Clinical Briefs By Louis Kuritzky, MD
Clinical Briefs
By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville. Dr. Kuritzky is an advisor for Endo, Kowa, Pricara, and Takeda.
Supplementation in Older Adults with Wounds
Source: Sallit J. Rationale for zinc supplementation in older adults with wounds. Ann Long-Term Care: Clin Care Aging 2012;20:39-41.
Zinc deficiency is defined as a serum zinc level < 60 mg/dL. Unfortunately, there is some question about the reliability of zinc levels to accurately reflect zinc status, since some persons with prototypic symptoms of zinc deficiency (loss of appetite, diarrhea, hair loss, delayed wound healing, and smell and taste disturbances) have normal zinc levels. Residents of long-term care facilities are at risk for zinc deficiency, both because they may be consuming diets that are lower in zinc and also because they may not absorb zinc from the diet as well as younger persons. For instance, one clinical trial of patients from nursing homes (n = 617) found that almost half had subnormal zinc levels. Some medications can compound the issue diuretics can deplete zinc.
The roles of zinc in wound healing are diverse, including collagen and protein synthesis, cell proliferation, and immune function. The body's demands for zinc are thought to increase at the time of injury, and continue through the early inflammatory phase; hence, zinc deficiency at this time can delay wound healing.
When a long-term care facility resident sustains a wound, although it is reasonable to ascertain zinc status through serum levels and treat accordingly, it appears equally reasonable based upon a high level of suspicion of zinc deficiency to simply supplement zinc at moderate doses (15-30 mg/d), since such dosing is well tolerated. Indeed, a clinical trial at slightly higher supplementation doses (25-50 mg/d × 3 months) has documented a beneficial effect on wound healing in zinc- deficient individuals. The authors suggest that 40 mg/d be the maximum dose administered to non-deficient persons, due to tolerability issues (diarrhea, nausea, vomiting, vertigo).
Association of Psoriasis with CV Risk Factors
Source: Shapiro J, et al. Psoriasis and cardiovascular risk factors: a case-control study on inpatients comparing psoriasis to dermatitis. J Am Acad Dermatol 2012;66:252-258.
In the last decade, the recognition that rheumatoid arthritis (RA) is associated with adverse cardiovascular (CV) outcomes has been increasingly highlighted, to the point that some voices suggest including the presence of RA as a formal CV risk factor of similar impact to having a low HDL. Psoriasis (PSR) and RA share some common features, especially including their responsiveness to similar disease-modifying therapies, suggesting common pathophysiology. The mechanism by which RA imparts increased CV risk is unclear, though it is commonly attributed simply to the deleterious effects of chronic inflammation. Might PSR also be associated with CV risk?
To examine this issue, Shapiro et al performed a case-control study that compared PSR inpatients (n = 1079) to age- and gender-matched inpatient controls who had other non-psoriatic dermatitis issues, such as atopic dermatitis and contact dermatitis (n = 1079).
Multivariate logistic regression found that PSR was associated with greater odds ratio (OR) for diabetes (OR = 1.43) and hypertension (OR = 1.31). Although PSR was associated with CVD, the association was no longer present when correcting for obesity and hypertension. Although the pathogenesis of increased CV risk associated with PSR is uncertain, the fact that PSR produces systemic effects on tumor necrosis factor alpha and other inflammatory markers may be critically linked.
Occupational Stress and Hypertension
Source: Rosenthal T, Alter A. Occupational stress and hypertension. J Am Soc Hypertens 2012;6:2-22.
The consequences of job-related stress (JRS) have been the object of a great deal of research. Of course it is difficult to determine the best measurement tool for JRS, and it is equally difficult to explain how similar levels of JRS are interpreted and managed differently by different individuals. Some of the data on JRS and its relationship to blood pressure suggest that JRS need not necessarily be perceived to be associated with adverse effects. Nonetheless, several lines of evidence lead to the conclusion that identification of JRS is replicable and consequential in some settings.
For instance, a review of data from 34 studies on professional drivers (e.g., bus drivers) found a consistently increased risk of heart disease and hypertension, attributed to a wide range of psychological and physical stressors. To describe the inherent stressful conflict of bus drivers, the authors remind us that the drivers are constantly dealing with the competing agendas of staying on time and optimizing safety.
Despite the large amount of descriptive data that help us identify the negative impact of job stress on health, there is little substantive information that anyone has found highly effective methods to improve outcomes from JRS. It is likely that reducing JRS and its consequences will require interventions on a public health level.
Zinc deficiency is defined as a serum zinc level < 60 mg/dL. Unfortunately, there is some question about the reliability of zinc levels to accurately reflect zinc status, since some persons with prototypic symptoms of zinc deficiency (loss of appetite, diarrhea, hair loss, delayed wound healing, and smell and taste disturbances) have normal zinc levels.Subscribe Now for Access
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