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22-07-2012 | Article

Global medical news in review: July 15-21, 2012

MedWire News: A roundup of select stories of interest to US physicians from the MerckMedicus Medical News wire.

Some older patients regret prostate cancer treatment

Men with cardiovascular (CV) disease are significantly more likely to regret their prostate cancer treatment choice than men without this comorbidity, and have an increased risk for adverse effects, US researchers warn in BJU International.

"This study highlights the growing importance of considering comorbidity when counselling patients about prostate cancer treatment options, and provides a rationale for men with [CV] comorbidity to give additional consideration to active surveillance for their newly diagnosed prostate cancer," says Paul Nguyen (Dana Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts).

Overall, 14.8% of 795 patients with biochemical cancer recurrence included in the Comprehensive, Observational, Multicenter, Prostate Adenocarcinoma (COMPARE) registry reported treatment regret a median of 5.5 years after treatment. The patients had undergone prostatectomy (n=410), external beam radiation (n=237), brachytherapy (n=124), or androgen deprivation therapy (n=24).

Almost a third (30.6%) of the patients had CV disease, such as myocardial infarction, congestive heart failure, angina, diabetes, stroke, or circulation concerns. These patients were significantly more likely to experience bowel toxicity related to treatment than those without CV comorbidity (44.4 vs 35.8%).

Noting that younger age (odds ratio=0.97 per year increase in age) also predicted regret, the researchers say these patients may regret choosing a conservative treatment that missed the opportunity of a cure.

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Physician-targeted intervention could reduce depression in elderly

Older patients whose physicians take part in a practice audit and education-based intervention have reduced odds for depression and self-harm at 24 months ‑ significantly so in the case of self-harm, show results of an Australian trial.

The effect of the intervention was primarily due to the relative reduction of self-harm behavior among patients who were symptomless at baseline, say the researchers.

As reported in the Annals of Family Medicine, the study involved a total of 21,762 adult patients aged a mean 71.8 years, under the care of 373 general practitioners, of whom 188 (n=11,402 patients) were randomly assigned to the intervention, and 185 (n=10,360 patients) to a control group.

The intervention involved distribution of printed material concerning practical aspects of assessment and management of depression and self-harm in later life, a practice audit of 20 active patients with detailed feedback, and newsletters outlining the progress of the study relative to physicians' individual practices.

Physicians in the control group took part in the practice audit, but only received pooled feedback data, and received no printed educational material.

After adjustment for potential confounders including patients' baseline depression and self-harm scores (measured on the Patient Health Questionnaire and the Depressive Symptom Index Suicidality Subscale, respectively), those under the care of physicians in the intervention group were 10% less likely to experience either outcome after 12 and 24 months than controls.

The effect of the intervention on depression was not significant (odds ratio=0.93), report Osvaldo Almeida, from the University of Western Australia, Perth, and colleagues. However, the effect of the intervention on patients' suicide ideation or attempts over 24 months was significant, with a reduction of 20% compared with the control group.

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As if hemorrhoids were not enough…

Men may be more likely to suffer from erectile dysfunction (ED) if they have previously been diagnosed with hemorrhoids, particularly if they are aged under 40 years, report researchers.

Herng-Ching Lin (Taipei Medical University, Taiwan) and colleagues conducted an analysis showing that 1572 (24.9%) of 6310 individuals who had been diagnosed with ED between January 2001 and December 2009 had also previously received a diagnosis of hemorrhoids. However, of 31,550 individuals who were matched for age and index year and who did not have ED, only 4491 (14.2%) had previously been diagnosed with hemorrhoids.

Logistic regression analysis showed that the men who had ED were 90% more likely than those who did not have it to have previously suffered from hemorrhoids.

Further analysis by age group revealed that the association was strongest among younger men, write Lin et al in the International Journal of Andrology.

Indeed, of the men with ED, those aged less than 30 years were 3.71 times more likely to have previously experienced hemorrhoids than their age-matched controls, while those aged 30‑39 years and 40‑49 years were 2.39 and 1.69 times more likely, respectively, compared with their age-matched controls.

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Alzheimer's roots go way back

The pathologic process of Alzheimer's disease (AD) begins more than 20 years before clinical symptoms become apparent, say researchers.

Their conclusions are drawn from analysis of the Dominantly Inherited Alzheimer Network, a worldwide network of centers treating patients with autosomal dominant AD. This yielded 128 patients with a known mutation for AD.

The earliest change in these patients was a decline in levels of amyloid-beta in the cerebrospinal fluid relative to those in control participants without AD mutations. This occurred at about 25 years before the expected age of symptom onset, defined as the age at which participants' parents had first developed clinical symptoms (45.7 years on average). The participants developed mild dementia an average of 3.3 years after the age of parental onset.

However, significant differences in Mini-Mental State Examination scores between patients and controls appeared from 5 years before the patients were diagnosed with dementia.

"These findings suggest that the diagnosis of clinical dementia is made late in the course of the biologic cascade of autosomal dominant Alzheimer's disease," Randall Bateman (Washington University School of Medicine, St Louis, Missouri) and colleagues write in The New England Journal of Medicine.

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Disabled children at risk for violence

Children with disabilities are significantly more likely to be victims of violence than those who are not disabled, suggest findings from a systematic review and meta-analysis of published studies.

"The impact of a child's disability on their quality of life is very much dependent on the way other individuals treat them. This research establishes that the risk of violence to children with disabilities is routinely three to four times higher than that of non-disabled children," said lead study author Mark Bellis (Liverpool John Moores University, UK) in a press statement.

Bellis and team identified 17 studies with estimates of prevalence of violence against individuals aged 18 years or younger with disabilities, relative to their peers without disabilities.

Prevalence rates of violence against children with disabilities were reported in 16 studies, including a total of 14,721 individuals. Pooled prevalence estimates were 26.7% for combined violence measures, 20.4% for physical violence, 18.1% for emotional abuse, 13.7% for sexual violence, and 9.5% for neglect.

When the researchers assessed the prevalence of violence in children with mental or intellectual disabilities, they found a pooled prevalence of 26.8% for physical violence, 26.7% for emotional abuse, 21.2% for any violence, 14.5% for sexual violence, and 7.8% for neglect, they report in The Lancet.

Estimates for violence risk were then calculated from 11 studies including a total of 13,505 children with disabilities, who were found to have a 3.68-, 3.56-, and 2.88-fold increased risk for any type of violence, physical violence, and sexual violence, respectively, compared with nondisabled children.

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Effect of PPIs on clopidogrel is minimal

The interaction between proton pump inhibitors and clopidogrel is "clinically unimportant," say researchers in the BMJ .

Ian Douglas (London School of Hygiene and Tropical Medicine London, UK) and co-workers found an association between proton pump inhibitor use and myocardial infarction (MI) in patients prescribed clopidogrel and aspirin.

Moreover, there was no association with MI for the other 2C19 inhibitors ‑ fluoxetine and paroxetine ‑ or non-2C19 inhibitors ‑ citalopram and ranitidine ‑ in these patients.

"The use of a proton pump inhibitor with clopidogrel and aspirin is well proved to prevent harm through gastrointestinal bleeding, and we should continue to consider proton pump inhibitors as important prophylactic drugs in patients at high risk," the authors write.

Of the 24,471 patients prescribed clopidogrel and aspirin who were included in the study, 12,439 (50%) were also prescribed a proton pump inhibitor at some point.

Death or MI occurred in 1419 (11%) patients while they received a proton pump inhibitor compared with 1341 (8%) patients who did not receive one.

Multivariate analysis showed that the hazard ratio (HR) for the association between proton pump inhibitor use and death or incident MI was a nonsignificant 1.37.

Similar results were seen when the authors looked at the secondary outcomes of the study with exposure to drugs other than proton pump inhibitors that would not be expected to interact with clopidogrel.

Indeed, the results were comparable between other 2C19 inhibitors and non-2C19 inhibitors for these outcomes, at HRs ranging from 1.13 to 1.73, and 1.14 to 1.84, respectively.

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Iron supplements for unexplained fatigue in women

Iron deficiency may be underdiagnosed in women of child-bearing age who report considerable fatigue, say researchers whose randomized controlled trial results show a significant reduction in fatigue after women took iron supplements.

Specifically, the team reports an almost 50% fall in mean scores on the Current and Past Psychological Scale (CPPS) for fatigue in women assigned to iron supplementation for 12 weeks, compared with a 29% drop in their counterparts given a placebo ‑ a significant difference.

None of the women were anemic at study baseline: all had hemoglobin levels of at least 12.0 g/dL, although they had borderline low ferritin levels (under 50 µg/L), remark the researchers.

"If fatigue is not due to secondary causes, the identification of iron deficiency as a potential cause may prevent inappropriate attribution of symptoms to putative emotional causes or life stressors, thereby reducing the unnecessary use of health care resources, including inappropriate pharmacologic treatments," suggest Bernard Favrat (University of Lausanne, Switzerland) and colleagues.

They randomly assigned 198 women aged between 18 and 50 years who reported fatigue levels of at least 6 on a Likert scale of 1‑10, and had no known pathology that could explain it, to either 80 mg/d oral prolonged-release ferrous sulfate (n=102) or placebo (n=96) for 12 weeks.

CPPS and global fatigue index scores (as measured by the multidimensional assessment of fatigue scale) improved by a significant 3.5 and 4.0 points, respectively, in women treated with iron supplements compared with their peers who received placebo.

However, the women's anxiety and depression scores ‑ other quality of life indicators not directly related to fatigue ‑ were unaffected by treatment assignment, write Favrat et al in the Canadian Medical Association Journal.

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By Neil Osterweil