Your Family Physician

Young people with asthma have nearly twice the incidence of depression compared to their peers without asthma, and studies have shown that depression is associated with increased asthma symptoms and, in some cases, death.

How stress and depression play upon one another to worsen asthma is a lingering question.

A new study by researchers at the University at Buffalo has shown that depressed children with asthma exhibit a dysregulation of the autonomic nervous system along with increased airway compromise.

It is thought to be the first study to examine pathways linking emotional stress, depressive symptoms, autonomic nervous system dysregulation and airway function in childhood asthma.

The study appears in the July 2009 issue of The Journal of Allergy and Clinical Immunology.

Bruce D. Miller, M.D., and Beatrice L. Wood, Ph.D., professors of psychiatry and pediatrics in the UB School of Medicine and Biomedical Sciences, designed and carried out the study in collaboration with other UB researchers.

"The autonomic nervous system, or ANS, is composed of two opposing divisions -- the sympathetic and parasympathetic nerves, which check one another and thus control critical body functions outside of conscious awareness," explained Miller, chief of the UB Division of Child & Adolescent Psychiatry and senior staff psychiatrist at Women & Children's Hospital of Buffalo, a UB-affiliated teaching hospital. "The ANS is influenced by stress and emotions."

"Children with asthma and high depression symptoms showed a preponderance of parasympathetic over sympathetic nervous system reactivity in the ANS," he continued. "This imbalance within the ANS could explain the increased airway resistance that we found in depressed asthmatic children in our study."

The study involved 90 children with asthma, aged 7-17. Forty-five asthmatic children with symptoms of depression were compared with 45 asthmatic children without symptoms of depression. Both groups viewed scary, sad (death) and happy scenes from the movie E.T.: The Extraterrestrial.

All children wore electrodes to collect data on heart and respiratory function, which showed the level of activation and reactivity of the sympathetic and parasympathetic divisions. The researchers assessed airway function before the movie, after the death scene and after the movie.

"The depressed group consistently showed greater parasympathetic activation along with decreased sympathetic activation in response to the emotional provocations – a pattern that would have a detrimental effect on the airways," said Miller.

"In contrast, the group without symptoms of depression showed consistent activation of the sympathetic pathway, which would support better airway function under stress. To our knowledge, this is the first report in the literature to demonstrate an association linking stress, depression and increased airway resistance in asthmatic children."

Results also showed that bias toward parasympathetic reactivity was most pronounced in the children during scenes portraying family distress or loss, death and dying.

"These findings reinforce previous results from our laboratory that associated relational stress within the family with child depression and increased asthma activity," said Wood.

"Although these findings are promising and support our hypotheses," she continued, "we need further studies to replicate and extend these findings, and to examine whether treatment for depression reduces shift to the parasympathetic and improves lung function in children with asthma."

The authors believe these findings indicate the importance of screening children with asthma for depressive symptoms, of following these children closely and referring them for psychosocial counseling when indicated.

Co-authors on the study were Mark Ballow, M.D., an asthma specialist from the UB Department of Pediatrics; ChiunYu Hsu, a student in the UB Neuroscience Graduate Program, and JungHa Lim, Ph.D, formerly a UB post-doctoral student, and currently on the faculty at Korea University.

Source : http://www.sciencedaily.com/releases/2009/07/090716113352.htm

For the treatment of women with heavy menstrual loss, microwave endometrial ablation (MEA) has "many advantages" over transcervical resection of the endometrium (TCRE), clinicians from the UK conclude based on results of a long-term follow-up study.

"Not only is MEA as effective at reducing menstrual symptoms, it achieves higher levels of satisfaction and acceptability, is simple to learn, faster to perform, less expensive, and is acceptable under local anesthetic and acceptable for use in the outpatient setting," they note in the July issue of BJOG: An International Journal of Obstetrics and Gynaecology.

In the paper, Dr. Kevin G. Cooper and colleagues from Aberdeen Royal Infirmary, UK, report outcomes at a minimum of 10 years post-procedure in 129 women who underwent MEA and 134 who underwent TCRE for heavy menstrual loss. All of the women had similar baseline characteristics.

According to the report, 77 MEA-treated women (60%) and 70 TCRE-treated women (52%) reported being "totally or generally" satisfied with treatment; "the difference is not statistically significant," the study team notes.

Bleeding and pain scores were highly significantly reduced and similar following both MEA and TCRE, achieving amenorrhea rates of 85% and 88%, respectively.

After 10 years, significantly fewer women in the MEA arm than the TCRE arm had had a hysterectomy (17% versus 28%).

"With the known operative advantages, lower costs and fewer hysterectomies, it is clear that MEA is more effective and efficient treatment for heavy menstrual loss than TCRE," Dr. Cooper and colleagues conclude.

"Although not quite as versatile as TCRE," they note, "it can also treat the majority of endometrial cavities including those with cavities up to 12 cm and those with nonobstructing submucosal fibroids."

Source : http://www.medscape.com/viewarticle/705481?src=mpnews&spon=34&uac=133298AG

Oral sex and open-mouthed kissing increase the risk of acquiring oral infections of human papillomavirus (HPV), according to a report in the May 1st issue of The Journal of Infectious Diseases.

"Performing oral sex is not without risks," Dr. Maura L. Gillison commented to Reuters Health. "It is associated with sexually transmitted infections, such as gonorrheal pharyngitis, that are immediately symptomatic, and now is associated with oral HPV infections that are asymptomatic yet may lead to oral cancer 10-20 years later."

Dr. Gillison from The Ohio State University, Columbus, and colleagues explored whether sexual behaviors were associated with the odds of oral HPV infection in adult 332 outpatients and in 210 college-aged men. Oral samples were collected and purified DNA was analyzed for 37 HPV types.

The investigators found that 4.8% of adult outpatients and 2.9% of college-aged men had oral HPV infection.

Among adult outpatients, the odds of oral HPV infection were significantly elevated among current tobacco smokers and among individuals who reported having either more than 10 oral or more than 25 vaginal sex partners during their lifetime.

Similar risk factors applied to the college-aged men. For them, having at least 6 recent oral sex or open-mouthed kissing partners and being older were independently associated with increased odds of developing oral HPV infection.

For the 28% of college-aged men who reported never having performed oral sex, having at least 10 lifetime or at least 5 recent open-mouthed kissing partners was associated with a significantly higher risk of developing oral HPV infection.

"Our data suggest that oral HPV infections that could predispose to cancer may be transmitted by very common behaviors such as open-mouth or 'French' kissing," Dr. Gillison concluded.

"Given that the (HPV) vaccine does not have any therapeutic value against pre-existing infections, this may be relevant to the timing of administration of vaccination," Dr. Gillison said. "Although the CDC recommends that the vaccine be administered between the ages of 9 and 12 ideally, in practice it is often administered to girls between the age of 14-16. Oral exposure may have occurred prior to that age."

J Infect Dis 2009;199:1263-1269.

Source : http://www.medscape.com/viewarticle/702692

Best Evidence Reference

Lucas M, Asselin G, Merette C, Poulin M, Dodin S. Ethyl-eicosapentaenoic acid for the treatment of psychological distress and depressive symptoms in middle-aged women: a double-blind, placebo-controlled, randomized clinical trial. Am J Clin Nutr. 2009;89:641-651.

Abstract

This study was selected from Medscape Best Evidence, which uses the McMaster Online Rating of Evidence System. Of a possible top score of 7, this study was ranked as 6 for newsworthiness and 7 for relevance by clinicians who used this system.

Summary

Depression affects women disproportionately compared with men, and symptoms of psychological distress may be particularly prevalent during the perimenopausal period. The current study of ethyl-eicosapentaenoic acid for the management of psychological distress among middle-aged women produced primarily negative results, which is consistent with other clinical trials of fish oil for depression. At this time, there is insufficient evidence to recommend fish oil for the treatment of depression.

Background

Depression is one of the most significant international public health problems today, and it affects women disproportionately. The lifetime prevalence of major depression among women varies widely with the population studied, but it is generally between 6% and 17%.^[1] Depression is 1.5 to 3 times more common among women compared with men, and a report from the World Health Organization (WHO) identified depression as the leading cause of disease-related disability among women around the world, with rates of disability 50% higher than among men.^[2]

While the gender difference in the prevalence of depression is evident by adolescence, the question of whether depression is particularly more common during perimenopause and menopause is controversial. Research suggests that rates of depressive symptoms increase in the year prior to and following women's last menstrual period, with a peak prevalence of psychological distress in 28.9% of women in early menopause.^[3] However, some epidemiologic studies have demonstrated no increase in the risk for depression among women at midlife, and there also does not appear to be an increased prevalence of depression in the postmenopausal vs premenopausal period.^[4]

Women have many options to treat depression and its symptoms, but many women may prefer treatment that does not require a prescription. In one study from Finland, 35.4% of a large population-based sample reported the use of complementary and alternative medicine.^[5] Women were more likely to use complementary medicine compared with men, and the presence of depression and anxiety disorders was positively associated with the use of complementary medicine as well.

One popular treatment women may consider for a variety of health benefits is fish oil, and fish oil has some evidence of efficacy in the treatment of depression. In a small study of patients with major depression, the addition of ethyl-eicosapentaenoic acid (E-EPA) to conventional antidepressant therapy significantly improved depression rating scores by week 3 compared with placebo.^[6] On a larger scale, epidemiologic studies suggest that societies that consume higher amounts of fish and omega (n)-3 fatty acids have lower rates of depression.^[7]

Current Trial

The current study examines the effects of E-EPA as monotherapy among middle-aged women with psychological distress. Women between the ages of 40 and 55 years were eligible for study participation. All participants had moderate-to-severe psychological distress, as measured by a score of 72 or less on the Psychological General Well-Being Schedule (PGWB). Women with severe depression were excluded from study participation, as were those who had been in menopause for over 5 years. However, women who met criteria for major depression were allowed into the trial.

Study participants were randomized to receive either E-EPA n-3 fatty acid supplementation or placebo as 500-mg capsules 3 times daily for 8 weeks. The study was double blind, and a small dose of regular fish oil was added to the placebo tablets to mimic any fish taste of the active treatment.

The main study outcome was the change in the PGWB. Researchers also followed multiple other depression rating scales.

One hundred twenty women underwent randomization, and 106 participants provided data at 8 weeks. The number of women dropping out of the study protocol was higher in the placebo compared with the E-EPA group.

Baseline data were similar when comparing randomized groups, except the percentage of women who met criteria for a major depressive episode was higher in the placebo (26.2%) compared with the E-EPA (22%) group. The mean age of participants was 48 years, and three quarters of the women had a college education or more. Nearly half of the women reported being physically active at least 3 times per week, and 20% were smokers.

Over 80% of participants took at least 80% of the study treatments, with no difference between treatment groups. Furthermore, blood tests confirmed that red blood cell concentrations of polyunsaturated fatty acids (PUFAs) increased in the E-EPA group and remained stable in the placebo group during the study period.

While 50% and 6% of women receiving E-EPA and placebo, respectively, noted a fishy taste of the capsule, there was no significant difference between groups in correctly guessing their assigned treatment. Beside the fishy taste, more women receiving E-EPA reported constipation as an adverse event during the study period.

Mean baseline scores on the PGWB indicated that 63.8% were under severe psychological distress, and 36.2% women were experiencing moderate distress. At 8 weeks, the PGWB score improved to a similar extent in both treatment groups. Similarly, the overall scores on the depression scales improved slightly in both the E-EPA and placebo groups.

Despite these negative main results, E-EPA was more successful in improving both psychological distress and depression scores in the subgroup of women without a major depressive episode. However, placebo therapy was associated with better performance compared with E-EPA among women with major depression.

Commentary

The study discussion focuses on the benefit of E-EPA among women without major depression, although this ignores the fact that this was a largely negative trial. E-EPA failed to improve the main study outcome compared with placebo, and placebo was actually more effective than E-EPA among women with major depression. This latter result particularly calls into question any benefit of E-EPA in this population.

The negative results of this trial are consistent with larger studies of fish oil for depression. In one 12-week trial comparing EPA and docosahexaenoic acid (DHA) with placebo among 218 patients with mild to moderate depression, the active treatment was not associated with improved mood, mental health, or cognitive function outcomes.^[8] In addition, another trial by Grenyer and colleagues^[9] of 83 patients receiving oral antidepressants failed to demonstrate any benefit of fish oil supplementation compared with placebo, despite evidence of good compliance with study treatment. Finally, a trial of EPA plus DHA among 302 community-dwelling older adults failed to improve depression scores or mental well-being compared with placebo.^[10] In this trial, both low-dose and high-dose fish oil supplementation were ineffective after a fairly long (26 weeks) intervention.

There are mixed results in reviews of supplementation with PUFAs for depression. One review published in 2006 noted that EPA improved depression in 4 of 7 randomized trials.^[11] In all of the positive trials, EPA was added to existing antidepressant or mood-stabilizing medications. Another systematic review of 18 randomized controlled trials found limited effects of PUFAs on depression and significant heterogeneity of results due to publication bias in the accumulated scientific literature.^[12] Finally, a meta-analysis from 2007 found that omega-3 PUFAs did have a significant antidepressant effect among patients with either depression or bipolar disorder.^[13] However, study heterogeneity and publication bias precluded the researchers from recommending omega-3 PUFAs to treat depression.

Depression and depressive symptoms are frequently comorbidities associated with other chronic disease, particularly among middle-aged and older adults. Many adults consume fish or take fish-oil supplements to reduce lipid levels, which is well supported in the scientific literature. EPA appears most effective in reducing triglyceride levels, with minimal effects on low- and high-density lipoprotein cholesterol.^[14] This treatment can improve the rate of cardiac events, and the prospect of combination treatment with fish oil and a medication from the statin class of drugs appears particularly promising. A trial of EPA combined with a statin with 4.6 years of follow-up demonstrated that combination treatment was associated with a significant 19% reduction in major coronary events compared with statin treatment alone.^[15] In addition, fish oil has a modest effect in reducing blood pressure among patients with hypertension, and it has been demonstrated to reduce morning stiffness and the number of painful joints among patients with rheumatoid arthritis.^[14]

Fish oil also appears safe and is generally well-tolerated. Patients should certainly consider making fish a regular part of their diet, provided that they avoid consuming large quantities of fish associated with high levels of mercury. Fish oil supplements are another viable treatment option, particularly for patients at higher risk for cardiovascular disease. However, the current study and collective body of research do not provide the level of evidence necessary to recommend fish oil to improve mood, whether for the management of psychological distress or major depression.

Clinical Pearls

• Depressive symptoms are more common in the perimenopausal period, although the prevalence of depression among women does not increase significantly after menopause.
• In the current study, E-EPA failed to improve psychological distress and measures of depression in a cohort of middle-aged women with moderate-to-severe psychological distress at baseline.
• However, when the study analysis was limited to women without a major depressive episode, E-EPA was associated with significant improvements in psychological distress and depression scores.
• The body of clinical data regarding the efficacy of fish oil in improving mood is mixed and does not currently support a recommendation to use fish oil for this indication.

Source : http://www.medscape.com/viewarticle/704937

Vegetarian diets, if well-planned, are healthful and nutritious for all age groups and can help prevent and treat chronic diseases, according to an updated position paper released by the American Dietetic Association. The revised recommendations are published in the July issue of the Journal of the American Dietetic Association. The position was adopted by the House of Delegates Leadership Team in 1987 and was reaffirmed in 1992, 1996, 2000, and 2006; the updated position paper is to remain in effect until December 31, 2013.

"Common reasons for choosing a vegetarian diet include health considerations, concern for the environment, and animal welfare factors," write Winston J. Craig, PhD, MPH, RD, from Andrews University in Berrien Springs, Michigan, and Ann Reed Mangels, PhD, RD, LDN, FADA, from the Vegetarian Resource Group in Baltimore, Maryland. "Vegetarians also cite economic reasons, ethical considerations, world hunger issues, and religious beliefs as their reasons for following their chosen eating pattern.... Individual assessment is required to accurately evaluate the nutritional quality of the diet of a vegetarian or a self-described vegetarian."

Defining and Planning a Vegetarian Diet

The American Dietetic Association defines a vegetarian diet, or lacto-ovo vegetarian diet, as one that does not include meat, fowl, seafood, or products containing those foods. The lacto-vegetarian diet also excludes eggs and primarily consists of grains, vegetables, fruits, legumes, seeds, nuts, and dairy products. The vegan, or total vegetarian, eating pattern excludes eggs, dairy, and other animal products. Within these broad definitions, there is still variation in the degree to which animal products are excluded.

A well-planned vegetarian diet can meet current recommendations for all vital nutrients, including protein, omega-3 fatty acids, iron, zinc, iodine, calcium, and vitamins D and B-12. However, use of supplements or fortified foods may be helpful to boost intake of important nutrients in certain cases.

The American Dietetic Association contends that carefully planned vegetarian diets, including vegan diets, are healthful and nutritionally sufficient for individuals of all ages, including pregnant or lactating women, infants, children, adolescents, and athletes. During pregnancy, adherence to a nutritionally adequate vegetarian diet can lead to positive health outcomes for both the mother and infant.

Furthermore, well-constructed vegetarian diets may offer health benefits in terms of preventing and treating certain chronic diseases, including heart disease, cancer, obesity, and diabetes. Vegetarian diets are linked to lower risk for death from ischemic heart disease, according to findings of an evidence-based review. In addition, low-density lipoprotein cholesterol levels, blood pressure, and body mass index appear to be lower in vegetarians than in nonvegetarians, as do rates of hypertension, type 2 diabetes, and cancer.

The position paper also reviews available evidence concerning the effects of vegetarian diets on cardiovascular disease, obesity, osteoporosis, renal disease, dementia, diverticulitis, and rheumatoid arthritis.

Specific vegetarian considerations regarding specific nutritional programs are also reviewed, including the Special Supplemental Nutrition Program for Women, Infants, and Children; child nutrition programs; feeding programs for elderly adults; corrections facilities programs; military and armed forces programs; and other institutions and quantity food service organizations.

During the next decade, the number of vegetarians in the United States is expected to increase. Vegetarian diets are typically characterized by certain healthful features that may lower the risk for chronic disease — notably, reduced consumption of saturated fat and cholesterol and increased consumption of fruits, vegetables, whole grains, nuts, soy products, fiber, and phytochemicals with potent antioxidant, antiproliferative, and cancer-protective activity.

However, individual diets should be evaluated to ensure that they are nutritionally adequate, given the variability of dietary habits among vegetarians. Other important roles for food and nutrition professionals are to educate vegetarians regarding sources of key nutrients, food purchase and preparation, and individual dietary modifications to meet their specific requirements.

Recommendations for a Healthy Diet

Specific recommendations to help ensure that vegetarians have healthful diets with sufficient nutrients are as follow:

• The diet should contain a wide variety of healthful foods, including whole grains, vegetables, fruits, legumes, nuts, and seeds, as well as dairy and eggs if desired.
• Consumption of foods that are high in sugar, sodium, and fat, particularly saturated fat and trans-fatty acids, should be minimized.
• The diet should contain a wide range of healthful fruits and vegetables.
• For vegetarians who consume dairy products and eggs, moderation is recommended, as well as use of lower-fat dairy products.
• A regular source of vitamin B-12 is recommended, as well as of vitamin D if sunlight exposure is limited.
• Nutritionists should be able to recommend local, reliable sources for purchase of vegetarian foods, or mail order sources in some communities where suitable local sources are unavailable.
• To facilitate meeting nutrient needs on a vegetarian diet, clinicians should collaborate with family members, especially the parents of children following vegetarian diets.
• Practitioners unfamiliar with the principles of vegetarian nutrition should help their vegetarian patients find a nutritionist or other qualified provider to advise them regarding their diet.

"It is the position of the American Dietetic Association that appropriately planned vegetarian diets, including total vegetarian or vegan diets, are healthful, nutritionally adequate, and may provide health benefits in the prevention and treatment of certain diseases," the position paper authors write. "Well-planned vegetarian diets are appropriate for individuals during all stages of the lifecycle, including pregnancy, lactation, infancy, childhood, and adolescence, and for athletes.... Food and nutrition professionals can assist vegetarian clients by providing current, accurate information about vegetarian nutrition, foods, and resources."

J Am Diet Assoc. 2009;109:1266–1282.

Source : http://www.medscape.com/viewarticle/705344?sssdmh=dm1.496281&src=nldne

Providing heart-failure patients with a structured exercise program on top of cardiac resynchronization therapy (CRT) boosts the functional and hemodynamic improvements of biventricular pacing, prompting investigators to suggest it is reasonable to provide exercise programs to all patients after CRT [1].

"Cardiac resynchronization normally improves their status by one New York Heart Association [NYHA] classification, and with that they feel better and their quality of life improves," senior investigator Dr David Wright (Liverpool Heart and Chest Hospital, UK) told heartwire . "They can then exercise a bit more. We felt that because they have the benefit from improved circulation from the pacemaker, the peripheral changes due to long-term lack of exercise can be reversed. We thought that exercise on top of their pacemaker would add extra benefit, and that's exactly what this research shows."

The study, published in the June 23, 2009 issue of the Journal of the American College of Cardiology, included 50 patients referred for CRT. Functional class and quality-of-life scores were assessed and exercise tests with hemodynamic measures performed, before implantation and at three months. At three months, patients were randomized to the structured exercise program or to the control group.

Patients randomized to the exercise program underwent a 12-week program of physician-supervised exercise training three times per week for 30 minutes. The session consisted of walking 10 minutes on the treadmill, cycling for 10 minutes, and then an additional 10 minutes of walking. Intensity increased from 80% of peak heart rate in the first month to 90% in the last month.

Three months after CRT implantation, there were significant improvements in functional, hemodynamic, and echocardiographic measures. After randomization, however, patients in the exercise arm had further improvements in NYHA functional class, exercise hemodynamic measures, and quality-of-life scores.

Exercise and Hemodynamic Results After Randomization

Measure	Exercise, 3 mo	Exercise, 6 mo	Change	Control, 3 mo	Control, 6 mo	Change
NYHA functional class	2	1a	1b	2	2	--
Exercise duration (s)	581	752a	17 b	542	572a	30
Peak VO2 (mL/kg/min)	18.74	20.10a	1.37b	18.08	18.07	-0.01
Ejection fraction	32.8	37.3a	4.5	32.6	35.0	2.5
Left ventricular end-diastolic dimension (cm)	6.64	6.40	-0.20	6.57	6.34a	-0.23
Minnesota Living with Heart Failure score	34.6	26.2a	-8.4b	29.0	29.5	1.6

a. p<0.05 compared with 3 months
b. p<0.05>

"In this group of patients, we've seen almost a doubling of the beneficial effects of biventricular pacing," Wright told heartwire . "CRT devices are in and of themselves expensive and the surgery is expensive, but the benefits of cardiac resynchronization therapy are significant. The cost of cardiac rehabilitation is very small compared with the implantation of a CRT device, yet you get additional benefits in terms of exercise improvement and quality-of-life improvement. We feel that it's a little bit of a cost for lot of an additional benefit."

Juice Is Worth the Squeeze

In an editorial accompanying the published study, Dr Stanley Rubin (Veterans Affair Medical Center, Los Angeles, CA) notes that exercise training is a class 1 recommendation (level of evidence B) for patients with current or prior symptoms of heart failure with reduced systolic function, based largely on evidence showing that training increases exercise duration, intensity, and distance on six-minute-walk tests and also improves quality of life [2]. However, the HF-ACTION study, previously reported by heartwire , showed a structured program did not improve survival or decrease hospital length of stays.

However, Rubin states that the "juice" is likely worth the "squeeze," meaning that the benefits of exercise training are sufficient to justify their effort. In addition, he notes that while hard end points are yet unproven, such as in the "elusive prize of increased survival and decreased hospital stay," improved soft end points, including quality of life and functional capacity, would be welcomed by most patients and physicians.

Rubin adds that while every patient is eligible, exercise is not advised for systolic-dysfunction heart-failure patients with significant aortic stenosis or those with other illnesses that prevent movement. After a physician properly determines a patient's eligibility, training should emphasize aerobic activities, with a small amount of strength training included.

Wright said that based on these findings, health services at his hospital and throughout Liverpool now prescribe exercise rehabilitation for all CRT patients. "If you have a heart attack or bypass surgery, you're then entered into a rehabilitation program," he said. "That hasn't been the case with cardiac resynchronization devices."

References

1. Patwala AY, Woods PR, Sharp L, et al. Maximizing patient benefit from cardiac resynchronization therapy with the addition of structured exercise training. J Am Coll Cardiol 2009; 53:2332-2339.
2. Rubin SA. Remix: Exercise training and cardiac resynchronization therapy in heart failure. J Am Coll Cardiol 2009; 53:2340-2342.

Clinical Context

Study Highlights

• Patients were recruited for study participation from 1 study center. All participants had NYHA class III or IV heart failure and were awaiting CRT. Eligible patients had stable heart failure for at least 1 month and were free of noncardiac physical limitations.
• All patients received CRT with an atriobiventricular pacemaker. They underwent randomization to an exercise therapy or control group at 3 months after CRT.
• The exercise group underwent three 30-minute sessions per week of aerobic activity, all under the supervision of a physician. The work load during exercise was gradually increased to 90% of participants' peak heart rate at baseline. The control group received no special instructions regarding exercise training.
• The main outcomes of the study were results of exercise testing, quality-of-life assessments, echocardiography, and peak muscle strength on knee extension at 6 months after CRT.
• 50 participants entered the study. The mean age was 64.4 years, and 92% of participants were men. Patients had a mode NYHA functional class of III.
• 3 months after CRT (at the time of randomization to exercise therapy or control groups), peak exercise oxygen uptake, exercise duration, and NYHA class function were improved from baseline. Left ventricular ejection fraction and quality of life were also improved.
• The randomized groups were similar with regard to outcomes at 3 months after CRT.
• At 6 months after CRT, improvement in peak exercise oxygen uptake, quality-of-life scores, and NYHA functional class continued to improve in the exercise group.
• Compared with the control group, the exercise group experienced significantly improved outcomes in NYHA functional class, exercise duration, peak exercise oxygen uptake, and quality of life.
• At 6 months, the exercise group had no significant improvement in left ventricular end-diastolic dimension vs usual care, but the mean left ventricular ejection fraction improved in the exercise group vs the control group.
• Leg extension power was similar between groups at 6 months.
• No patient experienced complications from the exercise training.

Clinical Implications

• Among patients with systolic dysfunction heart failure, aerobic exercise improves ventricular remodeling and ejection fraction. It also improves peak exercise oxygen uptake, work capacity, and health-related quality of life.
• In the current study, an exercise therapy program improved peak exercise oxygen uptake, exercise duration, quality-of-life scores, and NYHA functional class among patients who had received CRT for heart failure.

Source : http://cme.medscape.com/viewarticle/704959?src=cmemp

Intakes of meat, eggs, or dairy products are not consistently linked to risks for breast cancer, according to the results of a prospective study reported ahead of print in the June 2 issue of the American Journal of Clinical Nutrition.

"Meat, eggs, and dairy products — prominent features of the Western diet — have been consistently associated with increased breast cancer incidence and mortality in ecological studies; moreover, there has been an ecological trend of increasing breast cancer mortality coincident with the increase in consumption of animal products that occurred after World War II," write Valeria Pala, from Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy, and colleagues. "The 2007 World Cancer Research Fund report concluded that observational epidemiologic studies do not consistently implicate consumption of any animal food in breast cancer risk."

Using data from the European Prospective Investigation into Cancer and Nutrition, the investigators studied the association of meat, egg, and dairy intake with breast cancer risk among 319,826 women who provided dietary information between 1992 and 2003. Multivariate Cox proportional hazard models allowed estimation of disease hazard ratios (HRs).

During median follow-up of 8.8 years, 7119 cases of breast cancer were diagnosed. There was no consistent association between the risk for breast cancer and dietary intake of any of the food groups studied, with use of either categoric or continuous exposure variable models.

In the categoric model, high intake of processed meat was linked to a small increase in breast cancer risk (HR for highest vs lowest quintile, 1.10; 95% confidence interval [CI], 1.00 - 1.20; P for trend = .07). In premenopausal women only, subgroup analyses suggested an association of breast cancer risk with butter consumption (HR for highest vs lowest quintile, 1.28; 95% CI, 1.06 - 1.53; P for trend = .21).

Findings for red meat intake (beef, veal, pork, and lamb) were heterogeneous between countries (Q statistic = 18.03; P = .05), which was explained (P = .023) by the proportion of meat cooked at high temperature (eg, frying, deep frying, roasting, barbecuing, and grilling).

Limitations of this study include possible errors generated by differences in the dietary assessment, collection of dietary information only at baseline, and lack of information on early-life eating habits of participants.

"We have not consistently identified intakes of meat, eggs, or dairy products as risk factors for breast cancer," the study authors write. "Future studies should investigate the possible role of high-temperature cooking in the relation of red meat intake with breast cancer risk."

Funding for this study was provided by a large number of international research foundations, as detailed in the original article. The study authors have disclosed no relevant financial relationships.

Am J Clin Nutr. Published online June 2, 2009.

Clinical Context

Study Highlights

• 319,826 women aged 20 to 70 years were recruited from Denmark, France, Germany, Greece, Italy, Norway, Spain, the Netherlands, and the United Kingdom.
• Exclusion criteria were prevalent cancer at recruitment, missing diagnosis, in situ breast cancer, incompletion of at least 1 diet and lifestyle questionnaire, first and last percentiles of total energy intake to basal metabolic rate ratio, and missing data on confounders.
• Country-specific or center-specific food questionnaires were used to assess food intake in the prior year.
• Exposure variables were total daily intake in grams per day of red meat (beef, veal, pork, and lamb), poultry, processes meat, eggs, milk, cheese, and butter.
• High-temperature cooking was defined as frying, deep frying, roasting, barbecuing, and grilling.
• Countries that cooked up to 45% of red meat by high temperature were Italy, Germany, Norway, Greece, and the United Kingdom.
• Countries that cooked more that 45% of red meat by high temperature were Spain, Sweden, France, Denmark, and the Netherlands.
• Cancer diagnoses were reported by cancer registries, social security records, pathology registries, and follow-up of participants and next-of-kin.
• Each subject was observed until cancer diagnosis, loss to follow-up, death, or end of follow-up.
• Median follow-up was 8.8 years or 2,812,610 person-years.
• 7119 women were diagnosed with invasive breast cancer.
• The UK group had the lowest intake of animal products, excluding milk and butter.
• The most variations in intake occurred for butter (<> 8 g/day for France and Germany) and for processed meat (6.2 g/day for Greece to > 39 g/day for Germany and Sweden).
• Analysis adjusted for energy intake, weight, height, alcohol intake, smoking, education, and menopause status.
• Categoric and continuous multivariate analyses showed that no food group was consistently associated with breast cancer.
• Processed meat was linked with breast cancer in the categoric model only for the last vs first quintile of intake (HR, 1.10; 95% CI, 1.00 - 1.20; P = .065 for trend).
• Semi-skim milk intake was modestly associated with breast cancer in the continuous model (HR, 1.04; 95% CI, 1.00 - 1.09 for each 150 g/day).
• Red meat intake showed significant between-country heterogeneity of HRs.
• Subanalysis showed that the link between red meat intake and breast cancer risk was significant in countries with an increased proportion of high-temperature cooking.
• Analysis stratified by menopausal status showed that high butter intake was linked with breast cancer risk in premenopausal women (HR, 1.28; 95% CI, 1.06 - 1.53).

Clinical Implications

• Intakes of eggs and dairy products are not consistently linked with an increased risk for breast cancer in women.
• Meat intake is not linked with breast cancer risk, although between-country heterogeneity in results might be explained by high-temperature cooking.

Source : http://cme.medscape.com/viewarticle/704523?src=cmenews