Treating depression in teens has lasting benefits

January 31st, 2010

Longer-term treatment of depression for adolescents is associated with persistent benefits, even after treatment ends, according to results of the Treatment for Adolescents with Depression Study (TADS).

TADS is a randomized, controlled trial evaluating the effectiveness of three common treatments for adolescents with depression: the antidepressant Prozac (also called fluoxetine); “talk therapy,” also called cognitive-behavior therapy (CBT); their combination (Prozac plus CBT), and, where appropriate, management with a placebo pill (used as a control condition).

A total of 327 depressed teens who participated in the study received active treatment for 36 weeks and were then followed for 1 year.

Dr. John March, of Duke University Medical Center, Durham, North Carolina, and colleagues found that the treatment benefits in terms of lower levels of depression and suicidal thoughts observed at the end of active treatment persisted during follow-up.

In addition, the findings demonstrate that longer-term treatment results in clinically meaningful improvement even when active treatment is stopped, they report in the American Journal of Psychiatry.

“In contrast, to earlier reports on short-term treatments, in which worsening after treatment is the rule, the longer treatment in the TADS was associated with persistent benefits” over 1 year of follow-up, March and colleagues note.

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World Trade Center Workers Twice as Likely to Have Asthma

January 24th, 2010

World Trade Center rescue and cleanup workers have asthma rates twice that of the general population, a new study shows.

In 2005, about 8 percent of workers and volunteers who had spent time at Ground Zero reported having an asthma attack during the previous year, compared to about 4 percent of the general population. The rate of asthma attacks among World Trade Center workers had been less than 1 percent in 2000.

Reports of problems with asthma continued to rise for several years after the attacks. Less than 3 percent of World Trade Center workers reported ever having been diagnosed with asthma attacks pre-9/11, while 16 percent reported in 2005 through 2007 that they had asthma attacks at some point.

“Twice as many World Trade Center responders are suffering from asthma when compared to those their age from the general population,” said senior study author Dr. Paul Enright, a research professor of medicine at the University of Arizona. He conducted the study along with Hyun Kim and colleagues at Mount Sinai School of Medicine, New York City.

The study was to be presented Tuesday at the American College of Chest Physicians’ annual meeting in San Diego.

Researchers followed about 20,000 responders who received an initial medical exam between July 2002 and December 2007 at a World Trade Center Medical Monitoring and Treatment Program clinic.

Participants were asked if they had experienced an asthma attack in the last year, and whether they had ever been diagnosed with asthma.

The average amount of time spent at World Trade Center sites was about 80 days. About 86 percent of the law enforcement, construction and other rescue, recovery and debris removal workers in the study were men, 59 percent were white and their mean age was 43.

Previous research has found that new asthma diagnoses peaked soon after 9/11 and then fell to closer to normal in the ensuing years. A study in the August issue of the Journal of the American Medical Association found that most new asthma diagnoses — that is, people who were asthma-free prior to the attacks — occurred in the 16 months after the attacks, said Lorna Thorpe, deputy commissioner of epidemiology for the New York City Health Department and senior author of that study.

This study is different in that it measures not new diagnoses, but actual asthma attacks.

One drawback to the new study is that the group of patients who were followed wasn’t static. Because people can drop in and out of the monitoring program, those who came for their initial evaluation years after the attacks may have been more likely to be among those whose health wasn’t improving.

“The question is, are the people who stay in and keep being seen the sicker ones while the healthier ones drop out? If so, that may explain the reason for the rise in asthma over time,” Thorpe said.

Furthermore, she added, it would be interesting to know the mental state of those who continue to experiencing asthma attacks. Coughing and wheezing due to asthma could bring back memories of the horror, triggering emotional stress that in turn could make asthma attacks worse.

“The physical health conditions and the mental health conditions are highly overlapping,” Thorpe said.

Dr. Norman H. Edelman, chief medical officer for the American Lung Association, said it was important to continue to follow responders and their asthma rates.

Typically, asthma comes on quickly after the lungs are exposed to the toxic pollutants or caustic dust that resulted from the blasts, then declines as the lungs heal.

“Ordinarily, when people get exposed to toxic stuff, you get an immediate reaction. We don’t expect a delayed effect,” Edelman said. “We saw 9/11 responders who got sick pretty quickly. Some got better. Some did not. What we haven’t seen are people who present with asthma two or three years later related to 9/11.”

Diseases of the spongy part of the lungs, such as mesotheliomia from asbestos exposure, may take years or decades to develop. But asthma is a disease of the airways, which is typically apparent right away.

Researchers said there was no evidence that asthma rates continued to rise after 2005.

“However, the majority of those who developed asthma during or after their World Trade Center exposures have continued to have asthma attacks many years later,” Enright said. “Their asthma did not spontaneously resolve within a few months after their WTC exposure ceased.”

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Switch to ‘Light’ Cigarettes Makes Quitting Tougher

January 17th, 2010

Experts have long known that “low-tar” and “light” cigarettes aren’t any healthier than regular cigarettes, and new research suggests they have another drawback: People who switch to them are less likely to quit, even those who switch specifically because they want to stop smoking.

In fact, “switching to ['light' cigarettes] for any reason is associated with continuing to smoke,” said study author Dr. Hilary Tindle, a researcher at the University of Pittsburgh’s Division of General Internal Medicine.

However, she acknowledged that the research does not prove that switching leads directly to a lower rate of quitting.

According to the authors, an estimated 84 percent of cigarettes sold in the United States are so-called low-tar and low-nicotine, with many of them called “lights.” Some smokers may assume they’re healthier than other cigarettes, but medical researchers say smokers still suck in about the same level of carcinogens. And research has shown that “lighter” cigarettes don’t reduce smoking-related illness and death.

Regardless of what brand they smoke, “the average smoker dies 13 to 14 years earlier than he or she would die if he or she did not smoke,” Tindle said.

In the new study, published online Nov. 3 in the journal Tobacco Control, researchers examined the results of a 2003 survey of 30,800 people in the United States who had smoked within the past year. Thirty-eight percent of them had switched to “lighter” cigarettes, with the largest percentage of those — 26 percent — saying they’d done so for better flavor. Forty-three percent mentioned one, two or three reasons for switching, with quitting smoking being one of those reasons.

However, those who had switched were 46 percent less likely to have quit smoking.

Why might switchers be more likely to continue smoking? “Prior research suggests that switching may resolve smokers’ cognitive dissonance about smoking — something along the lines of, ‘Well, since I’m smoking a [supposedly] healthier cigarette, I really don’t have to worry about lung cancer, heart disease, impotence, wrinkles, early death [fill in the blank] because my health is not at risk,’” Tindle said. “This type of rationale may keep more health-conscious smokers smoking.”

But there are other possible explanations, added Robert West, a researcher who studies tobacco use at University College London in England. It’s possible, for example, that people who switch are already more dependent on cigarettes and less able to quit, he said.

What to do? “In Europe, tobacco companies are not allowed to call cigarettes low tar or imply that they are in any way safer,” West said.

Regardless of how cigarettes are marketed, Tindle said, “the best solution for the problem of how to live longer and healthier is to quit smoking now.”

In related news, a study published Nov. 3 in the Journal of Epidemiology and Community Health finds that smoking during pregnancy is linked to a higher level of behavioral problems in offspring later in life, even among those as young as 3.

A team from the University of York in the England tracked 14,000 mother-and-child pairs and found that maternal smoking during pregnancy was associated with significantly higher odds for attention-deficit hyperactivity disorder (ADHD) and other behavioral woes, compared to children born to nonsmoking mothers.

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Statins May Worsen Fatigue in Heart Failure Patients

January 11th, 2010

Statins may boost the risk of fatigue and shortness of breath in some patients with heart failure, a new study suggests. But a second report found the cholesterol-reducing drugs reduce the risk of clots in those with cardiovascular disease, and experts think the benefits outweigh the risks.

Dr. Gregg C. Fonarow, a professor of cardiology at the University of California at Los Angeles, said patients shouldn’t reconsider their use of the statins based on the results of the small U.S. study.

“Patients with heart failure who have an indication for statin therapy, such as coronary artery disease or diabetes, should remain on physician-prescribed statin therapy,” Fonarow said.

At issue is treatment for heart failure, a condition that occurs when the heart fails to beat properly. An estimated 5.7 million people in the United States suffer from heart failure, which can cause fatigue, shortness of breath and fluid build-up in the lungs and legs.

“Approximately two-thirds of patients with heart failure have coronary artery disease,” Fonarow said. “In these patients, statins, while not improving overall survival, have been shown to lower the risk of a cardiovascular event and decrease the likelihood of being hospitalized. In patients with heart failure but without vascular disease, neither benefit nor harm has been demonstrated in clinical trials of statin therapy.”

Researchers at Northeastern University and Massachusetts General Hospital looked at the medical records of 136 patients with heart failure. They wanted to see how statin use, mainly of the drug atorvastatin (Lipitor), affected two types of heart failure — systolic and diastolic.

Fonarow explained that the heart fails to contract normally in people with systolic heart failure. In those with diastolic heart failure, the heart may not relax properly or be abnormally stiff, he said.

The study findings were to be released this week at the American College of Chest Physicians annual meeting, in San Diego.

Those who had diastolic heart failure and took a cholesterol drug had almost half as much exercise tolerance as those with the condition who didn’t take the drugs, the researchers found.

“Some patients with diastolic heart failure may be more prone to the adverse effect of statins on muscle. It may be that patients with particular preexisting factors will experience unfavorable results from statin therapy, including exercise intolerance, dyspnea [shortness of breath], and fatigue,” study author Lawrence P. Cahalin, a researcher at Northeastern University, said in a statement.

“Not all statins are alike, and not all patients are alike. Some statins are stronger than others and are likely to act differently, given particular patient characteristics, and produce different degrees of wanted and unwanted effects,” Cahalin said. “In our continuing study, we hope to identify patient characteristics that are associated with favorable and less than favorable results from statin therapy.”

For now, Cahalin said tests are in order if heart failure patients taking statins suffer from fatigue, shortness of breath and inability to exercise for very long.

In another study to be released at the meeting, researchers report that statins may help prevent blood clots in people with cardiovascular disease.

Previous research has linked atherosclerosis, a condition in which fatty material builds up along artery walls, and venous thrombosis (VTE). Researchers from Albert Einstein Medical Center in Philadelphia, who were investigating the association between statin use and incidence of VTE, reviewed data on 593 patients who were hospitalized for heart attack or ischemic stroke.

“In our study, statin therapy demonstrated a protective effect on this group of patients, reducing their overall incidence of developing VTE,” said study author Dr. Danai Khemasuwan.

Patients in the non-statin group were three times as likely to develop VTE as patients receiving statins, they found.

Given the good news/bad news conclusions of these two reports, patients should not panic, experts said. Statins provide significant benefits for patients with cardiovascular disease, Dr. Kalpalatha Guntupalli, president of the American College of Chest Physicians, said in a statement. However, as for any new medication prescribed, clinicians should closely monitor the effects that different types of statins have on individual patients.

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Autoimmune Disorder Linked to Stroke, Heart Attack in Women

December 29th, 2009

Women under 50 with a certain form of the autoimmune condition called antiphospholipid syndrome are at greatly increased risk for heart attack and stroke, and that risk is even higher when these women smoke or take birth control pills, new research shows.

Antiphospholipid syndrome occurs when autoantibodies attach to cell membranes and interfere with the normal clotting mechanism of the blood.

In the study, researchers in the Netherlands analyzed data on more than 1,000 young women and found that those with a particular type of antiphospholipid antibody, called lupus anticoagulant, are 43 times more likely to suffer a stroke and five times more likely to have a heart attack than the general population of young women.

Women with lupus anticoagulant who smoke or take birth control pills have a much higher risk of stroke (87-fold and more than 200-fold, respectively) and heart attack (34-fold and 22-fold, respectively), the researchers found. Both smoking and birth control pills enhance the action of lupus anticoagulant, they explained.

The study authors estimated that lupus anticoagulant is present in about seven in 1,000 women, but previous studies have suggested a higher prevalence.

The study appears in the Sept. 27 online edition and in the November print issue of The Lancet Neurology.

The findings show that young women with lupus anticoagulant need to be warned about the dangers of smoking and the use of oral contraceptives, Dr. Kathryn Kirchoff-Torres and Dr. Steven R. Levine, of the Stroke Center at Mount Sinai School of Medicine in New York City, wrote in an accompanying editorial.

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Men Not Being Told Enough About PSA Tests

December 22nd, 2009

Most men are not being told the pros and cons of PSA tests, two new studies find.

Although PSA tests can detect prostate cancer, they can’t predict which cancers are aggressive and which are so slow-growing that they don’t need to be treated. This leads to overtreatment, which can have immediate consequences, such as impotence and incontinence, and only a tiny increase in survival, researchers say.

“Men in the United States have not been adequately told about the questions regarding the efficacy of prostate cancer screening,” said Dr. Otis W. Brawley, chief medical officer at the American Cancer Society, who was not involved in either study.

“They have been misled and over-promised,” he said. “People have replaced the hope that prostate cancer screening is beneficial with the message that it is definitely beneficial.”

The reports are published in the Sept. 28 issue of the Archives of Internal Medicine.

In the first study, a team led by Dr. Richard M. Hoffman, from the New Mexico VA Health Care System, collected data on 3,010 men 40 and older reached by telephone. Among these men, 375 had undergone or discussed PSA screening in the past two years.

In all, 69.9 percent of the men had discussed screening with their doctor before making a decision. Of these men, 14.4 percent chose not to have the test. In most cases the doctor brought up having the test (64.6 percent), with 73.4 percent recommending it, which was the only point of the discussion, the researchers said.

“Thirty percent of the men said it wasn’t even discussed at all,” Hoffman said. “Men who did discuss screening heard about the benefits of screening; very few heard about the side effects of screening.”

In addition, most men didn’t know a lot about prostate cancer, Hoffman said. In fact, only 47.8 percent of men correctly answered any of three questions about prostate cancer risk and screening, Hoffman said.

“This is a very important decision. We think it should be an informed or shared decision, and it’s not happening,” he said.

The problem with getting the test is that a positive result is going to lead to a biopsy, and only one out of four men who have a biopsy have cancer, Hoffman said.

One reason these discussions aren’t taking place is that doctors don’t have enough time to discuss screening and prostate cancer in general with their patients, Hoffman said.

Men should educate themselves about the pros and cons of PSA testing, Hoffman said. There are various aids for making such a decision both on the Internet and in print, he said.

In the second report, Kirsten Howard, a senior lecturer in health economics at the University of Sydney in Australia, and colleagues created a statistical model, based on family history, to provide information for men who have low, moderate and high risk for prostate cancer.

“The results of the model predict that benefits and harms of annual PSA screening vary with age and risk level,” Howard said.

For example, screening 1,000 men every year from age 40 to 69 only reduces the number who will die from prostate cancer by age 85 from 30 to 28, Howard said.

“So instead of 30 out of the thousand dying from prostate cancer by age 85, only 28 will die of prostate cancer. By the time they are 85, about 640 will have died from all causes of death whether they were screened or not,” she said. “Higher risk men have more prostate cancer deaths averted, but also more prostate cancer diagnosed and related harms.”

From the model, screened men are about two to four times more likely to be diagnosed with prostate cancer than men who do not get the screening, but death rates from prostate cancer and from other causes are similar in both groups, Howard said.

“The net mortality benefit is small, and this needs to be weighed against the increased chances of being diagnosed and treated for prostate cancer,” she said. “Before undergoing PSA screening, men should be aware of the possible benefits and harms, and of their chances of these benefits and harms occurring.”

Dr. Michael Pignone, an assistant professor of cancer prevention and control at the University of North Carolina at Chapel Hill and author of an accompanying journal editorial, said that “when you total up the potentially beneficial and potential detrimental consequences of PSA screening, it is not clear that the net effect of PSA screening is beneficial.”

Pignone noted that the consequences of prostate cancer treatment, such as impotence and incontinence, occur with treatment. “You suffer the down sides right away,” he said. “You only get the benefits, in most cases, far into the future.”

Pignone noted that even men with prostate cancer are more likely to die from heart disease or dementia than their cancer. Your chance of dying from prostate cancer is one in a 1,000, while the odds of dying from another cause is 113 in 1,000, he said.

Brawley noted that the American Cancer Society is reviewing its recommendations for PSA screening, and is expected to change them next year.

“Men should know that there are huge question marks, and for some men who are very concerned, perhaps they should get screened. For some men who are less concerned about prostate cancer, perhaps they should not get screened,” Brawley said. “But men should not be told that prostate cancer screening is more beneficial than we have evidence to show.”

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Younger Women With Colon Cancer Outlive Men

December 15th, 2009

A new study suggests that estrogen or other hormones could help younger women with colorectal cancer live longer than men with the disease.

“We’ve known for a while that estrogen prevents colorectal cancer, but this is the first study to suggest it may improve outcomes once you have colorectal cancer,” said study co-author Dr. Heinz-Josef Lenz, co-director of gastrointestinal oncology and colorectal cancer at the University of Southern California/Norris Comprehensive Cancer Center, in a statement.

Lenz and colleagues examined medical records of 52,882 patients who had metastatic colorectal cancer over a 16-year period. Women age 18 to 44 years lived an average of three months longer than men — 17 months versus 14 months.

But the effect wasn’t the same for older women. They survived for an average of seven months, compared to nine months for men.

Lenz thinks estrogen levels could be playing a role. Dr. James Abbruzzese, chair of gastrointestinal medical oncology at the University of Texas M. D. Anderson Cancer Center, said in a statement that improvements in care may also be a factor: Those who were diagnosed after 2000 lived longer.

“In terms of the chemotherapy we have available, since 2000 the regimens employ more agents and have become much more aggressive. Therefore, it may be expected to inhibit normal hormonal cycles leading to lower hormonal levels in these women, so other factors may be playing a role as well. It may not just be hormones,” Abbruzzese said.

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More women having a healthy breast removed

December 8th, 2009

A small but growing number of women with breast cancer are choosing to have the unaffected breast removed in an effort to prevent a recurrence, researchers reported Monday.

Using data from New York State hospitals, the researchers found that between 1995 and 2005, the prevalence of preventive mastectomy among women with a history of cancer in one breast more than doubled.

The procedure was performed in about 2 percent of all women diagnosed with breast cancer in 1995 and 1996 — rising to just over 4 percent by 2005.

In contrast, there was only a small increase in preventive mastectomies among women who had no personal history of breast cancer but were considered at risk because of a strong family history of the disease.

The findings suggest that while the number of preventive mastectomies performed each year in New York was small, the procedure is becoming more common, the researchers report in the journal Cancer.

The more marked increase among women with a history of breast cancer raises some concerns, senior researcher Dr. Stephen B. Edge, of the Roswell Park Cancer Institute in Buffalo, told Reuters Health.

The central issue, he explained, is that there is no evidence that removing the unaffected breast improves long-term survival.

While preventive mastectomy likely cuts the chances of cancer developing in the second breast, the ultimate impact on survival is a more complicated matter.

Edge noted that among women who are not at high genetic risk of breast cancer — about 95 percent of all breast cancer patients — the odds of developing cancer in the second breast are between 10 percent and 20 percent over 20 to 30 years.

The large majority of those cancers, he added, are detected early and effectively treated.

So in deciding whether to have a preventive mastectomy, women need to consider the uncertain long-term benefits and the risk of complications — which include bleeding, infection and nerve damage.

“Women need to be carefully counseled on the issues of the risks of developing a second cancer, and the largely minimal or no impact this may have on their survival,” Edge said.

The study findings are based on data from hospital discharge records and the New York State cancer registry. Of the nearly 70,000 women who underwent mastectomies between 1995 and 2005, 9 percent — 6,275 women — had one for preventive reasons.

Of women having a preventive mastectomy, 81 percent had a history of breast cancer. The number of these procedures rose from 295 in 1995 to 683 in 2005.

Meanwhile, the number of preventive procedures performed among women with no personal history of breast cancer showed a much a smaller change — 106 in 1995, versus 128 in 2005.

The data cannot offer any potential reasons for the increases, and Edge said there is “clearly” a need for more research into the factors that are influencing women’s decisions on preventive mastectomy.

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Sleep Training Helps Ease Insomnia Tied to Arthritis

November 26th, 2009

Cognitive behavioral therapy for insomnia helps improve pain and sleep in older people with osteoarthritis and insomnia, researchers say.

Their study included 23 patients (mean age 69) who received CBT-I and 28 patients (mean age 66.5) who were assigned to a control group that received information on stress management and wellness. The CBT-I program consisted of eight weekly two-hour classes in which they received sleep-training tips and exercises.

Patients in the CBT-I group reported significantly decreased time to fall asleep (an average decrease of 16.9 minutes at the beginning of the study and 11 minutes at one year after treatment). The cognitive behavioral therapy group also had a decrease in wake after sleep-onset times (an average of 37 minutes initially and 19.9 minutes one year later) and pain (improvement of 9.7 points initially and 4.7 points one year later). Increased sleep efficiency was also noted in the CBT-I group (improvement of 13 percent initially and 8 percent one year after treatment), the researchers found.

No significant improvements in any measure were reported in the control group.

The findings suggest that insomnia is not just a symptom of osteoarthritis but is actually a co-existing illness, lead study author Michael V. Vitiello, a professor at the University of Washington in Seattle, said in a news release. About 60 percent of people with osteoarthritis report pain during the night, and better sleep quality can reduce their suffering, he added.

“The particular strength of CBT-I is that once an individual learns how to improve their sleep, study after study has shown that the improvement persists for a year or more,” Vitiello said in the news release.

The study appears in the Aug. 15 issue of the Journal of Clinical Sleep Medicine.

This and other research shows that “CBT-I can not only improve sleep but that improvement of sleep may lead to improvement in co-existing medical or psychiatric illnesses, such as osteoarthritis or depression, and in the case of our study, that these additional benefits can be seen in the long term,” Vitiello said.

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Health Tip: Managing Menstrual Cramps

November 22nd, 2009

Menstrual cramps signal an unwelcome time of the month for many women.

The U.S. National Library of Medicine offers these suggestions to help relieve the pain and discomfort of monthly menstrual cramps:

Use an over-the-counter pain reliever, such as naproxen sodium or ibuprofen.
Apply a hot water bottle or heating pad to the abdominal area.
Perform regular exercises, such as walking or pelvic exercises.
Stick to a healthy diet rich in fruits, vegetables and whole grains. Avoid salt, sugar, caffeine and alcohol.
Perform relaxation techniques, such as meditation or yoga.

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