Clinical Briefs-By Louis Kuritzky, MD
Clinical Briefs-By Louis Kuritzky, MD
Incidence Trends for Colorectal Cancer
Clinicians use a variety of tools to screen for colorectal cancer, including rigid sigmoidoscopy, flexible sigmoidoscopy, and colono-scopy. Success of such methods is predicated upon tumors being resectable and within the reach of the tool used. There has been literature support for the observation that tumor geography is shifting such that "left-sided" tumors (i.e., located in the sigmoid colon and more distal, excluding the anus) are becoming less frequent, and "right-sided" tumors (i.e., proximal to the sigmoid colon) more common. Flexible sigmoidoscopy, which detects left-sided tumors, maintains its viability only so long as a sufficient proportion of disease burden remains within the 65 cm range. If tumor burden geographically shifts sufficiently, choice of screening tool will be directly affected.The purpose of the current study was to examine, by means of analysis of the California State Cancer Registry, the incidence of left-sided and right-sided colon cancers. It would be anticipated that sigmoidoscopy would favor reduction in incidence of left-sided cancers.
Overall, colorectal cancer incidence decreased steadily by 19% over 10 years, but left-sided cancers decreased more than twice as much as right-sided tumors. A good deal of this left-sided cancer reduction is attributed to sigmoidoscopic screening and subsequent tumor resection. Inciardi et al posit that the increased frequency of right-sided colorectal cancers should stimulate consideration of modification of screening processes, in essence to more frequently use colonoscopy as the routine screening tool. Inciardi JF, et al. Am J Med 2000; 109:277-281.
Osteoporotic Fractures Study
The public health as well as personal effect of osteoporosis (OSPS) and its sequelae remains abundant. The last five years have seen a proliferation of available tools to combat and prevent this disorder, including agents shown to effectively reduce fractures in subjects at risk for glucocorticoid-induced OSPS in both genders. Calcitonin (CTN) has demonstrated an ability to decrease bone resorption and improve or stabilize bone mineral density (BMD) in osteoporotic patients. Since BMD is a surrogate end point, and the patient and clinician alike are ultimately concerned with fracture reduction efficacy, the issue that no large, randomized, prospective trial of CTN for fracture reduction has been performed may have been a limiting factor in therapeutic selection of this agent for treatment of OSPS. To that end, the Prevent Recurrence of Osteoporotic Fractures (PROOF) study (n = 1255) was undertaken.Subjects were randomized to receive either calcitonin nasal spray at doses of 100-400 IU daily, or placebo, in addition to 1000 mg/d calcium supplements and 400 IU vitamin D daily. Inclusion criteria were postmenopausal status, and presence of either vertebral fractures or BMD greater than 2 standard deviations below normal. Patients were followed for five years.
Use of CTN (200 IU/d) resulted in a 33% reduction in new vertebral fractures, even in persons without a major effect on BMD. Whether CTN reduces fracture through decreased bone turnover, improved bone quality, improved bone strength, improved bone mineralization, or some combination of such factors remains to be determined. Chesnut CH, et al. Am J Med 2000; 109:267-276.
Periodontal Disease and CHD Risk
Atherosclerosis, at its most fundamental level, is felt to be an inflammatory disease. Much attention has recently been focused upon the associations observed between disorders like periodontitis and gingivitis with cardiovascular end points such as myocardial infarction (MI). Since MI, gingivitis, and periodontal disease all occur with increasing age, increased duration of smoking, and increased body fat, it has been unclear whether the association of oral disorders and coronary disease is causal, or merely concomitant.In order to better define this relationship, Hujoel et al studied data from the 1971-1975 NHANES 1 study (n = 8032). Addressing status of participants for the presence or absence of periodontitis or gingivitis at baseline, the population of adults age 26-74 who were followed through 1992 in whom a first MI occurred. Each of the participants underwent a general history and physical examination, laboratory tests, and a dental examination.
Gingivitis at baseline was not associated with cardiovascular risk; the presence of periodontitis was associated with a trend toward greater coronary heart disease, but this association did not achieve statistical significance. Since this study is the largest to date to address this issue, it is felt that the association of poor oral health with cardiovascular end points, if any, must be small. On the other hand, even if the absolute contribution to cardiovascular risk is small since periodontitis is a common disorder, future studies addressing larger populations might better delineate the potential for effect on end points like MI. Hujoel PP, et al. JAMA 2000;284: 1406-1410.
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