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AHA/ASA Releases Updated Secondary Stroke Prevention Guidelines

News Author: Pauline Anderson
CME Author: Charles P. Vega, MD

CME/CE Released: 10/25/2010; Valid for credit through 10/25/2011

October 25, 2010 — New recommendations on metabolic syndrome treatment and acknowledgement of a place for stenting in the management of symptomatic carotid stenosis are among the changes seen in updated secondary stroke prevention guidelines from the American Heart Association (AHA)/American Stroke Association (ASA).

The new guidelines were published online October 21 in Stroke. The document notes that the American Academy of Neurology "affirms the value" of the guideline as an educational tool for neurologists and that it has been reviewed and the content affirmed by the American Association of Neurological Surgeons and the Congress of Neurological Surgeons.

The aim of the statement is to provide comprehensive and timely evidence-based recommendations on the prevention of ischemic stroke among survivors of ischemic stroke or transient ischemic attack, the authors write.

This and other AHA stroke-related statements are updated on a regular basis, with these secondary stroke prevention guidelines last being updated in 2006, said Robert J. Adams, MD, professor of neuroscience at the Medical University of South Carolina, Charleston, and a member of the review committee.

"We make a continual effort to get the best recommendations we can looking at the evidence, and as you'll see in some areas, we felt that we couldn't really make a recommendation because we felt we didn't have enough data," Dr. Adams told Medscape Medical News. "Those are basically by default or de facto areas where we think more research is needed."

This update is also among the first to flag new recommendations within the text of the document, said Dr. Adams. "We decided to point out to the reader what was new."

New Metabolic Syndrome Recommendations

All 3 recommendations pertaining to metabolic syndrome are new. The syndrome is a confluence of several physiological abnormalities that increase the risk for vascular disease. According to AHA/ASA criteria, metabolic syndrome is recognized when 3 of the following features are present:

• increased waist circumference (≥102 cm in men; ≥88 cm in women),
• elevated triglyceride levels (≥150 mg/dL),
• reduced high-density lipoprotein cholesterol (<40 mg/dL in women; <50 mg/dL in men),
• elevated blood pressure (systolic ≥130 mm Hg, or diastolic ≥ 85 mm Hg), and
• elevated fasting glucose (≥100 mg/dL).

To prevent a secondary stroke or transient ischemic attack in patients who have metabolic syndrome, clinicians should treat the individual components of the syndrome that are also stroke risk factors, particularly dyslipidemia and hypertension, the new guidelines note.

Management of patients with metabolic syndrome should include counseling on diet, exercise, and weight loss to reduce vascular risks, but the utility of screening patients for metabolic syndrome after stroke has not been established.

There is considerable controversy surrounding this syndrome, largely because of uncertainty regarding its etiology and clinical usefulness, the authors write. The disorder has been related to an increased risk for diabetes, cardiovascular disease, and all-cause mortality.

The association between metabolic syndrome and risk for first ischemic stroke has been examined in several recent studies, with all except 1 confirming the association, but with only 1 study examining the association between metabolic syndrome and risk for stroke recurrence.

In the Warfarin Aspirin Symptomatic Intracranial Disease (WASID) trial, participants with metabolic syndrome were more likely to have a stroke, myocardial infarction, or vascular death during 1.8 years of follow-up than participants without metabolic syndrome (hazard ratio [HR], 1.6; 95% confidence interval [CI], 1.1 - 2.4; P = .0097). Patients with the syndrome were also at increased risk for ischemic stroke alone (HR, 1.7; 95% CI, 1.1 - 2.6; P = .012).

Cardiac features of metabolic syndrome improve with weight loss, which has also been shown to improve insulin sensitivity, lower plasma glucose, low plasma low-density lipoprotein cholesterol, lower plasma triglycerides, raise high-density lipoprotein cholesterol, lower blood pressure, reduce inflammation improve fibrinolysis, and improve endothelial function in patients with metabolic syndrome.

Carotid Artery Stenting

Also included in the revised guidelines is updated research pertaining to carotid artery stenting for extracranial symptomatic carotid disease, based on results of large clinical trials, including the Carotid Revascularization Endarterectomy vs Stent Trial (CREST), most recently reported.

Carotid endarterectomy is recommended for these symptomatic patients with high-grade stenosis (70% - 99%) if the perioperative morbidity and mortality risk is estimated at less than 6%, as well as for those with moderate stenosis (50% - 99%); neither stenting nor surgery is recommended for stenoses less than 50%.

However, the writing group notes that carotid artery stenting is indicated as an alternative to surgery for symptomatic patients at average or low risk for complications associated with endovascular intervention when the diameter of the lumen of the internal carotid artery is reduced by more than 70% by noninvasive imaging or more than 50% by catheter angiography.

"The recommendation is that for certain patients with symptomatic high-grade carotid stenosis and factors that make carotid endarterectomy not favorable, such as previous radiation therapy or previous surgery, or certain medical conditions which increase risk for surgery, that carotid artery stenting is a reasonable alternative," commented Dr. Adams.

Stenting in that setting is "reasonable when performed by operators with established periprocedural morbidity and mortality rates of 4% to 6%," the authors add — rates similar to those seen in stenting and surgery trials.

Finally, a new recommendation is that all of these patients receive optimal medical therapy, including antiplatelet therapy, statins, and a risk factor modification.

Atrial Fibrillation

New recommendations on the management of atrial fibrillation (AF) are based on data from the Atrial Fibrillation Clopidogrel Trial with Irbesartan for Prevention of Vascular Events (ACTIVE) study and ACTIVE A, an arm of the study that compared aspirin with clopidogrel plus aspirin in patients with AF who were considered unsuitable for vitamin K antagonist therapy.

Patients were considered "unsuitable" for warfarin based on physician judgment or patient preference — criteria that were somewhat controversial when this study was first presented. Trial results showed less stroke but more bleeding with clopidogrel plus aspirin vs aspirin alone.

In the new guidelines, however, authors write that "on the basis of uncertainty of how to identify patients who are 'unsuitable' for anticoagulation, as well as the lack of benefit in the analysis of vascular events plus major hemorrhage, aspirin remains the treatment of choice for AF patients who have a clear contraindication to vitamin K antagonist therapy but are able to tolerate antiplatelet therapy."

The combination of clopidogrel plus aspirin carries a bleeding risk similar to warfarin and so is not recommended for those with a hemorrhagic contraindication to warfarin, the authors note.

Another new recommendation is that for patients with AF who are at high risk for recurrent stroke, but who require temporary interruption of oral anticoagulation, bridging therapy with a low-molecular-weight heparin is reasonable, said Dr. Adams.

These new AF guidelines were written before regulatory approval of the oral thrombin inhibitor dabigatran, based on encouraging results in the previously reported Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) study.

"No recommendation will be provided for dabigatran in the current version of these guidelines because regulatory evaluation and approval has not yet occurred," the authors note in the document. "However, the availability of a highly effective oral agent without significant drug or food interactions that does not require coagulation monitoring would represent a major advance for this patient population."

They also discuss the WATCHMAN left atrial appendage occlusion device, studied in the Embolic Protection in Patients with Atrial Fibrillation (PROTECT-AF) trial as an alternative to oral anticoagulants. "This approach is likely to have the greatest clinical utility for AF patients at high stroke risk who are poor candidates for oral anticoagulation; however, more data are required in these populations before a recommendation can be made."

Intracranial Atherosclerosis

There is also new research in the area of intracranial atherosclerosis. "There is some new information on the use of antiplatelet agents; it actually didn't substantially change the guidelines, but it makes the choice somewhat easier, and provides additional information that we didn't have before," said Dr. Adams.

The new information was from the WASID trial, on which the recommendation for aspirin over warfarin is based. Aspirin doses of 50 to 325 mg/day are recommended, the authors write. Intracranial stenting is considered investigational at this time, and its utility is still unknown, they note.

As well, there is a new recommendation concerning maintenance of blood pressure, suggesting that for patients with stroke or transient ischemic attack caused by 50% to 99% stenosis of a major intracranial artery, long-term maintenance of blood pressure lower than 140/90 mm Hg and total cholesterol level lower than 200 mg/dL may be reasonable, and there is also a new recommendation against bypass surgery in these patients.

Conflict of Interest Scrutiny

Finally, another new element to these guidelines was the "scrutiny" of committee members reviewing the literature to minimize conflicts of interest, said Dr. Adams.

"How that was managed this time was that we were all given assignments in areas that were unrelated to anything we put on the conflict of interest form;" the upshot is that he was reviewing research, "that I have no interest in or ever spoken about."

All members of the writing group were required to complete and submit a disclosure questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.

Stroke. Published online October 21, 2010.

Additional Resource
Clinicians can use the AHA Get With the Guidelines-Stroke Toolkit to obtain more information on stroke prevention.

http://www.medscape.org/viewarticle/731103?src=cmemp

regards, taniafdi ^_^

How Are You Choosing a Specialty?

Joshua Batt, Medical Student, 05:32PM Nov 20, 2010

he cut was made, some dissection performed and the baby was pulled out. I was holding our patient's uterus in one hand and assisting my attending with the other during a scheduled cesarean section. All I could think was how this doctor's job is simply amazing. How many people can say that they get to open a person's body, pull out a living organism and twelve inches away, you can stare the patient in the face and have a discussion with them?

Between the work of the anesthesiologist and the obstetrician, I was enthralled by the situation. Their team effort and training made the operation a success. Baby was beautiful, mom and dad were happy and the medical crew had performed well. It was not a long procedure, but one that left me wondering if I could be doing this as a career. Yet another moment of reflection needed if I am ever going to decide what to be "when I grow up."

That question, "What are you going to be when you grow up?" continues to haunt me as time rushes past. At least I have the doctor part down; now to narrow things down a little. It certainly doesn't help going into residency applications and interviews with multiple fields of interest and no geographical preference. There are simply too many places, professions, and programs to choose from.

Some aids I have found include the specialty flowchart, the University of Virginia's Medical Specialty Aptitude Test (MSAT), and The Ultimate Guide to Choosing a Medical Specialty. There are days when I agree with their advice and other days I think they are in left field. What have you found useful in making your decision?

Source:
http://boards.medscape.com/forums?128@55.L76CafhiDNn@.2a04c4a5!comment=1



regards, taniafdi ^_^

Women Who Suffer Migraine With Aura Have Better Outcomes After Stroke

Article Date: 01 Dec 2010 - 2:00 PST

Women with a history of migraine headache with aura (transient neurological symptoms, mostly visual impairments) are at increased risk of stroke. However, according to new research reported in Circulation: Journal of the American Heart Association stroke events in women with migraine with aura are more likely to have mild or no disability compared to those without migraine.

In a new analysis of the Women's Health Study involving 27,852 women over 13.5 years, researchers found those who have migraine with aura and who experience an ischemic stroke were twice as likely to have no significant disability from stroke.

"The message from this study should be reassuring for migraineurs," said Tobias Kurth, M.D., Sc.D., the study's principal author and associate epidemiologist at Brigham and Women's Hospital in Boston, Mass.

"It is important for women who have migraine with aura to know that their risk of stroke is considerably low and there is high likelihood of a migraine-associated stroke being mild."

The reason for these results is unclear. But Kurth, who is also director of research at INSERM in Paris, France, speculated that mechanisms, perhaps involving smaller vessels - not the traditional mechanisms for stroke, lead to a smaller size stroke.

Compared to those without migraine history, women with migraine and aura were more likely to have a good to excellent functional outcome - defined as having no symptoms and no significant disability, researchers said.

Women participating in the study were divided into four groups: 22,723 who reported no migraine history; 5,129 who reported a migraine history; 3,612 who had active migraine; and of those who reported active migraine, 1,435 reported active migraine with aura.

Researchers evaluated functional ability after stroke at hospital discharge using the modified Rankin Scale, a seven-point scale that measures degree of impairment.

At the onset of the study, women completed a questionnaire about their headaches that allowed classification into the groups of migraine with and without aura, history of migraine or no history of migraine. Each following year, the women reported new medical conditions, including transient ischemic attack (TIA) or stroke, which were confirmed after medical record review.

During 13.5 years of follow-up, 398 TIAs and 345 ischemic strokes occurred.

Women in the study were primarily Caucasian, average age 55, healthy and working in the healthcare field.

There is currently little reason to believe that the association differs for women with other characteristics or men, Kurth said.

The first author is Pamela M. Rist, M.Sc., a doctoral student at the Harvard School of Public Health and research fellow at Brigham and Women's Hospital. Other co-authors are: Julie E. Buring, Sc.D.; Carlos S. Kase, M.D.; Markus Schurks, M.D., M.Sc. Author disclosures are on the manuscript.

The Women's Health Study is supported by grants from the National Heart, Lung, and Blood Institute and the National Cancer Institute. Grants from the Donald W. Reynolds, Leducq and Doris Duke Charitable foundations funded part of the study.

Source:
Karen Astle
American Heart Association  

Source:
http://www.medicalnewstoday.com/articles/209654.php

regards, taniafdi ^_^

Protein in the Urine: A Warning Sign for Cognitive Decline

 Released: 11/10/2010 3:00 PM EST
Embargo expired: 11/20/2010 9:15 PM EST

1. Small Amounts of Urinary Protein Predict More Rapid Cognitive Decline in Elderly Women
Screening Efforts in Older Individuals May Be Warranted

A new study has found that low amounts of albumin in the urine, at levels not traditionally considered clinically significant, strongly predict faster cognitive decline in older women. The study involved more than 1,200 women aged >70 years in the Nurses' Health Study who were phoned every two years for three cycles and tested for general cognition, verbal/word memory, verbal fluency (speed in making word associations), and working/short-term memory. Julie Lin, MD (Brigham and Women’s Hospital) and her colleagues found that participants with a urinary albumin-to-creatinine ratio of >5 mcg/mg at the start of the study experienced cognitive decline at a rate 2 to 7 times faster in all cognitive measures than that attributed to aging alone over an average 6 years of follow-up. “The strongest association was seen with a decline in the verbal fluency score, which has been attributed to progressive small vessel disease in the brain, which supports the view that albuminuria is an early marker of diffuse vascular disease,” said Dr. Lin. “Therefore, in light of the aging U.S. population, which is at risk for cognitive decline and vascular disease, simple, non-invasive screening for albumin in the urine as an independent predictor for subsequent cognitive decline may represent an important public health issue.”

Study co-authors include Fran Grodstein, PhD, Jae Hee Kang, PhD, and Gary Curhan, MD, ScD, (Brigham and Women's Hospital).

Disclosures: Dr. Curhan is a consultant for Takeda Pharmaceuticals; receives grants/research support from Astellas and honoraria from Takeda Pharmaceuticals. Dr. Lin, Dr. Grodstein, and Dr. Hee Kang reported no other financial disclosures.

The study abstract, “A Prospective Study of Albuminuria and Cognitive Decline in Women,” [SA-FC355] will be presented as an oral presentation on Saturday, November 20 Day, Date at 5:18 PM MT in Room 405 of the Colorado Convention Center in Denver, CO.

2. Urinary Protein Excretion Increases Risk of Cognitive Impairment
Simple Urine Tests Could Identify Individuals at Risk

Two characteristics of kidney disease—excreting protein in the urine (albuminuria) and low kidney function—increase individuals’ risk of becoming confused and forgetful. To see whether these two characteristics are related or independent in their effects on cognitive decline, Manjula Kurella Tamura, MD (Stanford University) and her colleagues studied clinical data from 19,399 individuals participating in the Renal Reasons for Geographic and Racial Differences in Stroke (REGARDS) study. A total of 1,184 participants (6.1%) developed cognitive impairment over an average follow-up of 3.8 years. Individuals with albuminuria were 1.31-1.57 times more likely to develop cognitive impairment compared to individuals without albuminuria. This association was strongest for individuals with normal kidney function (eGFR ≥60 ml/min/1.73m2) and attenuated among individuals with low levels of kidney function. Conversely, low kidney function (eGFR <60 ml/min/1.73m2) was associated with a higher risk for developing cognitive impairment only among individuals without albuminuria. Surprisingly, individuals with albuminuria and normal kidney function had a higher probability for developing cognitive impairment as compared to individuals with moderate reductions in kidney function (eGFR 45-59 ml/min/1.73m2) in the absence of albuminuria. The findings indicate that the presence of protein in the urine, even in small amounts, could be a warning sign that a patient may later have difficulty thinking clearly. “The results are important because albuminuria is easily measured and potentially modifiable. Incorporating information about albuminuria along with kidney function should help clinicians identify patients at high risk for subsequent cognitive decline and dementia,” said Dr. Kurella Tamura.

Study co-authors include Virginia Wadley, PhD, Mary Cushman, Frederick Unverzagt, PhD, Neil Zakai, MD, Brett Kissela, MD, David Warnock, MD, and William McClellan, MD (for the REGARDS Study Group, University of Alabama at Birmingham).

Disclosures: The study received pharmaceutical company support in addition to funding from the National Institute of Neurological Disorders and Stroke. Dr. Cushman is a consultant for Glaxo Smith Kline and receives grants/research support from Amgen. Dr. Unverzagt holds ownership in Eli Lilly. Dr. Warnock is a consultant for Genzyme and Gilhead, holds ownership in Parion and Relypsa, and receives honoraria from Genzyme, Amicus, Amgen, Gilhead, and Shire. Dr. McClellan receives grant/research support from and is a scientific advisor for Amgen. Dr. Wadley, Dr. Zakai, and Dr. Kissela reported no financial disclosures.

The study abstract, “Albuminuria, Kidney Function and the Incidence of Cognitive Impairment in US Adults,” [SA-FC359] will be presented as an oral presentation on Saturday, November 20 Day, Date at 6:06 PM MT in Room 405 of the Colorado Convention Center in Denver, CO.

# # #

ASN Renal Week 2010, the largest nephrology meeting of its kind, will provide a forum for 13,000 professionals to discuss the latest findings in renal research and engage in educational sessions related to advances in the care of patients with kidney and related disorders. Renal Week 2010 will take place November 16 – November 21 at the Colorado Convention Center in Denver, CO.

The content of this article does not reflect the views or opinions of The American Society of Nephrology (ASN). Responsibility for the information and views expressed therein lies entirely with the author(s). ASN does not offer medical advice. All content in ASN publications is for informational purposes only, and is not intended to cover all possible uses, directions, precautions, drug interactions, or adverse effects. This content should not be used during a medical emergency or for the diagnosis or treatment of any medical condition. Please consult your doctor or other qualified health care provider if you have any questions about a medical condition, or before taking any drug, changing your diet or commencing or discontinuing any course of treatment. Do not ignore or delay obtaining professional medical advice because of information accessed through ASN. Call 911 or your doctor for all medical emergencies.

Founded in 1966, the American Society of Nephrology (ASN) is the world’s largest professional society devoted to the study of kidney disease. Comprised of 11,000 physicians and scientists, ASN continues to promote expert patient care, to advance medical research, and to educate the renal community. ASN also informs policymakers about issues of importance to kidney doctors and their patients. ASN funds research, and through its world-renowned meetings and first-class publications, disseminates information and educational tools that empower physicians.

Source:
http://www.newswise.com/articles/view/570605/?sc=dwhp
regards, taniafdi ^_^

'Doctor, Are You Telling Me the Truth?' Exclusive Ethics Survey Results

Shelly M. Reese.
Posted: 11/30/2010.

"Honesty is the best policy" and "the patient always comes first."

As absolute and correct as those aphorisms may be, they can be hard for doctors to apply in the complex world of modern medicine.

A recent Medscape medical ethics survey of over 10,000 physicians found that when it comes to patient treatment, a significant number of physicians struggle when it comes to topics relating to honest, straight-forward communication, and even pain management. Physicians from a broad range of specialties answered 3 questions pertaining to patient treatment:

-     Would you ever hide information from a patient about a terminal or preterminal diagnosis, because you believe that it will bolster their spirit or attitude?
-      Would you ever prescribe a treatment that's a placebo, simply because the patient wanted treatment?
-      Would you ever undertreat a patient's pain, because of a fear of repercussions or because you are concerned that a patient -- even a terminal patient -- might become addicted?

Open Communication Is Often Difficult

When it comes to delivering bad news, 59.8% of physicians indicate they "tell it exactly as I see it," while 14.6% indicate that they soften the news and "give hope even if there is little chance." Two percent indicate that unless a patient is going to die imminently, they don't tell him or her how bad the situation is and nearly one quarter (23.8%) say "it depends."

"The kind of compassion that brings people into medicine is the type of compassion that is needed for delivering bad news," says Kenneth Goodman, PhD, Director of the Bioethics Program at the University of Miami and author of Ethics and Evidence-Based Medicine: Fallibility and Responsibility in Clinical Medicine. But that compassion should never compromise the truth, he cautions.

Many of the physicians surveyed augmented their responses noting that, while they are honest, they try hard to deliver bad news in the most gentle, humane, and supportive way possible. That's exactly what patients should expect from their doctors, Goodman advises. But in "softening" the truth, he believes that doctors don't need to deviate from it.

"If there is something positive you can say, by all means say it. But only tell the truth: 'I will be there with you. I will help you manage your pain. I will see to it that you can arrange your affairs.' Those are truthful things," Goodman says.

When doctors withhold information, they make it more difficult for patients to chart their course and undermine their own credibility.

From the patient's point of view, "If I don't know my time is limited I can't put my affairs in order. I can't say, 'I'm sorry,'" he says. What's more, "it's not like patients are asking Dr. Kildare, 'What are my chances, Doc?' Patients are increasingly educated. If you don't tell them, they're going to be looking it up on the internet the next day, so you should probably be the source of the data, because you're a human and you care about them."

Goodman advises that the same rationale applies to the use of placebos. Nearly one quarter (23.5%) of respondents said they would prescribe a treatment that was essentially a placebo to a patient simply because he or she wanted treatment. Another 18.2% said, "It depends."

Physicians who were willing to provide "placebo" treatment generally fell into 2 camps. Some said they would do it to appease a patient but only after telling them it wouldn't do them any good. One doctor noted that he'd prescribe vitamins and supplements, "but I'd tell them I thought it was worthless"; while another would prescribe a cream for hemorrhoids, "but they are also forewarned" that the treatment wouldn't do any good.

Still another noted, "In this day and age, many patients will not accept that the best treatment is tincture of time and they have no hesitation about reporting you to the state board or hospital administrator. So, I figure out something that will do the least potential harm and try that."

Others say they'd be willing to prescribe a benign but ineffectual treatment in hopes of achieving a positive placebo effect. "Placebo works up to 50% of the time," said one. "Placebos ARE a form of treatment!" noted another and, "Placebo can be psychologically beneficial and I don't see that as placebo," wrote a third.

Physicians in the first group need to be able to stand their ground in the face of insistent patients, Goodman advises. After all, they are the medical experts.

"Doctors need to be able to say, 'I'm sorry, there is nothing I can do,' No physician is going to provide drugs for a recreational purpose. Why, if a patient asks for an antibiotic for a virus or a prescription that won't work, should he get it?" Goodman asks. As for those hoping to achieve a placebo effect he notes, if a patient finds out he or she has been prescribed a placebo, it will cause irrevocable damage to the physician-patient relationship.

Pain Management Quandaries

While the first 2 patient treatment questions in the survey pertained to communication, the last addressed pain management. While the overwhelming majority (84.1%) of physicians said they would never undertreat pain, a handful (5.6%) said they would, and about 1 in 10 (10.3%) said they would have to evaluate the situation before making a decision.

After filtering out responses from physicians – many of them emergency department doctors – noting that they routinely deny drug-seeking "frequent fliers" prescriptions for pharmaceuticals, the theme frequently voiced by doctors was that they would undertreat pain due to fear of lawsuits. A number of respondents augmented their answers with frustrated, emotional responses about state medical boards, government intrusion, and litigious patients.

Comments included: "I undertreat not due to concerns about addiction but concerns about Drug Enforcement." "We live in a real world. I would like to think I would answer 'no' if real tort reform took place." "I bet we all would in today's drug-abusing, litigious society." And "The state boards can wreck a doctor without appeal."

Despite those concerns, others remained steadfast. "I have only the patient to believe as to how much pain they are experiencing. I have been lied to at times over the years, but I would rather try to believe people than to deny everyone because of some bad actors," wrote one.

When Treatment Denial Causes Suffering

Another noted that physicians' fears of repercussions have "caused patients to suffer needless pain. If a physician does not feel competent or comfortable handling pain issues, (s)he should refer that patient to a reputable pain specialist. Pain is a legitimate medical condition, which we took an oath to alleviate when possible. If the treatment is appropriate and well documented with the current safeguards in place, there should be no fear."

Most respondents who elaborated on their answers, however, drew a sharp distinction between patients with chronic conditions and the terminally ill. Many noted that they do not prescribe narcotics to patients with chronic conditions, refer them to pain management specialists, and are vigilant when it comes to chronically ill patients who tend to "lose" prescriptions too often. When it comes to treating the terminally ill, however, respondents spoke in a single voice: treat their pain.

"Terminal patients should be able to get whatever they need whenever they need it," wrote one. "Terminal patients get whatever they need," said another. A third noted, "Terminal patients should never be allowed to suffer with pain because of inadequate treatment, especially fear of addiction: what difference does it make if they are going to die addicted to narcotics?"

Source:
http://www.medscape.com/viewarticle/732693?src=mp&spon=25
regards, taniafdi ^_^

Never Stop Learning

Kendra Campbell, MD, Psychiatry/Mental Health, 02:51PM Dec 4, 2010

 

"Cultivate the society of the young, remain interested, and never stop learning." -- Marcus Tullius Cicero

I’ve always been intrigued by learning new things. I believe that my spark for learning was ignited by my phenomenal parents. Some of the first memories I have as a child are of my parents taking the family on hikes through the Shenandoah National Park in Virginia. I remember my mother pointing out interesting looking flowers and trees, naming their genera and species, and sharing with us fascinating tidbits about them. When I was a child, we had very little access to television, and I can recall complaining to my father, “dad, I’m bored!” He would frequently respond with, “then go read the encyclopedia.” I would walk up to the shelf of encyclopedias, pick a random letter off the shelf and read everything there was to know about things that started with the letter “K.” (Ahhh, life before Wikipedia!)

Although I have about 19 years of formal education under my belt, there’s still so much about the world that I don’t know and don’t understand. But my hunger to learn about the world around me continues to drive me to seek out more opportunities and experiences.

Before I truly understood what being a doctor was all about, I thought that medical school was the golden mecca. In my ignorance, I believed that medical school was where you learned how to be a doctor. How very wrong I was! 

When I first started residency, I thought, “okay, this is where I will really become a doctor...where I will learn all there is to know about my specialty.” Well, it turns out that I was wrong again!

The lesson that I’ve discovered is that being an excellent physician truly means being a lifelong learner. You will never know everything. And the pace at which we are making new discoveries ensures that if you stop reading, you will quickly be “behind the times.” 

But it’s not just about keeping up with all the new scientific facts and discoveries, it’s actually quite a bit more complicated than that. To be a great healer, one must never stop listening to their patients. One must continue to see each patient as an opportunity to learn something new about people, how to heal them, and how to heal oneself.

Now that I’m a resident, I am in the unique and extraordinary position of being both a student and a teacher. I learn something new every day from my patients, the nurses, and the attendings. But I also get to impart some knowledge to the upcoming batch of doctors. 

A few days ago, I had a medical student tell me that she had learned many skills from me, which she would carry with her for the rest of her medical career. This was a momentous reminder to me of the power and gift that is teaching. 

I think the philosopher and writer, Jiddu Krishnamurti put it well: 

"There is no end to education. It is not that you read a book, pass an examination, and finish with the education. The whole of life, from the moment you are born to the moment you die, is a process of learning."

 http://boards.medscape.com/forums?128@55.GJwDaC62EAg@.2a051b8c!comment=1

regards, taniafdi ^_^

Experiencing Happiness as a Medical Student

Joshua Batt, Medical Student, 03:39PM Dec 5, 2010

 Is your happiness conditional? Do we delay the experience of feeling happy until we have achieved the next step? At one time happiness was conditional on getting into medical school, next was passing the boards, then it is graduating medical school and finally when we become an attending...then we will be happy. What is wrong with being happy now in the role we fill today?

Srikumar Rao's recent discourse, "Plug Into Your Hard Wired Happiness," really drives home the point that we can enjoy life as it is without setting emotional pleasure aside to await a measurable outcome. He encourages investing not only in the outcome, but also in the process. Unfortunately, we are focused too often on the end goal without seeing the smaller steps before us, whether we fail or succeed.

This principle can be easily applied to life as a medical student. We strive every day to choose the right answers on exams, please our clinical professors, and learn extensive amounts of information for future use. There will be many times when we fall short of an errorless performance. If we recognize the role we are playing now as students, we will make the progress needed to obtain the final outcome we all had in mind at the beginning. Invest in the process and enjoy the journey, it is just as important as the end product.

I love being a medical student. It pushes me to explore my interpersonal, critical thinking, and knowledge based skills. I have made my fair share of mistakes on exams and with my clinical preceptors. Like a child experiencing something for the first time, it is still a wonderful exploration of who I am and who I want to be, despite the difficulties. Don't wait until the end to experience happiness; you might just put it off again. Find ways to be happy every day, even when the going gets tough.

 http://boards.medscape.com/forums?128@55.GJwDaC62EAg@.2a051fb0!comment=1

regards, taniafdi ^_^

Science Explains Why Breaking Up Is Hard to Do

Helen Fisher, a biological anthropologist at Rutgers University in New Brunswick, New Jersey, knows all about love. She has observed the brain regions associated with romantic love light up as a man gazes at his inamorata, both in new relationships and in decades-long marriages. Fisher seems to have become a bit jaded by years of Hallmark moments, however. “Who cares about people who are happily in love?” she wants to know. “It’s when you’ve been rejected that you turn into a menace.” So she has started exploring the science of heartbreak instead.

In a study published in May, Fisher and her colleagues asked 15 people who had recently been dumped but were still in love to consider two pictures—one of the former partner and one of a neutral acquaintance—while an MRI scanner measured their brain activity. When looking at their exes, the spurned lovers showed activity in parts of the brain’s reward system, just as happy lovers do. But the neural pathways associated with cravings and addictions were activated too, as was a brain region associated with the distress that accompanies physical pain.

Rejected lovers also showed increased neural response in regions involved in assessing behavior and controlling emotions. “These people were working on the problem, thinking, what did I do, what should I do next, what did I learn from this,” Fisher says. And the longer ago the breakup was, the weaker the activity in the attachment-linked region. In other words: Love hurts, but time heals.

source:
http://discovermagazine.com/2011/jan-feb/97
regards, taniafdi ^_^

How Can Leg Cramps Be Treated?

Jodi H. Walker, PharmD
Adjunct Faculty, Albany College of Pharmacy, Albany, New York; Clinical Pharmacy Coordinator, VA Medical Center, Bath, New YorkPosted: 06/14/2010

Idiopathic leg cramps are presenting more and more frequently in the healthcare community. Leg cramps have historically been underreported. However, as patients become increasingly informed through television and the Internet and become aware of such conditions as the restless legs syndrome, treating leg cramps is a common issue facing healthcare providers today.

Although quinine sulfate has been shown to be efficacious in treating leg cramps, the Food and Drug Administration (FDA) banned over-the-counter use in 1994 due to risk for potentially fatal hypersensitivity reactions, thrombocytopenia, and cardiac arrhythmia.^[1] In 2006, the FDA banned marketing of unapproved prescription quinine products.^[2] Quinine remains available by prescription for treatment of malaria, but its risks as a preventive or treatment for leg cramps outweigh any potential benefit.^[2]

Nonpharmacologic therapy is not well-established but may warrant an initial trial before treatment with medication. Hydration, warm or cold compresses, exercising, or calf stretches may provide some benefit.^[3]

Although no specific medical treatment is indicated for leg cramps, several drugs have been used with varied success. Calcium-channel blockers, such as diltiazem, have been used to treat nocturnal leg cramps. Vitamin B complex (including 30-mg vitamin B6) has also shown effectiveness.^[4]

Patients with chronic leg cramps should consult with their healthcare provider to investigate underlying causes. A differential diagnosis is important when patients with leg cramps are being examined, because many disorders, such as tetany, myalgia, the restless legs syndrome, and peripheral vascular disease, can have symptoms that present as leg cramps.^[3]

Quinine continues to be used off-label to treat nocturnal leg cramps; however, an FDA postmarketing review states that there are no reliable data to support its use, and although it is often effective, serious adverse effects have occurred.^[2] The American Academy of Neurology systematically reviewed the available evidence on symptomatic treatment of muscle cramps and their recommendations include the following^[4]:

• Consider vitamin B complex or calcium-channel blockers, such as diltiazem.
• Avoid routine use of quinine.
• Potentially consider quinine for an individual trial once side effects are evaluated; side effects must be carefully monitored.

References

1. Brinker AD, Beitz J. Spontaneous reports of thrombocytopenia in association with quinine: clinical attributes and timing related to regulatory action. Am J Hematol. 2002;70:313-317. Abstract
2. FDA Drug Safety Newsletter. Postmarket Reviews - Volume 2, Number 2, 2009. US Department of Health and Human Services. US Food and Drug Administration. Available at: http://www.fda.gov/Drugs/DrugSafety/DrugSafetyNewsletter/ucm167883.htm Accessed May 14, 2010.
3. Sheon RP. Nocturnal leg cramps, night starts and nocturnal myoclonus. Available at: http://www.uptodate.com/home/index.html (subscription required to view). Accessed April 29, 2010.
4. Katzberg HD, Khan AH, So YT. Assessment: symptomatic treatment for muscle cramps (an evidence-based review). Report of the Therapeutics and Technology Assessment subcommittee of the American Academy of Neurology. Neurology. 2010;74:691-696. Abstract

Source:
http://www.medscape.com/viewarticle/723218

regards, taniafdi ^_^

Doctors Claim HIV-Positive Patient Cured by Stem Cells

By Ronnie Koenig Dec 14th 2010 3:12PM

German doctors announced what could be ground-breaking news in the fight against HIV and AIDS. An HIV-positive patient, who had developed acute myeloid leukemia, is said to have been cured of his HIV infection after a bone marrow transplant, which was performed in 2007.

The 'Berlin Patient,' a U.S. citizen named Timothy Ray Brown, underwent a procedure in which HIV-resistant stem cells from an individual with an unusual genetic profile were introduced into his body. The donor patient's CD4 cells lacked the CCR5 co-receptor -- the most common variety of HIV uses CCR5 co-receptors as a "docking station," attaching to it in order to enter and infect CD4 cells. People with this particular genetic mutation are almost completely protected against infection.

Brown underwent grueling treatment for leukemia, two stem cell transplants and also suffered from a serious neurological disorder, which required a brain biopsy. Before the stem cell transplant he received chemotherapy treatment that destroyed most of his immune cells, as well as total body irradiation and received immunosuppressive drugs to prevent rejection of the stem cells. After all of this, HIV was undetectable by both viral load testing (RNA) and tests for viral DNA within cells.

In an interview with the German news magazine, Stern, Brown was asked if might have just decided to live with HIV rather than undergo this lengthy and difficult process. "Perhaps," he answered. "Perhaps it would have been better, but I don't ask those sorts of questions anymore."

Berlin doctors published his detailed case history in the New England Journal of Medicine in February 2009. Now they've published a follow-up report in the journal Blood, saying: "It is reasonable to conclude that cure of HIV infection has been achieved in this patient."

The revelations about the 'Berlin Patient' point to the fact that a cure for HIV could be developed using genetically engineered stem cells. NAM Aidsmap reports that the German researchers and San Francisco-based immunologist Professor Jay Levy are stressing the importance of suppressing CCR5-bearing cells, either through transplants or gene therapy.

Dr. David J. Ores, a general practitioner on the Lower East Side of Manhattan says that while the thought of a cure for HIV is appealing, he's not sure if this one case is the answer.

"This patient has many unique factors," Ores told AOL Health. "He had leukemia. Twice. He had all sorts of chemotherapy and radiation. Twice. His genetics are unique to himself (like anyone else). The HIV could be dormant for now. We also don't know which sub-type of HIV he had. Or if he had other infections in the past which effect his immune system."

Ores goes so far as to question whether the 'Berlin Patient' actually had HIV in the first place. "Maybe his leukemia affected the HIV test since HIV is, in fact, leukemia as well. Recall, HIV was originally classified as 'HTLV type one' which stands for Human T-Cell Leukemia Virus (HTLV). So maybe his other leukemia affected the test for the other HIV leukemia (HIV)."

Still, Ores says that if the research is indeed valid, any advancements it creates toward finding a cure would be a positive thing.

Last year, several US research groups announced they had received funding to explore the development and implantation of CCR-5 deficient stem cells.

But even if these techniques prove to be successful, they will no doubt be very expensive, meaning that they would be reserved for people with no treatment options left, or cancer patients already requiring a bone marrow transplant.

The 'Berlin Patient's' road to recovery was not an easy one -- he endured chemotherapy, immunosuppresive drugs and stem cell transplants -- but in the end, his tough journey could pave the way for advancements toward an eventual cure for HIV that all people can benefit from.

Source :
http://www.aolhealth.com/2010/12/14/doctors-claim-hiv-positive-patient-cured-by-stem-cells/

regards, taniafdi ^_^

iTwin USB filesharing solution now shipping in America

Hope you didn't put your life on pause waiting for the iTwin to ship to the US of A, 'cause it took just over a full year to do so. The company's self-named device has finally been listed for sale in America this week, with just 50 limited edition builds able to head out prior to Christmas. If your memory has faded somewhat over the past 14 months, this twin-stick solution is meant to pass files between two USB-enabled devices, but unlike Infinitec's IUM, it's not making any bold promises related to media streaming. The concept is simple enough; just plug one of the twins into your computer, and the other into your pal's computer. It relies on 256-bit AES encryption to keep things secure, and if that's good enough for you, the source link is the where you need to be. These first-run kits are selling for $99 (plus $10 shipping), with a choice of gunmetal gray and lime green awaiting you, and if you miss your shot now, general availability will hit early next month.

 

 

regards, taniafdi ^_^

Welcome to Social Networking

regards, taniafdi ^_^

Estrogen Alone is Effective for Reducing Breast Cancer Risk

Newswise — SAN ANTONIO — While endogenous estrogen (i.e., estrogen produced by ovaries and by other tissues) does have a well-known carcinogenic impact, hormone replacement therapy (HRT) utilizing estrogen alone (the exogenous estrogen) provides a protective effect in reducing breast cancer risk, according to study results presented at the 33rd Annual CTRC-AACR San Antonio Breast Cancer Symposium, held Dec. 8-12. 

“Our analysis suggests that, contrary to previous thinking, there is substantial value in bringing HRT with estrogen alone to the guidelines. The data show that for selected women it is not only safe, but potentially beneficial for breast cancer, as well as for many other aspects of women’s health,” said lead researcher Joseph Ragaz, M.D., medical oncologist and clinical professor in the faculty of medicine, School of Population and Public Health at The University of British Columbia, Vancouver, BC, Canada.

“These findings should intensify new research into its role as a protective agent against breast cancer,” he added.

Ragaz and colleagues reviewed and reanalyzed data from the Women’s Health Initiative (WHI) hormone replacement therapy trials. WHI is a national health study that focuses on strategies for preventing heart disease, breast and colorectal cancer, and fracture in postmenopausal women. The WHI was launched in 1991 and includes more than 161,000 U.S. women aged 50 to 79 years. 

“Over the last 30 years HRT has been used almost indiscriminately by women expecting the benefit of reducing cardiac risks, while providing a protective effect against bone fracture, and improving overall quality of life,” said Ragaz. “The WHI results as originally interpreted led to a major pendulum swing against HRT.”

The WHI HRT trial consisted of two cohorts of women; the estrogen-alone group of women without a uterus and the estrogen-plus-progestin group of women with a uterus. 

Ragaz and colleagues reanalyzed the WHI studies in more detail and found that subsets of women with no strong family history of breast cancer who received estrogen alone had a significantly reduced breast cancer incidence. In addition, the 75 percent of women without benign disease prior to the trial enrollment also had a reduced breast cancer risk. 

“Reduction of rates of breast cancer in the majority of women who are candidates for estrogen-based HRT is a new finding because estrogen was always linked with a higher incidence of breast cancer,” Ragaz said, “yet estrogen administered exogenously is actually protective for most women.”

Based on the results of this current analysis, Ragaz suggested that “while the use of HRT with estrogen alone may reduce the risk of breast cancer and may also be appropriate to manage menopausal symptoms, further research is warranted to elaborate on the optimum treatment regimen, to refine the selection of ideal candidates for estrogen therapy, and to understand the estrogen mechanisms that support the prevention of human breast cancer.” 

“The recommendations based on prior analyses of the results of the WHI HRT studies was not to use HRT, but we are optimistic this will change,” he said. “Our conclusion, based on the data presented, should enhance considerations for an early approval of HRT based on estrogen-alone for the majority of selected women suffering with menopausal symptoms and galvanize new research on HRT to define the optimum regimens for individual women.”

Source:

http://www.newswise.com/articles/view/571256/?sc=dwhp
regards, taniafdi ^_^

WOMEN, DEPRESSION AND OBESITY: WHAT'S EATING YOU?

Washington, DC (December 14, 2010) — The Society for Women’s Health Research (SWHR) presented the topical Capitol Hill briefing, Holiday Blues: Women, Depression and Obesity on Thursday, December 9, which featured four panelists detailing the links between depression and obesity.

Obesity is the newest health threat due in large part to American’s sedentary lifestyle and poor food choices. Co-morbidities of obesity include depression, heart disease, stroke, type II diabetes, hypertension, some cancers, osteoporosis and more. Sex differences in obesity play a role in fat distribution, higher financial burden on women, and incidence rates. According to the Centers for Disease Control, in 2008 33.2% of females were obese, with a body-mass index (BMI) of 30 or higher.

Belinda Needham, PhD, Assistant Professor and Director of Graduate Studies at the University of Alabama at Birmingham, spoke to the effects of obesity and depression, “17% of women will experience serious depression; females are two times as likely to be depressed as males, and women gain weight faster than men.” Needham presented findings from a community study to gauge the effects of obesity on depression and discovered women had higher BMIs at the start of the study and ended up larger than men at the end of the study. She concluded that depression led to weight gain and not the other way around.

“Elevated depressive symptoms affect over 25% of adolescents, and adolescent girls with elevated depressive symptoms are 2.5 times more likely to develop obesity at a later point in time compared to girls without depressive symptoms,” said Lauren B. Shomaker, PhD, Adjunct Scientist in the Unit on Growth and Obesity, National Institute of Child Health and Human Development. “Depressive symptoms lead to an increase in stress-induced eating, which results in obesity. And depression is theorized to alter physical fitness by a loss of pleasure in previously enjoyed physical activities.”

Fortunately, there are researchers leading studies to reverse this trend. Jay Breines, Executive Director, Holyoke Health Center, launched a pilot program at his health center in Holyoke, Mass. to combat obesity and teach proper nutrition and exercise habits to high-risk populations. His program integrated physicians, dentists, nurses, outreach workers, and promotoras among many others to provide a full care team for the participants to fight obesity and stop depression from taking hold. Breines closed with an advisory message to fellow community health organizers battling obesity, “We must engage at the community level to save money on our healthcare system.”

Christine Ferguson, Director, STOP Obesity Alliance and Research Professor, George Washington University School of Public Health and Health Services, outlined the obesity cost burden. Ferguson’s research team found the overall annual costs of being obese are $4879 for an obese woman and $2646 for an obese man. “There is a real, tangible economic impact for those women who are obese in our society,” said Ferguson. Obese women are paid less than average-weight women whereas obese men are paid the same as average-weight men. This can be partly attributed to social stigmatization and the already present gender wage gap.

“The key to obesity policy is to relate more to the health aspect, and less the aesthetic,” said Ferguson. Focusing on health versus looks may decrease depression and boost self-esteem. We need to support programs that target adolescents and teach healthy lifestyle habits in order to stave off depression as well as obesity.

Depression may lead to weight gain and vice versa, thus treatment for either should target both mind and body. Properly training physicians on weight-related issues, providing health and nutrition centers in high-risk communities, and focusing on the health aspects of obesity are just a few more ways to fight the fat and, in turn, defeat depression this holiday season and beyond.

source :

http://www.womenshealthresearch.org/site/News2?page=NewsArticle&id=11021

regards, taniafdi ^_^