Deaths from congestive heart failure among elders with normal systolic function
Many elders with congestive heart failure (CHF) retain normal systolic function. Researchers studied a population-based prospective cohort of 5888 people (65 or older) to determine the relation among CHF, systolic function, and death. At baseline, 5% of participants had CHF; among these, left ventricular systolic function as determined by echocardiography was normal in 63%, borderline (ejection fraction [EF], 0.45-0.54) in 15%, and impaired (EF, < 0.45) in 22%.
During 6 years of follow up, all-cause mortality was significantly higher among those with CHF than those without CHF (45% vs. 16%). Mortality rates were 25 per 1000 person-years in participants without CHF and with normal systolic function, 87 per 1000 person-years in participants with CHF and with normal systolic function, and 154 per 1000 person-years in participants with CHF and with impaired systolic function. Analyses that adjusted for relevant clinical variables confirmed the increased mortality associated with CHF regardless of systolic function.
Essentially, impaired systolic function usually suggests a poor prognosis, but normal systolic function does not eliminate the increased risk for death associated with CHF in elders.
This summation of the article “Outcome of congestive heart failure in elderly persons: Influence of left ventricular systolic function, The Cardiovascular Health Study” by Gottdiener et al (Ann Intern Med 2002;137:631-9), appeared in the December issue of Journal Watch .
Daily glucocorticoid use increases risk of spinal fractures
Daily dosing with oral glucocorticoids (corticosteroids) for chronic diseases was found to be a strong predictor of spinal fracture at 1 year, according to data presented last October at the annual scientific meeting of the American College of Rheumatology. The risk of fracture increased incrementally with every 1 mg increase above 7.5 mg in the daily dose of the glucocorticoid.
Up to half of patients on chronic glucocorticoid therapy may experience an osteoporotic fracture. In as few as 3 months, chronic use of steroids can cause significant bone loss, which could lead to fracture.
This study was sponsored by The Alliance for Better Bone Health, a partnership between Aventis and Procter & Gamble. For details, contact www.pgpharma.com .
Hematology experts warn of potentially fatal syndrome associated with heparin
Vascular specialists/hematologists from The Cleveland Clinic and other leading institutions are calling on physicians and other health care professionals to focus greater attention on recognizing and diagnosing heparin-induced thrombocytopenia (HIT), a serious immune reaction to heparin. An estimated 12 million patients per year receive heparin, and a significant number of casualties related to complications of HIT could be potentially avoided by early recognition.
Contrary to widespread belief, HIT is not a rare condition. It could occur in as many as 360,000 to 600,000 individuals (3%-5% of heparin users) each year, a number nearly twice that of new breast cancer cases diagnosed annually and nearly equal to the number of new cases of angina each year. Exact numbers are lacking because of a general underrecognition of the syndrome.
Because HIT is a potentially life-threatening condition, physicians need to be cautious and assume that a patient who develops absolute or relative thrombocytopenia (low platelet count) during or soon after heparin exposure has HIT until proven otherwise. Additional signs and symptoms of HIT include swollen and painful legs, abdominal pain and low blood pressure, and skin lesions, particularly at the site of heparin injection, as well as typical signs of heart attack (chest pain) or stroke (dizziness or slurred speech). For more information, visit www.clevelandclinic.org .
Task force issues caution on combined hormone therapy
The US Preventive Services Task Force has recommended against the use of combined estrogen and progestin therapy for preventing cardiovascular disease and other chronic conditions in postmenopausal women.
Sponsored by the Agency for Healthcare Research and Quality, the task force found evidence for both benefits and harms of combined estrogen and progestin therapy, one of the most commonly prescribed hormone regimens. However, the group concluded that harmful effects of the combined therapy are likely to exceed the chronic disease prevention benefits for most women.
The task force further concluded that the evidence is insufficient to recommend for or against the use of estrogen alone to prevent chronic conditions in postmenopausal women who have had a hysterectomy. A study of estrogen therapy in women who have had hysterectomies is continuing as part of the National Institutes of Health Women's Health Initiative because it has not yet found clear benefit or harm. Estrogen alone or estrogen and progestin together are commonly referred to as hormone therapy or hormone replacement therapy.
The task force concluded that combined hormone therapy could increase bone mineral density and reduce the risk of fractures and may reduce the risk of colorectal cancer. They found equally strong evidence, however, that combined hormone therapy increases the risk for breast cancer, blood clots, stroke, and gallbladder disease. In addition, evidence reviewed by the group suggests that hormone therapy does not reduce the risk of heart disease and that estrogen and progestin combined actually increase the risk of heart attacks. The effects of hormone therapy on dementia, cognitive function, and ovarian cancer are uncertain.
The hormone therapy recommendations and background evidence for clinicians are available at ***www.ahrq.gov/clinic/3rduspstf/hrt/hrtrr.htm .
Study of postmenopausal women with heart disease finds potential for harm from hormone therapy and antioxidant vitamins
A study sponsored by the National Heart, Lung, and Blood Institute (NHLBI) found that postmenopausal women with heart disease who took hormone therapy and high dose antioxidant vitamins, either alone or in combination with hormones, did not have fewer heart attacks, deaths, or progression of coronary disease. In fact, both treatments showed a potential for harm. Although the actual numbers of deaths in the study were small, participants taking both active hormones and vitamins had the highest death rate whereas participants on placebo versions of both treatments had the lowest death rate.
The results of the Women's Angiographic Vitamin and Estrogen (WAVE) trial were published in the November 20 JAMA.
“This study adds to the growing body of evidence that hormone therapy is not helpful in the treatment or prevention of heart disease, and it provides new information on the absence of benefit from high-dose antioxidant vitamins,” said NHLBI Director Claude Lenfant, MD.
WAVE, which studied 423 postmenopausal women at 7 clinical centers in the US and Canada, is the largest trial to use angiography (a special x-ray technique that shows blockages in the blood vessels of the heart) to assess the effects of hormone replacement therapy. It is also the first angiographic trial to look at antioxidants (high dose vitamins E and C) in conjunction with hormone therapy. The vitamin doses in the WAVE study were much higher than what is used in standard multivitamin preparations. More information is available at www.nhlbi.nih.gov .
Findings suggest revised approach to atrial fibrillation therapy
The preferred and most frequently used initial therapy for the common heart rhythm disorder atrial fibrillation (AF) is a strategy to restore and maintain a normal heart rhythm. However, a study supported by the National Heart, Lung, and Blood Institute (NHLBI) found that this heart rhythm strategy not only does not prevent more deaths than the alternative, often secondary, approach to treatment that merely controls the rate at which the heart beats but also may have some disadvantages, including more hospitalizations and adverse drug effects.
Results from the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial were published in the December 5 The New England Journal of Medicine . “The AFFIRM study has profound implications for the management of atrial fibrillation. For many physicians it should fundamentally alter their approach to treatment,” said Michael Domanski, MD, a cardiologist with the NHLBI and head of the institute's Clinical Trials Group. Visit www.nhlbi.nih.gov for details.
Ending hormone therapy leads to rapid bone loss in elderly women
Last July, researchers announced the ending of one portion of the Women's Health Initiative study as a result of evidence that questioned the safety and effectiveness of the estrogen-plus-progestin treatment in postmenopausal women. Now, researchers led by Dr. JC Gallagher at Creighton University have revealed that elderly women who stop taking hormone therapy experience significant losses in their bone mineral density (BMD). These losses could lead to severe osteoporosis and fractures.
“The recent hormone therapy findings in the WHT trial have caused many women to discontinue their treatments. However, until now we did not know how ending the hormone therapy would effect bone health,” said Dr. Christ-opher Gallagher, lead investigator on the study. “Our study demonstrates the critical need for these women to work with their doctors to monitor their bone health and to consider carefully the disadvantages of discontinuing hormone therapy and to also find alternative treatments to maintain their bone density if they decide to discontinue the therapy.” For more information, go to www.endo-society.org .
Evidence lacking on routine screening's ability to improve prostate cancer outcomes
Although screening for prostate cancer is part of a routine checkup for American men, a new finding issued in December from the U.S. Preventive Services Task Force concludes there is insufficient scientific evidence to promote routine screening for all men and inconclusive evidence that early detection improves health outcomes. The finding was published in the December 3 Annals of Internal Medicine .
The prostate cancer screening recommendation and materials for clinicians are available at www.ahrq.gov/clinic/3rduspstf/prostatescr . Previous task force recommendations, summaries of the evidence, easy-to-read fact sheets explaining the recommendations, and related materials are available from the AHRQ Publications Clearinghouse by calling (800) 358-9295 or sending an email to ahrqpubs@ahrq.gov . Clinical information is also available from the National Guideline Clearinghouse at www.guideline.gov .
Osteoarthritis linked to fluoride
Naturally fluoridated water is linked to knee osteoarthritis at levels lower than expected and in amounts many Americans consume daily, according to a study published in Rheumatology International , reports the New York State Coalition Opposed to Fluoridation (NYSCOF).
At high doses, fluoride, a well-known tooth and bone seeking element, undeniably damages bones and reportedly can cause arthritis. However, this study correlates knee osteoarthritis to fluoride at levels 1.9-3.6 mg/L that many Americans ingest daily from food, air, water, medicines, and dental products. For more information, visit www.orgsites.com/ny/nyscof .
What are the signs that your loved one may need long-term care?
Long Term Care Partners, which administers the federal Long Term Care Insurance Program sponsored by the U.S. Office of Personnel Management, suggests using this informal guidelines, the Independent Living Test, to assess whether a relative is at or near the point at which he or she would be unable to live independently.
Independent Living Test:
1.Are prescriptions not being refilled, resulting in failure to take medication when scheduled?
2.Has taking medication become difficult due to poor memory or confusion?
3.Have conditions previously under control become acute because medication is not being taken correctly?
4.Food and Groceries
1.Based on past food habits, are the cupboards frequently empty or being filled with unusual foods?
2.Is the food in the refrigerator often spoiled or kept long beyond the “use by” date?
3.Daily Business
1.Is the mail being picked up and opened regularly, or is it remaining uncollected or unopened?
2.Are credit cards or checkbook being misused or not balanced as well as in the past?
3.Social Contact
1.Has the amount of social contact changed dramatically, so that there are few public outings or limited social visits with close friends?
2.Has the ability to drive deteriorated? Is there a fear of driving or a recent history of multiple minor accidents that is leading to isolation?
3.Living Habits
1.Has there been a change in living habits, such as a change in dress or appearance, or a decline in personal hygiene not related to physical disability? Is dress appropriate for the weather?
2.Have housekeeping habits changed so that a normally neat and orderly home is now cluttered and not cleaned regularly?
3.Are pets that were normally well cared for suddenly not being fed or cared for as they had been in the past?
4.Solicitations Is there a sudden increase in ordering unnecessary items through mail or televised advertisements?
5.Calls to Family Members or Health Care Providers
1.Has there been a marked increase in panic calls to family or medical providers without apparent need?
2.Have unnecessary calls been made to 9-1-1?
More information is available at www.ltcfeds.com .
Resources
Abbott Laboratories has launched www.RA.com , an interactive Web site featuring the latest news, lifestyle issues, and resources for people with rheumatoid arthritis and their caregivers. RA.com is an interactive site that provides straightforward, unbiased information about RA, including facts and disease data, tips for recognizing RA, disease management tools, lifestyle issues, coping tips, an on-line catalog featuring products to make living with RA easier, and resource links.
CIGNA's PharmaAdvisor TM lets members make side-by-side comparisons of drug costs and effectiveness and empowers them to make more informed discussions with their physicians about choosing medications. The site will be available at no charge to virtually all CIGNA HealthCare members. PharmaAdvisor includes information on 11,000 generic and brand-name drugs and OTC drugs. As it rolls out, the tool will provide comparison information for drugs used to treat specific conditions, including acid reflux disease, allergies, depression, high blood pressure, high cholesterol, osteoarthritis, asthma, diabetes, ear infections, and migraine headaches. For details, visit www.mycigna.com .
The Medicare Rights Center playing cards better equip people to navigate through the Medicare maze and obtain the health care they need. Each card in the playable deck includes easy-to-read information on Medicare options, benefits, and rights; tips on preventive services covered by Medicare; how to appeal original Medicare and Medicare HMO decisions; how to get the best price for wheelchairs and other medical equipment; or what to consider when choosing a health plan. Two decks of cards cost $10 plus $3 for shipping. Bulk orders can be purchased at reduced rates and customized to include company name, logo, and message on the back of the cards. To place an order, call MRC at (800) 333-4114, ext. 39, or visit www.medicarerights.org .
The National Comprehensive Cancer Network has changed its Web site (www.nccn.org ) to allow physicians to more easily locate clinical trials. Physicians seeking new treatments for their patients with cancer often turn to clinical trials for answers. These research studies include trials testing new treatments, such as a new cancer drug or a new combination of drugs, new approaches to surgery or radiation therapy, or new therapies such as gene therapy or molecularly targeted therapy.
The Rehabilitation Nursing Foundation's Bowel Care Guidelines are now available in the resources section of the Association of Rehabilitation Nurses' Web site, www.rehabnurse.org .
American Society on Aging, in partnership with the Corporation for National and Community Service and Senior Corps, has a Senior Corps Web-Based Recruitment System for adults older than 55. This project connects older adults across the country with high quality volunteer opportunities in their communities. For more information, contact Valerie Jones at vjones@asaging.org or (415) 974-9602.
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