Postmenopausal women taking antidepressants may be at higher risk for stroke, death

Moral of the story: Postmenopausal women on antidepressants are 45% more likely than those not on such medication to have a stroke, and 32% more likely to die of any cause.

AMA Morning Rounds 12/15/09

Postmenopausal women taking antidepressants may be at higher risk for stroke, death.

The Los Angeles Times (12/14, Healy) "Booster Shots" blog reported that, according to a study published in the Archives of Internal Medicine, "postmenopausal women taking antidepressants are at higher risk of suffering a stroke or of dying of any cause than are those who do not take such medications." Investigators "followed 136,293 post-menopausal women, age 50 to 79, for just under six years," during which time "5,496 developed depression and were treated with antidepressant medication." Researchers found that over the course of "follow-up, the women on antidepressants were 45% more likely than those not on such medication to have a stroke, and 32% more likely to die of any cause."

        HealthDay (12/14, Edelson) reported that while the study found that "women on selective serotonin uptake inhibitors," such as "Celexa [citalopram], Paxil [paroxetine], Prozac [fluoxetine], and Zoloft [sertraline]," as well as "tricyclic antidepressants," had an increased risk for stroke and death, "the overall risk for any one woman remained very small."

High coffee, tea intake may reduce chances of developing type 2 diabetes

Moral of the story: Drinking coffee and tea reduces chances of developing type II (late onset) diabetes

Source: AMA Morning Rounds 12/15/09;  Arch Intern Med. 2009;169(22):2053-2063.

High coffee, tea intake may reduce chances of developing type 2 diabetes.

Bloomberg News (12/15, Gibson) reports that, according to a study published in the Archives of Internal Medicine, "drinking four cups of coffee, decaf, or tea daily can reduce the chances of getting type 2 diabetes by about 25 percent to 35 percent." Harvard University "researchers reviewed 18 studies of almost 500,000 people" and discovered that "for each cup of coffee people drank, their likelihood of getting diabetes dropped by seven percent."

        "Even better results were found for bigger coffee and tea consumers -- drinking three to four cups a day was associated with about a 25% reduced diabetes risk, compared with those who drank between none and two cups day," the Los Angeles Times (12/15, Stein) reports. In addition, investigators found "positive results with decaf coffee and tea." Specifically, those "who drank more than three to four cups of decaf a day had about a one-third lower risk than those who didn't drink any," while "tea drinkers who consumed more than three to four cups a day had about a one-fifth lower diabetes risk than non-tea drinkers."

        HealthDay (12/14, Gordon) and MedPage Today (12/14, Fiore) also covered the story.

Coffee, Decaffeinated Coffee, and Tea Consumption in Relation to Incident Type 2 Diabetes Mellitus
A Systematic Review With Meta-analysis
Rachel Huxley, DPhil; Crystal Man Ying Lee, PhD; Federica Barzi, PhD; Leif Timmermeister; Sebastien Czernichow, MD, PhD; Vlado Perkovic, MD, PhD; Diederick E. Grobbee, MD, PhD; David Batty, PhD; Mark Woodward, PhD



Background  Coffee consumption has been reported to be inversely associated with risk of type 2 diabetes mellitus. Similar associations have also been reported for decaffeinated coffee and tea. We report herein the findings of meta-analyses for the association between coffee, decaffeinated coffee, and tea consumption with risk of diabetes.
Methods  Relevant studies were identified through search engines using a combined text word and MeSH (Medical Subject Headings) search strategy. Prospective studies that reported an estimate of the association between coffee, decaffeinated coffee, or tea with incident diabetes between 1966 and July 2009.
Results  Data from 18 studies with information on 457 922 participants reported on the association between coffee consumption and diabetes. Six (N = 225 516) and 7 studies (N = 286 701) also reported estimates of the association between decaffeinated coffee and tea with diabetes, respectively. We found an inverse log-linear relationship between coffee consumption and subsequent risk of diabetes such that every additional cup of coffee consumed in a day was associated with a 7% reduction in the excess risk of diabetes relative risk, 0.93 [95% confidence interval, 0.91-0.95]) after adjustment for potential confounders.
Conclusions  Owing to the presence of small-study bias, our results may represent an overestimate of the true magnitude of the association. Similar significant and inverse associations were observed with decaffeinated coffee and tea and risk of incident diabetes. High intakes of coffee, decaffeinated coffee, and tea are associated with reduced risk of diabetes. The putative protective effects of these beverages warrant further investigation in randomized trials.

Author Affiliations: The George Institute for International Health, The University of Sydney, Sydney, Australia (Drs Huxley, Lee, Barzi, Czernichow, Perkovic, Batty, and Woodward and Mr Timmermeister); Department of Public Health, Avicenne Hospital, University of Paris 13, Paris, France (Dr Czernichow); The Julius Center for Health Sciences and Primary Care, Utrecht University Medical Center, Utrecht, the Netherlands (Dr Grobbee); Medical Research Council Social & Public Health Sciences Unit, University of Glasgow, Glasgow, Scotland (Dr Batty); and Mount Sinai School of Medicine, New York, New York (Dr Woodward).

Radiation overexposure from CT scans may be more widespread than previously estimated

Moral of the story: Again, watch out for those CT settings.

Source: AMA Morning Rounds 12/15/09

Radiation overexposure from CT scans may be more widespread than previously estimated.

The CBS Evening News (12/14, story 3, 2:20, Lapook) reported, "The problem of too much radiation during CT scans may be more widespread than anyone thought." In fact, "new research...found a wide variation in radiation dose for the most common CT scan like abdomen, pelvis, and chest. A survey of four hospitals found some patients received 13 times more radiation than others for the same type of scan."

        NBC Nightly News (12/14, story 8, 2:10, Bazell) reported, "Depending on the part of the body being scanned, each CT exposes a patient to an amount of radiation equal to between 30 and 440 chest X-rays." But, in a separate study, "researchers calculated that 72 million CT scans are performed in this country a year and concluded that could lead to 29,000 excess cancers and 15,000 excess deaths a year in the future."

        In that study, published in the Archives of Internal Medicine, researchers at the National Cancer Institute "found that people may be exposed to up to four times as much radiation as estimated by earlier studies," USA Today (12/15, Szabo) reports.

        Meanwhile, the second study, appearing in the same journal, of over 1,000 patients at four hospitals, showed that one woman out of 270 and one man out of 600 would suffer from cancer after undergoing a single heart scan at age 40, the Wall Street Journal (12/15, A3, Wang) reports. Researchers noted that the differences in radiation doses may be due to a lack of standardized settings and disparities in technology use.

        The Los Angeles Times (12/15, Maugh) reports that, in an accompanying editorial, Dr. Rita F. Redberg, editor of the journal, noted that "the articles...make clear that there is far more radiation from medical CT scans than has been recognized previously." Redberg said, "Even many otherwise healthy patients are being subjected to the radiation...because emergency [departments] are often sending patients to the CT scanner before they see a doctor."

        Bloomberg News (12/15, Ostrow) reports that in the National Cancer Institute study, "the authors predicted that lung cancer will be the most common radiation-related cancer followed by colon cancer and leukemia." For its part, the FDA "issued interim regulations Dec. 7 requiring closer monitoring of CT scans after more than 250 cases of exposure to excess radiation were reported since October."

        WebMD (12/14, Doheny), MedPage Today (12/14, Neale), NPR (12/15), Modern Healthcare (12/15, Rhea), HealthDay (12/14, Pallarito), and Reuters (12/15, Steenhuysen) also covered the story.

FDA investigates 300 radiation overdoses from CT scans.

Moral of the story: Just something to be aware of.  The CT might not be set correctly.

Source: AMA Morning Rounds 12/16/09

FDA investigates 300 radiation overdoses from CT scans.

NPR's (12/15, Neighmond) All Things Considered reported, "More than 300 patients may have received an overdose of radiation from a special type of CT scan used to image the brain. The Food and Drug Administration says the radiation overdoses occurred at three hospitals in Los Angeles County and one hospital in Huntsville, AL. FDA officials say there could be many more cases at hospitals nationwide as their investigation unfolds." Dr. Jeffrey Shuren, "acting director of the FDA's Center for Devices and Radiological Health," explained that "a regular CT scan to the brain is the equivalent of about 100 chest X-rays," whereas "a perfusion CT scan of the brain is equal to several hundred chest x-rays. Patients at the four hospitals who received excess radiation were exposed to the equivalent of several thousand X-rays instead -- three to eight times the expected radiation dose."

New, Higher Cancer Risk Estimates for CR Scans

Moral of the story: CT scans are being reevaluated for their cancer risk, which was underestimated in the past based on theoretical values and not actual practice data.

Source: ACP Internist Weekly 12/21/09

New estimates on cancer risk of CT scans

Two new studies warn of the cancer risk posed by CT scans and suggest some risk-reduction strategies.
A retrospective cross-sectional study calculated the radiation doses delivered by computed tomography (CT) scans performed at four different California hospitals. Doses ranged from 2 millisieverts (mSv) for a routine head CT to 31 mSv for a multiphase abdomen and pelvis scan. Many of the scans provided more radiation than is usually assumed to be the case; the median dose for a routine abdomen and pelvis scan was 66% higher than the expected 8 to 10 mSv. Even within each type of study, the effective dose varied significantly within and among the hospitals. There was a mean 13-fold variation between the highest and lowest doses for each procedure.
Extrapolating from these data, researchers calculated cancer risks, such that 1 in 270 women who underwent CT coronary angiography at age 40 would develop cancer from the scan. Risks were lower for men than women, and higher for younger than older patients (20-year-olds faced double the risk, 60-year-olds only half). The study was published in the Dec. 14/28 Archives of Internal Medicine.
Another study in the same issue used risk models to calculate how many cancers could eventually be attributed to CTs based on current scanning rates. Overall, they estimated that 29,000 future cancers could be caused by CT scans performed in the U.S. in 2007. Scans of the abdomen and pelvis contributed the most to the tally, and one-third of the cancers would be due to scans performed on patients between the ages of 35 and 54.
The authors of the studies and an accompanying editorial offered a number of solutions to this problem, including standardized protocols (such as have been applied to mammography), fewer multiple series examinations, dose reduction and registration, and greater use of American College of Radiology accreditation and criteria. The experts also called for a reduction in the number of inappropriate and unnecessary CT scans.

Breast-feeding may benefit a woman's heart.

Moral of the story: Again, another benefit to breast-feeding.

Source: AMA Morning Rounds 12/22/09

Breast-feeding may benefit a woman's heart.

HealthDay (12/21, Gordon) reported that breast-feeding may help protect a woman's heart, according to research scheduled to be published in Obstetrics and Gynecology. Investigators, "in a study of nearly 300 women," employed "two imaging techniques -- electron beam tomography and ultrasound -- to assess the health of the women's blood vessels." The researchers "found that 32 percent of the women who had not breast-fed had coronary artery calcification, compared with 17 percent of the breast-feeding moms."

Antidepressants' effectiveness may vary according to severity of depression.

Moral of the story: Antidepressants may not be useful for all patients with depression.

Source: AMA Morning Rounds 1/6/10

Antidepressants' effectiveness may vary according to severity of depression.

The New York Times (1/6, A12, Carey) reports that "some widely prescribed" medications "for depression provide relief in extreme cases, but are no more effective than placebo pills for most patients," according to a study published Jan. 6 in the Journal of the American Medical Association. After reviewing "data from previous trials on two types of" medicines, paroxetine (Paxil) or imipramine (Tofranil), researchers found that "their effectiveness varies according to the severity of the depression being treated."

        USA Today (1/6, Rubin) explains that University of Pennsylvania researchers "pooled data from six trials in which a total of 718 depressed patients were randomly assigned to take either an antidepressant or a placebo." After obtaining "patient-specific data from scientists involved with each trial," the team found that "antidepressants were more effective than a placebo only for patients with very severe depression, who made up 40% of trial participants but...represent fewer than 30% of depressed people who seek treatment in the real world."

        While "antidepressant medications probably provide little or no benefit to people with mild or moderate depression," the Los Angeles Times (1/6, Roan) reports that the study also suggests that "the mere act of seeing a doctor, discussing symptoms, and learning about depression probably triggers the improvements many patients experience while on medication." Meanwhile, "other research has also found that antidepressants are most effective for severe symptoms, said" Philip Wang, MD, PhD, deputy director of the National Institute of Mental Health. While antidepressants may not "work well for mild to moderate depression, it's also possible that people enrolled in antidepressant studies have robust placebo responses that mask some of the impact of the medication."

        According to the Wall Street Journal (1/6, Dooren), study author Robert DeRubeis, PhD, pointed out that the majority of studies assessing antidepressant medications included patients with severe depression and that such studies were submitted to the Food and Drug Administration for approval of these medicines. In contrast, because far fewer studies have included patients with mild depression, it remains unclear just how effective antidepressants, such as fluoxetine (Prozac) or paroxetine (Paxil), are in this large patient population.

        Meanwhile, Bloomberg News (1/6, Bennett) reports, "doctors, policy makers, and consumers should be made aware that there's little evidence to show antidepressants will benefit the majority of patients with less severe symptoms," the study authors concluded. Forbes (1/6, Langreth), the Columbus (OH) Dispatch (1/6, Crane), and Reuters (1/6, Stern) cover the story, as did HealthDay (1/5, Gardner), WebMD (1/5, Doheny), and MedPage Today (1/5, Gever).

Cutting global warming said to lead to positive health effects.

Moral of the story: Health improves as green house gas emisions fall.

Source: AMA Morning Rounds 12/28/09

Cutting global warming said to lead to positive health effects.

The AP (12/27, Borenstein) reported that research in a special issue of the Lancet suggests that "cutting global warming pollution would not only make the planet healthier, it would make people healthier too." United Nations Secretary General Ban Ki-Moon and the head of the World Health Organization," HHS Secretary Kathleen Sebelius said, "Relying on fossil fuels leads to unhealthy lifestyles, increasing our chances for getting sick and in some cases takes years from our lives. ... As greenhouse gas emissions go down, so do deaths from cardiovascular and respiratory diseases. This is not a small effect." Linda Birnbaum, director of the US National Institute of Environmental Health Sciences, explained that the Lancet studies looked "at the immediate benefits of doing something about the problem" rather than "looking at the health ills caused by future global warming, as past studies have."

Bedside exam may be superior to CT in detecting post-brain surgery complications.

Moral of the story: CT is shown yet again to be less effective than originally thought, but will likely to continue to be gold standard because of litigation and societal desire for technology

Source: AMA Morning Rounds 12/29/09

Bedside exam may be superior to CT in detecting post-brain surgery complications.

HealthDay (12/28, Dotinga) reported that, according to a study appearing online in the Journal of Neurosurgery, "the low-cost, simple, but elegant neurological exam appears to be superior to a routine CT scan in determining return to the operating room" due to "post-brain surgery complications." A review of "the medical records of 251 patients who underwent CT scans within 24 hours of surgery" revealed that "the scans failed to show who would need to go back to the operating room." But, bedside exams showed "serious problems in 10 cases that required urgent CT scans; three of the patients needed to go back to the operating room."

Gingko biloba not effective in preventing cognitive decline, improving memory.

Moral of the story: Ginko is probably not worth buying for your mental health.

Source: AMA Morning Rounds 12/30/09; JAMA. 2009; 302:2663-2670

Gingko biloba not effective in preventing cognitive decline, improving memory.

The CBS Evening News (12/29, story 9, 0:20, Smith) reported, "Americans spend a quarter billion dollars a year on" gingko biloba supplements, "hoping to improve their memory and slow cognitive decline."

        NBC Nightly News (12/29, story 5, 2:00, Williams) reported that "now, a major study shows" that gingko biloba, "one of the most popular supplements, flat out does not work."

        USA Today (12/30, Weise) reports that, according to a study published in the Dec. 23-30 issue of the Journal of the American Medical Association, "the popular botanical...does not improve memory, nor does it prevent cognitive decline in older people." After analyzing data "from the Ginkgo Evaluation of Memory study" on "more than 3,000 people between ages 72 and 96 for seven years," researchers from the University of Virginia Medical School "found that a twice-daily dose of 120 milligrams of ginkgo biloba extract was not effective in reducing the incidence of Alzheimer's dementia or dementia overall."

        According to the Los Angeles Times (12/29, Kaplan) "Booster Shots" blog, the National Center for Complementary and Alternative Medicine, "a branch of the National Institutes of Health, has been researching ginkgo for 10 years to see whether the type of clinical trials required for FDA-regulated pharmaceuticals would reveal any benefit. The new findings are in line with several other studies, including a Cochrane review published this year that found 'no convincing evidence' that the herb preserves mental function in any way."

        The investigators "found no evidence that ginkgo delayed or prevented normal declines in memory, language, attention, visuospatial abilities, or executive functions, such as anticipating outcomes and adapting to changing situations and thinking abstractly," HealthDay (12/29, Reinberg) reported. Moreover, "these results remained the same regardless of sex, age, race or education," the investigators found. However, the supplement was found to be safe, "and no serious side effects were noted," study author Steven T. DeKosky, MD, said.

        WebMD (12/29, DeNoon) reported that "in a written statement," Douglas MacKay, ND, of the Council for Responsible Nutrition, "a group representing the supplement industry," said that "the DeKosky study 'should not be viewed as the final work' on ginkgo." He stated that "as a former practicing licensed naturopathic doctor," he "would continue to recommend ginkgo biloba to older adults as a safe, effective option for supporting cognitive health."

Ginkgo biloba for Preventing Cognitive Decline in Older Adults
A Randomized Trial
Beth E. Snitz, PhD; Ellen S. O’Meara, PhD; Michelle C. Carlson, PhD; Alice M. Arnold, PhD; Diane G. Ives, MPH; Stephen R. Rapp, PhD; Judith Saxton, PhD; Oscar L. Lopez, MD; Leslie O. Dunn, MPH; Kaycee M. Sink, MD; Steven T. DeKosky, MD; for the Ginkgo Evaluation of Memory (GEM) Study Investigators

JAMA. 2009;302(24):2663-2670.
Context  The herbal product Ginkgo biloba is taken frequently with the intention of improving cognitive health in aging. However, evidence from adequately powered clinical trials is lacking regarding its effect on long-term cognitive functioning.
Objective  To determine whether G biloba slows the rates of global or domain-specific cognitive decline in older adults.
Design, Setting, and Participants  The Ginkgo Evaluation of Memory (GEM) study, a randomized, double-blind, placebo-controlled clinical trial of 3069 community-dwelling participants aged 72 to 96 years, conducted in 6 academic medical centers in the United States between 2000 and 2008, with a median follow-up of 6.1 years.
Intervention  Twice-daily dose of 120-mg extract of G biloba (n = 1545) or identical-appearing placebo (n = 1524).
Main Outcome Measures  Rates of change over time in the Modified Mini-Mental State Examination (3MSE), in the cognitive subscale of the Alzheimer Disease Assessment Scale (ADAS-Cog), and in neuropsychological domains of memory, attention, visual-spatial construction, language, and executive functions, based on sums of z scores of individual tests.
Results  Annual rates of decline in z scores did not differ between G biloba and placebo groups in any domains, including memory (0.043; 95% confidence interval [CI], 0.034-0.051 vs 0.041; 95% CI, 0.032-0.050), attention (0.043; 95% CI, 0.037-0.050 vs 0.048; 95% CI, 0.041-0.054), visuospatial abilities (0.107; 95% CI, 0.097-0.117 vs 0.118; 95% CI, 0.108-0.128), language (0.045; 95% CI, 0.037-0.054 vs 0.041; 95% CI, 0.033-0.048), and executive functions (0.092; 95% CI, 0.086-0.099 vs 0.089; 95% CI, 0.082-0.096). For the 3MSE and ADAS-Cog, rates of change varied by baseline cognitive status (mild cognitive impairment), but there were no differences in rates of change between treatment groups (for 3MSE, P = .71; for ADAS-Cog, P = .97). There was no significant effect modification of treatment on rate of decline by age, sex, race, education, APOE*E4 allele, or baseline mild cognitive impairment (P > .05).
Conclusion  Compared with placebo, the use of G biloba, 120 mg twice daily, did not result in less cognitive decline in older adults with normal cognition or with mild cognitive impairment.
Trial Registration  clinicaltrials.gov Identifier: NCT00010803

Author Affiliations: Departments of Neurology (Drs Snitz, Saxton, Lopez, and DeKosky and Ms Dunn) and Epidemiology (Ms Ives), University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Biostatistics, University of Washington, Seattle (Drs O’Meara and Arnold); Department of Mental Health, Johns Hopkins Medical Institutions, Baltimore, Maryland (Dr Carlson); Departments of Psychiatry and Behavioral Medicine (Dr Rapp) and Internal Medicine (Geriatrics/Gerontology), School of Medicine (Dr Sink), Wake Forest University, Winston-Salem, North Carolina; and School of Medicine, University of Virginia, Charlottesville (Dr DeKosky).