Clinical Briefs By Louis Kuritzky, MD
Clinical Briefs
By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville. Dr. Kuritzky is a consultant for GlaxoSmithKline and is on the speaker's bureau of GlaxoSmithKline, 3M, Wyeth-Ayerst, Pfizer, Novartis, Bristol-Myers Squibb, AstraZeneca, Jones Pharma, and Boehringer Ingelheim.
Effect of Lowering LDL Cholesterol Substantially Below Currently Recommended Levels in Patients with Coronary Heart Disease and Diabetes: the Treating to New Targets (TNT) Study
The TNT study (Treat to New Targets) demonstrated that intensive lipid lowering (ILL) with atorvastatin 80 mg/d in patients with stable coronary artery disease (CAD) provided more benefit than simply achieving an LDL of 100 mg/dL with atorvastatin 10 mg/d. This trial provided useful information because it came on the heels of the PROVE-IT trial, which had demonstrated that for persons with acute coronary syndromes, ILL provided greater risk reduction than modest LDL lowering. Whether patients with diabetes in the TNT trial enjoyed similar benefits from ILL had not been previously reported.
There were 1,501 diabetics in TNT. Those on atorvastatin 10 mg achieved a mean LDL of 98.6 mg/dL, compared to an LDL of 77.0 mg/dL for subjects on atorvastatin 80 mg. The lower LDL level was associated with a 25% relative risk reduction for a new primary event, defined as death from coronary heart disease, non-fatal MI, or stroke (103 events vs 135 events). Although all-cause mortality was slightly higher in subjects who received ILL, the difference was not statistically significant. Higher dose atorvastatin was not associated with any safety concerns.
Shepherd J, et al. Diabetes Care 2006;29:1220-1226.
Colonoscopy in Very Elderly Patients: Prevalence of Neoplasia and Estimated Impact on Life Expectancy
In contrast to guidance available for clinicians in reference to cessation of screening tools like PAP tests, where there is age-specific direction offered, the current guidelines on screening colonoscopy (sCOL) do not provide any age limit. Colon cancer incidence increases with age, so the yield of screening older persons would be anticipated to be greater than younger individuals. However, at advanced age life expectancy decreases, such that quantifying potential benefits must take age into account.
Lin et al, performed a cross-sectional study (n = 1,244) of sCOL in three groups divided by age: 50-54 years, 75-79 years, and > 80 years. Outcomes of the study included colonic neoplasia detected and gain in life expectancy, with comparisons between age groups.
There was a linear relationship between age and prevalence of neoplasia: 13.8% (age 50-54), 26.5% (age 75-79), and 28.6% (age > 80). Nonetheless, mean gain in life expectancy was substantially lower (6.5-fold lower!)in the oldest age group than the youngest.
Even though sCOL did provide gains in life expectancy, the results were markedly less substantial in the most aged seniors. These data do not provide evidence for any age limit to appropriate use of sCOL. Rather, they may assist in weighing the risk-benefit ratio for sCOL in older persons, depending upon their anticipated life expectancy, individual health issues, and personal preferences.
Lin O, et al. JAMA. 2006;295:2357-2365.
Is There an Iraq War Syndrome? Comparison of the Health of UK Service Personnel after the Gulf and Iraq Wars
The so-called Gulf War Syndrome (GWS) is an ill-defined umbrella term to describe the non-specific health complaints registered by armed forces personnel who served in this conflict. Subsequent to the 1991 Gulf War, data from the United States, United Kingdom, Canada, Denmark, and Australia corroborated increases in symptomatic disease, although no clearly-defined syndromic definition evolved. Indeed, it has been opined that the symptoms attributed to the Gulf War may simply be consistent with other issues such as emotional stress and new vaccinations.
Subsequent to the Gulf War, the UK Ministry of Defense funded a project to provide detailed surveillance of health issues for personnel serving in Iraq post the 2003 invasion. In addition to a checklist of the same 50 non-specific symptoms used in GWS screening, they also assessed fatigue (with a validated 13-item scale) and general health (with an item from the SF-36).
In contrast to personnel from the Gulf War, UK personnel in Iraq did not demonstrate any evidence of health effects. It is reassuring to note that heightened surveillance does not detect an "Iraq syndrome."
Horn O, et al. Lancet. 2006;367:1742-1746
The TNT study (Treat to New Targets) demonstrated that intensive lipid lowering (ILL) with atorvastatin 80 mg/d in patients with stable coronary artery disease (CAD) provided more benefit than simply achieving an LDL of 100 mg/dL with atorvastatin 10 mg/d.Subscribe Now for Access
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