrate intake to 20 g per day in the form of low-glycemic-index vegetables. After this, they could gradually increase their intake of carbohydrates by 5 g per day per week by adding more vegetables, a limited amount of fruits, and later small quantities of whole grains and dairy products until a stable and desired weight was achieved.

"The focus for this group was on limiting carbohydrate intake and to eat foods rich in fat and protein until they were satisfied," Foster noted.

The 154 participants assigned to the low-fat diet limited their energy intake to 1200 to 1500 kcal per day for women and 1500 to 1800 kcal per day for men, with approximately 55% of calories from carbohydrate, 30% from fat, and 15% from protein. "The focus for the low-fat group was on decreasing fat intake, and limiting overall energy intake in the form of calories per day was the primary behavioral target," Foster explained.

All participants attended sessions in groups of 8 to 12 once a week for the first 20 weeks. The sessions, which tapered to every other week for the next 20 weeks and then to every other month for the remainder of the two-year study, taught such strategies as keeping a food diary, limiting places and activities associated with overeating, increasing physical activity, recovering from overeating episodes, and reversing small weight gains.

Along with the similar one-year and two-year losses in average weight, there were no differences in body composition or bone-mineral density between the groups at any time during the study. For both groups, the change from baseline in hip and spine bone-mineral density was 1.5% or less at six, 12, and 24 months. For body composition, both groups experienced 5% reductions in lean mass and 11% to 20% reductions in fat mass.

HDL Rose Twice as High With the Low Carb Diet

An advantage for the low-carb diet over the low-fat diet with respect to HDL concentrations was seen at all time points, Foster said. Plasma HDL increased by about 20% at six months in the low-carb group. This persisted throughout the study and was more than double the rise observed in the low-fat-diet group. The increase in HDL was similar to that obtained with nicotinic acid, "the most effective HDL-raising pharmacologic intervention currently available," he noted.

"Everybody in the study did better in terms of their cardiovascular disease risk factors because they lost weight," he said, but the only significant difference was in HDL levels. "So it wasn't bad to be in the low-fat group for HDL. You still went up, but you went up even more if you were on the low-carb diet," Foster said.

Symptoms of bad breath, hair loss, constipation, and dry mouth were greater in the low-carb-diet group but, except for constipation, the differences disappeared after six months.

Dr Ronald Goldberg (University of Miami, FL), not an investigator with the study, said its behavior-modification program makes it less likely that the results obtained will be generalizable to other settings. "There really wasn't much advantage for the low-carb over the low-fat diet except for HDL. It seemed that what really mattered was the behavior-modification program, which was pretty robust. It might be hard to put that into practice in a typical community setting."

He added that the use of the behavioral intervention leveled the playing field between the two diets. "There is no question that it eliminated differences in adherence. There had been some evidence that people on low-carb diets adhere better, particularly in the short term, but by adopting a behavioral-intervention approach, the study authors were able to equalize the two groups, at least in their level of physical activity, attendance at meetings, and this kind of thing."

Weight Loss With Both Diets "Impressive"

Goldberg remarked that the observed sustained weight loss on both diets was impressive, as was the substantial 20% increase in HDL. "Raising HDL is not something that is easy to do in medicine."

The fact that this study looked at bone loss is also noteworthy, he commented. "This is the first study [of its kind] to look at bone. There has been a concern, particularly for low-carbohydrate diets, that there might be an excess of bone loss in the long term. Here, they show a slight reduction in bone density that was similar in both groups. The loss was very modest, and that was reassuring."


Sunscreen Ingredient Not Carcinogenic, Say Dermatologists

From Medscape Medical News
Nick Mulcahy

August 13, 2010 — There is "no convincing evidence" that a form of vitamin A, retinyl palmitate, which is an ingredient in many sunscreens, including top-selling brands, is carcinogenic.

This conclusion is made in an analysis authored by dermatologists published online August 6 in the Journal of the American Academy of Dermatology.

Lead author Steven Q. Wang, MD, from Memorial Sloan-Kettering Cancer Center in New York City, said the analysis is a response to the widely publicized 2010 Sunscreen Guide from the Environmental Working Group (EWG), a nonprofit research organization located in Washington, DC.

In their sunscreen guide, which was published in May, the EWG raised concerns about the safety of retinyl palmitate, and at that time the story was covered by many major media outlets, including WebMD.

The EWG said that sunscreen makers have added retinyl palmitate and related forms of vitamin A to 41% of sunscreens on the market in 2010.

The guide advised consumers to avoid sunscreens with retinyl palmitate, and recommended a variety of brands without the ingredient.

We have a disagreement over the data.

The EWG has written that government data "suggest" that retinyl palmitate is carcinogenic on skin exposed to sunlight.

In their analysis, Dr. Wang and colleagues take a look at these government data from the National Toxicology Program (NTP), part of the Department of Health and Human Services.

Unlike the EWG, Dr. Wang and colleagues do not see evidence that is highly suggestive that retinyl palmitate in sunscreen is carcinogenic.

"We have a disagreement over the data," Dr. Wang told Medscape Medical News.

Limiting sun exposure and wearing protective clothing are even more important.
The parties in this debate agree on one thing: sunscreens are not the most important form of protection against the sun. "Limiting sun exposure and wearing protective clothing are even more important for protecting your skin from cancer and premature aging," writes the EWG in their sunscreen guide.

Dr. Wang and his coauthors concur.

They write that "other photoprotection practices, such as avoiding excessive sun exposure, seeking shade, and wearing photoprotective clothing, hats, and sunglasses" should "serve as the primary tactic to reduce skin cancers and minimize photoaging changes associated with UV exposure."

Ten Years and Counting for FDA-NTP Guidance on Retinyl Palmitate

Ten years ago, in 2000, retinyl palmitate was selected for phototoxicity and photocarcinogenicity testing by the NTP, explain Dr. Wang and his coauthors.

The NTP proceeded with the testing on retinyl palmitate but the data are unpublished. Neither the NTP nor the US Food and Drug administration (FDA) has issued a final report on the findings. However, an FDA spokesperson told Medscape Medical News that a draft "technical report" based on these data will be available in mid-December.

Meanwhile, some of these rough data are available on the NTP's Web site; these have been reviewed by both the EWG and Dr. Wang and his colleagues.

Before delving into the NTP data, Dr. Wang and colleagues provide background on retinyl palmitate. They note that it is the storage form of retinol or vitamin A, which is "an essential and endogenous nutrient for human beings."

Human beings already have retinyl palmitate in their skin.
"Human beings already have retinyl palmitate in their skin," simplified Dr. Wang.

They also stress that a review of retinyl palmitate by the NTP is not damning of the compound.

"It should be emphasized that mere selection for testing does not mean the chosen compounds are dangerous or unsafe," the authors write.

"Retinyl palmitate was selected because of its widespread use in cosmetics and sunscreen products," they add.

The FDA's Voluntary Cosmetics Registration Program indicates that the number of formulations containing retinyl palmitate increased from 355 in 1992 to 667 in 2000, the authors point out.

"It is worthy to note that retinyl palmitate has also been used as a food additive and approved for use in over-the-counter and prescription drugs by the FDA," they write.

What the NTP Data Says—2 Versions

The EWG claims that the NTP data indicate that "tumors and lesions developed up to 21% sooner in lab animals coated in a vitamin A–laced cream (at concentrations of 0.1% to 0.5%) than in control animals treated with a vitamin-free cream."

As part of the NTP testing, the animals (lab mice) were exposed to the equivalent of up to 9 minutes of noontime Florida sunlight each day for a year, according to the EWG. The effects were statistically significant for all dose groups tested, they add.

However, Dr. Wang and his colleagues reviewed the data in a different manner, says the EWG, which quickly posted an online critique of the analysis from the dermatologists.

Dr. Wang and colleagues examine "only the absolute number of tumors (neoplasms) in exposed animals," writes the EWG. "They ignore data on the rate at which animals developed tumors and other skin damage."

Dr. Wang defended his team's approach. "This is the conventional way of showing results," he said about listing the number of tumors in the mice.

In their analysis, the authors found that the number of malignant neoplasms in the 2 groups of mice—those coated with a vitamin A–containing cream and those with a vitamin-free cream—exposed to low-dose UV radiation was significantly different. In the mice exposed to higher doses of radiation, the number of malignant neoplasms was not significantly different.

"Therefore, there is no conclusive evidence to indicate that the combination of [retinyl palmitate] and UV is photocarcinogenic," they write.

However, the EWG objected to the conclusion, which they say ignores the results in the mice exposed to low doses of radiation and concentrates on the results in mice exposed to high doses.

"This conclusion disregards the fact that animals in the higher-UV group were massively sickened by the sheer amount of UV radiation (with 82% developing malignant tumors, compared to 38% in the lower-dose group), potentially overwhelming the impact of skin damage caused by vitamin A," the EWG writes.

Dr. Wang believes his team's work was well done and subject to more scrutiny than the EWG's analysis. "The critical difference in our 2 presentations is that ours is in a peer-reviewed journal."

Conflict of Interest Questions

In their analysis, Dr. Wang and his coauthors—Stephen Dusza, DrPH, from Memorial Sloan-Kettering, and Henry Lim, MD, from the Henry Ford Hospital in Detroit, Michigan—report that there were no funding sources for the article. They also declare no conflicts of interest.

The EWG found these article-based disclosures misleading. Elsewhere, the EWG says, Dr. Wang and Dr. Lim have disclosed industry ties.

"Dr. Wang has disclosed that he has been a consultant to La Roche-Posay" the EWG writes in their online critique, saying that the company "markets sunscreens and uses vitamin A in eye creams."

"Dr. Lim has disclosed a consulting relationship with Johnson & Johnson (the maker of vitamin A–containing Neutrogena and Aveeno sunscreens) and La Roche-Posay," the EWG adds.

"Drs. Wang and Lim also volunteer on the Photobiology Committee of the Skin Cancer Foundation, a trade organization supported by the sunscreen industry. This committee sets criteria for the foundation's Seal of Recommendation and reviews the applications of companies [asking] to use the Seal on their products. Each company seeking the Foundation's endorsement must pay an annual $10,000 fee," the EWG further points out.

However, Dr. Wang suggested this was overblown. "We had no conflict of interest for this manuscript—no funding for this commentary," he said.

Furthermore, as part of the publication process at the Journal of the American Academy of Dermatology, the authors were required to fill out forms disclosing involvement with industry, said Dr. Wang. "That's how they found the other disclosures," he said, referring to the EWG. However, the text of article does not reveal where to access those forms.

J Am Acad Dermatol. Published online August 6, 2010. Abstract

Wednesday, August 11, 2010

H1N1 Influenza Pandemic Is Over, WHO Declares

From Medscape Medical News

Robert Lowes

August 10, 2010 — The controversial H1N1 influenza pandemic is officially over, the World Health Organization (WHO) declared today.

"We are now moving into the postpandemic period," said WHO Director-General Margaret Chan, MD. "The new H1N1 virus has largely run its course."

The 2009 H1N1 influenza virus has not disappeared, Dr. Chan noted, and it still poses a risk for serious illness, especially for young children, pregnant women, and persons with respiratory or chronic illnesses. However, the agency expects the virus to circulate and behave as one of several seasonal varieties in years to come, and not to dominate the pack.

"Many countries are reporting a mix of influenza viruses, again as is typically seen during seasonal epidemics," said Dr. Chan.

On June 11, 2009, WHO declared that transmission of the novel influenza virus had morphed into a full-blown pandemic, which is level 6 on a scale that the agency uses to classify influenza outbreaks. The postpandemic phase, which is at the end of the scale, indicates that influenza activity is at seasonal levels.

Earlier today, an emergency committee that advises Dr. Chan on the pandemic convened by teleconference and concluded that "the world was no longer experiencing an influenza pandemic, but that some countries continue to experience significant H1N1 (2009) epidemics," according to WHO.

During the spring and summer, virus transmission has dramatically tapered off in the Northern Hemisphere. WHO said on Tuesday that it had delayed making a decision on whether the pandemic was over until the emergency committee could assess the virus' behavior in the southern hemisphere during its winter influenza season. The committee concluded that for both hemispheres, 2009 H1N1 virus activity "no longer represented an extraordinary event requiring immediate emergency actions on an international scale."

Pandemic Less Deadly Than Feared Because of Hard Work, Good Luck

WHO has been accused in some quarters of declaring a "fake" pandemic, given that the H1N1 virus has killed fewer people than seasonal flu viruses on an annual basis in countries such as the United States. The agency has denied intentionally exaggerating the pandemic's severity for ulterior motives, such as boosting sales for vaccine manufacturers. Nevertheless, Dr. Chan said today that the pandemic "has turned out to be much more fortunate than what we feared a little over a year ago."

Dr. Chan attributed the fortunate outcome in the pandemic saga to a combination of hard work and "pure good luck."

"The virus did not mutate during the pandemic to a more lethal form," she said. "Widespread resistance to oseltamivir [Tamiflu; Roche Inc] did not develop. The vaccine proved to be a good match with circulating viruses and showed an excellent safety profile."

On another positive note, Dr. Chan said that infection rates of 20% to 40% in some areas have created a level of protective immunity, augmented by good vaccination coverage in many countries.

However, public health authorities should continue to remain vigilant about the 2009 H1N1 virus instead of letting down their guard, she said. For one thing, a small proportion of pandemic influenza patients — including young, healthy ones — experienced a severe form of primary viral pneumonia that was very hard to treat. Dr. Chan said nobody knows whether this pattern will continue during the postpandemic phase.

In addition, WHO expects the virus to change as a result of antigenic drift, lowering the protection offered by the community-wide immunity that has developed so far. At the same time, significant influenza outbreaks could occur in areas that got off lightly during the pandemic.

The WHO prescription for the postpandemic era mirrors its advice during the pandemic itself:

* Clinicians should vaccinate individuals against the 2009 H1N1 virus with either a monovalent vaccine or a trivalent seasonal vaccine that contains a strain of the pandemic virus (the United States will use the latter this fall).
* Good personal hygiene is still in order — clinicians should advise their patients to continue to cover their mouths when they sneeze or cough and to diligently wash their hands.
* As during the pandemic, patients who have a severe or deteriorating case of influenza should be treated with oseltamivir immediately, and clinicians should prescribe either oseltamivir or zanamivir (Relenza; GlaxoSmithKline) as soon as possible for patients who are higher risk for severe or complicated influenza.

Waist Circumference Linked to All-Cause Mortality in Older Adults

From Medscape Medical News

Laurie Barclay, MD

August 9, 2010 — Waist circumference (WC) is a risk factor for mortality in older adults, regardless of body mass index (BMI), according to the results of a large US cohort study reported in the August 9/23 issue of the Archives of Internal Medicine.

"[WC], a measure of abdominal obesity, is associated with higher mortality independent of [BMI]," write Eric J. Jacobs, PhD, from the American Cancer Society in Atlanta, Georgia, and colleagues. "Less is known about the association between WC and mortality within categories of BMI or for the very high levels of WC that are now common."

Using the Cancer Prevention Study II Nutrition Cohort, the investigators evaluated the association between WC and mortality among 48,500 men and 56,343 women, aged at least 50 years. Between 1997 and the end of follow-up in 2006, there were 9315 deaths in men and 5332 in women.

Risk for mortality was more than doubled for very high levels of WC after adjustment for BMI and other risk factors. Among men, relative risk (RR) of mortality was 2.02 (95% confidence interval [CI], 1.71 - 2.39) for WC 120 cm or larger compared with WC less than 90 cm. Among women, RR was 2.36 (95% CI, 1.98 - 2.82) for WC 110 cm or larger compared with WC less than 75 cm.

Within all categories of BMI, WC was positively associated with mortality. A 10-cm increase in WC in men was associated with RRs of 1.16 (95% CI, 1.09 - 1.23) for normal (BMI, 18.5 kg/m2 to <25 kg/m2), 1.18 (95% CI, 1.12 - 1.24) for overweight (BMI, 25 kg/m2to <30 kg/m2), and 1.21 (95% CI, 1.13 - 1.30) for obese (BMI, ≥30 kg/m2) BMI. For women, RRs were 1.25 (95% CI, 1.18 - 1.32), 1.15 (95% CI, 1.08 - 1.22), and 1.13 (95% CI, 1.06 - 1.20), respectively.

Limitations of this study include reliance on self-report and measurement for WC, observational design, possible confounding by factors associated with both larger WC and higher mortality, and possibly low generalizability because all study participants were 50 years or older, and nearly all were white.

"Results from this large prospective study emphasize the importance of WC as a risk factor for mortality in older adults, regardless of whether the BMI is categorized as normal, overweight, or obese," the study authors write. "Our results suggest that, regardless of weight, avoiding gains in WC may reduce risk of premature mortality."

The study authors have disclosed no relevant financial relationships.

Arch Intern Med. 2010;170:1293-1301.

Bisphosphonates Not Linked to Esophageal Cancer, Says Study

From Medscape Medical News

Nick Mulcahy

August 10, 2010 — Oral bisphosphonates are not significantly associated with esophageal or gastric cancer, according to a large cohort study from the United Kingdom published in the August 11 issue of JAMA.

The new study comes out about a year and a half after the US Food and Drug Administration (FDA) reported 23 cases of esophageal cancer between 1995 and 2008 in patients using alendronate and another 31 cases in patients using a variety of bisphosphonates in Europe and Japan.

These cases "possibly" indicate "risk of malignancy associated with bisphosphonate use," note the authors of the new study.

The authors took up the challenge of investigating the possible link between these cancers and oral bisphosphonates, the use of which has "dramatically" increased in recent years in the Western world.

The link was not proven in 2 recent smaller studies, say the authors, led by Chris Cardwell, PhD, from the Center for Public Health at Queen's University in Belfast, Northern Ireland.

The lack of a link to cancer stands in contrast to the proven link between the use of oral bisphosphonates and esophagitis.

"Oral bisphosphonates are known to cause serious esophagitis in some users," write Dr. Cardwell and his coauthors, who include Christian Abnet, PhD, from the Division of Cancer Epidemiology of the National Cancer Institute in Rockville, Maryland.

Esophagitis related to reflux is an "established risk factor for esophageal cancer through the Barrett pathway," they point out.

It is not known whether bisphosphonate-related esophagitis can also increase cancer risk.

However, "it is not known whether bisphosphonate-related esophagitis can also increase cancer risk," they say.

The new study does not make a determination about bisphosphonate-related esophagitis; it only examines whether the use of these drugs increases cancer risk.

The study consisted of more than 80,000 patients, who were mostly women and had a mean age of 70 years, and found that the incidence of esophageal and gastric cancer combined was 0.7 per 1000 person-years of risk in both the bisphosphonate user and control (nonuser) cohorts.

Bisphosphonate users were defined as any patient receiving at least 1 prescription between 1996 and 2006.

Hazard ratios did not reveal any difference in the risk for the cancers between the user and nonuser cohorts.

Importantly, there also was no difference in risk for esophageal or gastric cancer with duration of bisphosphonate intake, say the authors.

The mean follow-up time was 4.5 and 4.4 years in the bisphosphonate and control cohorts, respectively.

"Our study, to my knowledge, has the longest duration of follow-up of any study so far into bisphosphonates and esophageal cancer," Dr. Cardwell told Medscape Medical News.

The study was funded by the Medical Research Council in the United Kingdom, which describes itself as an independent agency.

Addressing the Call

Diane Wysowski, PhD, from the FDA, published the first-ever report on cases of esophageal cancer in users of oral bisphosphonates in January 2009 (N Engl J Med. 2009;360:89-90).

A few months later, the journal published a series of letters responding to the report. In her response to those letters (N Engl J Med. 2009;360:1789-1792), Dr. Wysowski called for further study of the matter.

"Such studies should include a control group and be of sufficient size, with a sufficient duration of exposure and follow-up and with analyses of confounding variables," she writes.

When Medscape Medical News asked Dr. Cardwell whether he and his team had fully addressed Dr. Wysowski's requirements, he said: "I think our study adequately addresses these issues better than any study to date."

To explore any association between oral bisphosphonate use and esophageal and/or gastric cancer, Dr. Cardwell and colleagues used the UK General Practice Research Database, the "world's largest computerized database of anonymized longitudinal patient records."

Bisphosphonate users were matched with controls of the same age and sex.

The study authors looked at the bisphosphonate users in a number of ways, including by "any use" and by the type of bisphosphonate.

They also looked at users by the amount prescribed, which was converted into "defined daily dose" (DDD) figures. To investigate dose response, analyses were conducted for users by DDDs that were equivalent to 6-month, 1-year, 2-year, and 3-year supplies. In these analyses, the follow-up period started from the date that the user received the required number of prescriptions to achieve 1 of these supply periods.


Of the bisphosphonate users in the database during the study period, 41,826 had at least 6 months of follow-up and qualified, along with their matched controls, for the study analyses.

With regard to patients with "any bisphosphonate use" and their matched controls, there was no difference in combined esophageal and gastric cancer risk between the cohorts before (hazard ratio [HR], 1.00; 95% confidence interval [CI], 0.77 - 1.29) or after (0.96 [95% CI, 0.74 1 25) adjustment for potential confounders.

The included variables such as smoking, alcohol use, and body mass index.

The authors also did not find any evidence of an increase in cancer risk by duration of use of the drugs. The durations ranged from 6 months to 3 years and beyond.

For example, there was no difference in risk between the patients who used the drugs for about a year and their matched controls.

"After receipt of 365 bisphosphonate DDDs (equivalent to a 1-year supply), the risk of esophageal and gastric cancer combined (or esophageal cancer alone) was similar in the bisphosphonate and control cohorts (unadjusted HR, 0.94 [95% CI, 0.64 - 1.39] and 0.88 [95% CI, 0.55 - 1.43], respectively)," they write.

The authors also did some analyses to maximize follow-up periods. In one analysis, they only included patients whose date of first receipt of bisphosphonates was before the year 2000. This subset of 7082 patients had a mean follow-up of 6.8 years. Still, there was no evidence of an association between bisphosphonate use and cancer risk.

The type of bisphosphonate (nitrogen-containing bisphosphonates, alendronate, and non-nitrogen-containing bisphosphonates) also did not show any association with cancer risk. Dr. Cardwell said that alendronate was separated out because Dr. Wysowski's report mentions alendronate specifically.

The authors, mindful of the importance of reflux in this population, also looked at cancer risk among a subset of patients who had a history of gastroesophageal reflux disease. Again, there was no evidence of elevated risk among the users of bisphosphonates.

Too few patients had a history of Barrett's esophagus to examine the cancer rates in this subgroup, say the authors.

I do not think that we have sufficient numbers of individuals with Barrett's esophagus.

Previously, Dr. Wysowski advised that clinicians would be "prudent" to "advise against the use of these drugs in patients with Barrett's esophagus."

Dr. Cardwell neither endorsed nor refuted this recommendation. "I do not think that we have sufficient numbers of individuals with Barrett's esophagus in our cohort to comment directly on this issue."

The authors have disclosed no relevant financial relationships.

JAMA. 2010;304:657-663.

Endocrine-Disrupting Chemicals Are Indoor Risk

From WebMD Health News
Kathleen Doheny

August 6, 2010 — Concentrations of endocrine-disrupting chemicals (EDCs) -- found in many everyday products and of concern due to potential health hazards -- are higher indoors than outdoors, according to a new study.

But they are equally present, the researchers found, in an urban, low-income community near an oil refinery and in a rural, affluent coastal community without much industry.

"The higher your exposure to consumer products, the higher your exposure to endocrine-disrupting chemicals," researcher Ruthann Rudel, director of research at the Silent Spring Institute, Newton, Mass., tells WebMD.

''The indoor consumer product exposure [to these chemicals] is more pervasive and consistent than we thought," she says of the study findings. "It cuts across geography and demography, based on this somewhat limited sample."

The study is published online in Environmental Science & Technology.

Taking Samples of EDCs

Rudel and her colleagues sampled indoor and outdoor air in two communities in the San Francisco Bay area. They looked for 104 compounds, including 70 suspected EDCs.

EDCs can mimic or disrupt the body's natural hormone system, Rudel says. As a result, they can hamper cell growth and development.

Since the mid-1990s, scientists have been focusing on the study of EDCs, Rudel says, to see how they might affect child development, reproduction, and cancers such as breast and prostate.

Rudel's team conducted the samplings in 2006 in Richmond, Calif., a low-income, urban industrial community and in Bolinas, Calif., a coastal community that is affluent and without much industry. They took samples from 40 Richmond homes and 10 Bolinas homes.

Tracking EDCs

The researchers found 39 chemicals outdoors and 63 indoors, including phthalates, parabens, PBDE flame retardants, PCBs, and pesticides.

The chemicals are found in such products as detergents, furniture, carpets, electronic equipment, pesticides, cosmetics, and building materials.

Higher indoor concentrations compared to outdoor were found for 32 of the EDCs, Rudel found, and only two of the EDCs were more common outdoors.

Indoor levels of EDCs were more similar than outdoor for the two communities.

The new findings, Rudel tells WebMD, ''build on a study we did in Cape Cod in 2003." But that East Coast study was entirely conducted indoors.

''This study demonstrates that chemicals from consumer products affect indoor air quality and exposures are ubiquitous," Rudel says in a written statement.

And some research has shown adverse health effects from typical exposure levels to such EDCs as phthalates, and flame retardants, she says. But, she says, more study is needed.

The sampling, she tells WebMD, may not reflect true exposure to a specific person. "These results reflect what is in the air, not what is on your body," she says.

Using a soap with EDCs, for instance, could result in higher levels on your skin than what is in the air, she says, as could skin contact with a fabric with stain-resistant coating.

It's important to collect exposure information, Rudel says, so regulatory agencies can focus their priorities on EDCs with high or common exposure and decide if control is needed.

Manufacturers can also use the information to make decisions about product formulations, she says, and consumers armed with this information can decide what to buy.

Second Opinion

The new findings add evidence to what some scientists have long suspected, says Charles J. Weschler, PhD, adjunct professor of environmental and occupational medicine at the University of Medicine and Dentistry of New Jersey and continuing visiting professor at the Technical University of Denmark in Copenhagen.

''It drives home the fact that a lot of these compounds that are potentially endocrine-disrupting are entering our bodies in part as a consequent of indoor exposures," he tells WebMD, although he says that some do come from food and drink as well.

''When you look at the indoor concentrations of some of these compounds," he says of the study findings, "it doesn't matter whether you live next to a refinery or in the woods."

In a study he conducted in 1984, Weschler says he measured some of the same compounds. "In 1984, we didn't realize these compounds were potential EDCs," he says. Back then, they regarded the compounds as additives that were used in a host of products.

"I think this paper is alerting those who really were not aware of the fact that indoor exposures really matter for a lot of these compounds," he says.

"When you buy that new shower curtain with the strong smell [from plasticizers], some of those chemicals are going to end up in you," he says.

How to Avoid EDCs

Research is ongoing, and until more is known, Rudel says concerned people can take a few measures to reduce potential exposure to the compounds.

•Use fewer products overall, such as cleaning products and cosmetics, that contain EDCs.
•Avoid fabrics coated with anti-stain chemical.
•Avoid use of antibacterial soaps, which contain triclosan, an EDC.

Ruthann Rudel, director of research, Silent Spring Institute, Newton, Mass.

Difficulties in "Letting Go" When Medicine Can Do Little More

From Medscape Medical News
Zosia Chustecka

August 3, 2010 — End-of-life discussions are difficult for doctors, a surgeon/writer admits in an essay entitled "Letting Go" that appeared in the August 2 issue of the New Yorker magazine.

There is a fine balancing act in these discussions between not killing hope and confronting other possibilities, including death. However, "talking about dying is enormously fraught," writes Atul Gawande, MD, a general and endocrine surgeon at Brigham and Women's Hospital in Boston, Massachusetts. He is also an associate professor of surgery at Harvard Medical School, and has been a staff writer at the magazine since 1998.

Many doctors admit to finding end-of-life discussions difficult, and often delay them, as previously reported by Medscape Medical News. It is an issue that many oncologists have to grapple with on a regular basis in their clinical practice, and it is regularly discussed in scientific journals and meetings. But in writing on the topic at length in the New Yorker, a magazine known for arts and cultural essays and humorous cartoons, Dr. Gawande brings the issue to a public forum.

In the article, he asks: "What should medicine do when it can't save your life?"

He illustrates the piece with several case histories. One patient was a young woman diagnosed with advanced lung cancer late in her first pregnancy. Although terminally ill, she was always optimistic that another treatment would help, and Dr. Gawande describes how he was "swept along by her optimism" and was unable to confront her with her likely grim prognosis.

"Doctors are especially hesitant to trample on a patient's expectation. You worry far more about being overly pessimistic than you do about being overly optimistic," he writes.

At the back of his mind was the "long tail of possibility" that this patient might be the one who defies the odds.

There is nothing wrong with such hope, he says, unless "it means we have failed to prepare for the outcome that is vastly more probable." In the case of the patient he was describing, this hope unfortunately left her and her family unprepared to deal with her death.

"We've created a multimillion-dollar edifice for dispensing the medical equivalent of lottery tickets — and have only the rudiments of a system to prepare patients for the near-certainty that those tickets will not win," he writes.

Issue Is Pressing and Expensive

"The issue has become pressing, in recent years, for reasons of expense," he points out. The terminally ill account for a lot of the soaring cost of healthcare — 25% of all Medicare spending goes toward the 5% of patients in their final year of life, and "most of that money goes for care in the last couple of months, which is of little apparent benefit."

Spending on cancer tends to follow a pattern, he notes. There are high initial costs as the cancer is treated, and then, if all goes well, these costs taper off.

For a breast cancer survivor, the average medical spend in 2003 was $54,000, most of it on the initial diagnosis, surgery, and where necessary radiation and chemotherapy.

However, for a patient with a fatal version of the disease, the cost curve is U-shaped, rising again toward the end, he points out. For a breast cancer patient with incurable disease, the average medical spend in the last 6 months of life was $63,000 in 2003.

"Our medical system is excellent at trying to stave off death with $8000-per-month chemotherapy, $3000-a-day intensive care, and $5000-an-hour surgery. Bt ultimately death comes, and no-one is very good at knowing when to stop."

When to Stop?

This question of when to stop is a modern problem, Dr. Gawande points out.

"For all but our most recent history, dying was typically a brief process. . . . The interval between recognizing that you had a life-threatening ailment and death was often just a matter of days or weeks."

"These days, swift catastrophic illness is the exception; for most people, death comes only after long medical struggle with an incurable condition — advanced cancer, progressive organ failure. . . . In all such cases, death is certain, but the timing isn't. So everyone struggles with this uncertainty — the how, and when, to accept that the battle is lost."

In the article, Dr. Gawande praises hospice care, and gives several examples of patients who greatly benefited from such care, including a young man with advanced pancreatic cancer. But he admits that all this was a revelation to him; his new understanding was gained first-hand after having accompanied a hospice nurse on her rounds.

Previously, he had equated hospice with "giving up" and a morphine drip, and he is certain that this view is shared by many doctors and patients.

In a live phone-in question-and-answer session with readers, a hospice worker commented on how patients and their caregivers often say "we wish we'd known about you sooner," and asks: "Shouldn't this be a wake-up for physicians? For the benefit of their patients and their patient's families?"

The hospice worker also noted that there appears to be a reluctance among physicians to discuss hospice with their patients, but at the same time there is an enthusiasm for "palliative care." The 2 are actually very similar, she pointed out: "What can we do to make physicians understand that hospice is just an extension of palliative care?"

Another person phoning in highlighted cultural differences, and described several scenarios in the Netherlands in which patients' wishes to stop treatment and die were respected. Dr. Gawande acknowledged the point, and wondered if there is more of a problem in the United States than elsewhere. He mentioned statistics from Sweden, where there has been a shift from around 90% to 30% in cancer patients dying in hospital over the past 2 decades, although he noted that some American centers have seen similar shifts in end-of life care.

"Fear of death (and facing death) seems to be a uniquely 20th century American problem," suggested one reader in an online commentary. "Why shouldn't there be continuous end-of-life discussions, held more casually during life's progression and not under the gun (if you will) at the end of one's life."

That reader criticized doctors for not being straightforward in discussing death, and called for more honesty. This was also a theme that emerged from a panel discussion at the National Comprehensive Cancer Network earlier this year, when experts urged "straight talk with compassion."

However, Dr. Gawande questioned whether these issues "are THAT culture-specific. I think it is common everywhere to come across people who hope against hope that they can be saved," and suggested that this is "just human nature."

"It seems to me that our job in medicine is to just deal with it. If we have to wait for people to stop yearning for the long tail — for the lottery ticket — in order to help them, we will be hurting a lot of people for a long time to come," Dr. Gawande said. "Instead, we need to become more effective in using the techniques that experts already have for walking people through these moments in their lives."

One way to improve is through training. "Experience alone does not produce improvement. You can communicate badly for 30 years," he pointed out.

"But deliberate practice with coaching makes for measurable improvements," he said. "And that's likely what we need in medicine. We train and retrain for surgical skills. We probably need to do so for these discussions with terminally ill patients, as well," he concluded.

Monday, August 9, 2010

Alcohol Consumption Inversely Associated With Risk for and Severity of Rheumatoid Arthritis

From MedscapeCME Clinical Briefs

News Author: Laurie Barclay, MD
CME Author: Désirée Lie, MD, MSEd

August 2, 2010 — Alcohol consumption appears to have an inverse and dose-related association with both risk for and severity of rheumatoid arthritis (RA), according to the results of a study reported online July 28 in Rheumatology. However, the investigators note various limitations of the study.

"We found that patients who had drunk alcohol most frequently had symptoms that were less severe than those who had never drunk alcohol or only drunk it infrequently," said lead author James Maxwell, a consultant rheumatologist at the Rotherham Foundation NHS Trust and an honorary senior clinical lecturer in the Academic Rheumatology Group at the University of Sheffield, Sheffield, United Kingdom, in a news release. "X-rays showed there was less damage to joints, blood tests showed lower levels of inflammation, and there was less joint pain, swelling and disability. This is the first time that a dose-dependent inverse association between frequency of alcohol consumption and severity of RA has been shown in humans."

The goal of the study was to examine the relationship between frequency of alcohol drinking and RA risk and severity. Patients with erosive RA (n = 873) and healthy control subjects (n = 1004) completed a self-reported questionnaire regarding frequency of alcohol consumption. After adjustment for age, sex, and smoking status, odds ratios (ORs) for RA risk were calculated on the basis of alcohol intake. The investigators calculated median values of all RA severity measures according to frequency of alcohol drinking and used the nonparametric trend test to evaluate association. To adjust for potential confounding, they used a negative binomial regression model.

Increased frequency of alcohol drinking was associated with a decreased risk for RA. Compared with participants reporting alcohol consumption on 10 or more days per month, nondrinkers had an OR for RA of 4.17 (95% confidence interval [CI], 3.01 - 5.77; P for trend < .0001).

"This finding agrees with the results from previous studies that have shown a decreased susceptibility to developing RA among alcohol drinkers," Dr. Maxwell said.

Increased frequency of alcohol drinking was inversely associated with all measures of RA severity including C-reactive protein, 28-joint disease activity score, pain visual analog scale, the modified Health Assessment Questionnaire, and modified Larsen score (P for trend, each < .0001). Frequency of alcohol drinking was still significantly and inversely associated with x-ray damage and the modified Health Assessment Questionnaire, even after adjustment for potential confounding in a multivariate regression model.

"There is some evidence to show that alcohol suppresses the activity of the immune system, and that this may influence the pathways by which RA develops," Dr. Maxwell said. "We do know that the changes in the immune system that lead to RA happen months and maybe even years before the arthritis actually develops. Once someone has developed RA, it's possible that the anti-inflammatory and analgesic effects of alcohol may play a role in reducing the severity of symptoms."

The study findings were independent of sex and the presence or absence of both the anticyclic citrullinated peptide (CCP)–positive and negative forms of RA.

"Anti-CCP antibodies are not present in most 'normal' people without arthritis," Dr. Maxwell said. "We know that these antibodies develop prior to the onset of RA, and are probably directly linked to the process which causes RA. Some patients have RA without having anti-CCP antibodies, but we know that the disease is much more severe in patients who do."

Limitations of the study include retrospective cross-sectional design, possible recall bias, and marked differences in age and sex between the RA group and the control group. In addition, frequency rather than quantity of alcohol consumption was recorded, and the predominantly Caucasian population precludes generalization to other ethnic groups.

"Further research is needed to confirm the results of our study and to investigate the mechanisms by which alcohol influences people's susceptibility to RA and the severity of symptoms," Dr. Maxwell concluded. "It is also possible that different types of alcoholic drinks may have different effects on RA."

The Arthritis Research Campaign supported this study. The study authors have disclosed no relevant financial relationships.

Rheumatology. Published online July 28, 2010.
Clinical Context

RA is a chronic condition affecting 1% of Caucasians. In subsets of patients, RA is defined by positive anti-CCP antibodies with genetic and environmental associations. Few studies have examined the effect of alcohol consumption on RA risk and disease severity, but some data suggest a protective effect.

This is an observational, cross-sectional, case-control study to examine the risk for RA associated with alcohol consumption and the effect of alcohol on disease severity.

Monday, August 2, 2010

Is Technology Bad for Medical Devices?

From Medscape Pediatrics
Highlights of PAS 2008: Pediatric Academic Societies and Asian Society for Pediatric Research Joint Meeting

Amy L Baxter, MD

Posted: 06/26/2008

Finally, concurrent with the move away from paper and toward recording medical data with electrons and pixels, one study evaluated the impact of electromagnetic interference (EMI) and fields on medical equipment.
If you've ever been frustrated because your cell phone doesn't work in a hospital, the study authors explained that towers are intentionally pointed away to avoid EMI interference.
This causes cell phones to power up to locate the nearest transponders, running down batteries and resulting in more EMI effects on the local machines.

The objective of this study was to determine whether EMI from known electromagnetic generating sources, such as cell phones, affected ED equipment.
Investigators took 7 wireless communication systems (1 analog cellular, 4 digital cellular, 1 BlackBerry, and 1 Bluetooth) and exposed 49 medical devices to their fields.

WLAN and Bluetooth systems did not cause any EMI, and the 27 medical devices compliant with IEC 606010102:2004 Edition 2.1 were not affected by any phone.

Of noncompliant machinery, cell phones and BlackBerry affected 5 medical devices at close distances (2-45 cm). An analog phone increased the temperature of 1 incubator, reduced the rate of 1 ventilator, and distorted the waveform of 1 electrocardiographic (ECG) monitor. Digital phones affected the same incubator and ventilator, 2 other ECG monitors, and a BlackBerry increased the temperature reading of the same incubator.

The 2-way radio system (GMRS/FRS systems, often carried by emergency medical services providers) caused 9 medical devices to malfunction at distances from 5 to 80 cm, including ceasing operation of one older ventilator and reducing the pressure of a newer oscillator. The study authors recommended adherence to 1 m for cell phones and BlackBerries and 3 m for 2-way radios.