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Automated external defibrillators at home

As you read this, someone somewhere in the United States is collapsing from a cardiac arrest. The odds are poor that she or he will survive this sudden disruption of the heart’s normal rhythm. Most of the 1,000 or so people who go into cardiac arrest each day die because they don’t get the treatment they need — an electric shock to the heart — fast enough.

Heart-shocking devices were once found only in hospitals and ambulances. Now they’re popping up in airports, movie theaters, fitness centers, casinos, malls, office buildings, and other places. These public versions, called automated external defibrillators (dee-FIB-rih-lay-tors), are so easy to use that sixth graders who have never seen one before can master their use in a minute or so, as shown in a 2002 study. This ease of use, combined with the fact that 3 in 4 cardiac arrests happen at home, have opened a national debate over whether it’s a good idea to have a defibrillator at home.The chances of surviving a cardiac arrest fall about 10% for each minute the heart stays in ventricular fibrillation. Shock the heart back into a normal rhythm within two minutes, and the victim has an 80% chance of surviving. Deliver that shock after seven minutes — the average time it takes an emergency medical team to arrive in many cities — and the odds are less than 30%. If someone near you goes into cardiac arrest, calling 911 is a must. Even if there’s a defibrillator nearby, you’ll need professional help as soon as possible. CPR is also important because it keeps blood flowing to the brain and other vital organs. Still, a home defibrillator could let you restore a healthy heart rhythm several crucial minutes sooner than emergency medical technicians.

Can home defibrillators help?

With a prescription from a doctor and $2,500 or so, you can buy a defibrillator for your home, office, or car at many large pharmacies or medical supply companies. The question is, should you? Experts in the areas of sudden cardiac arrest, emergency medicine, and public health don’t see eye-to-eye on this issue. Some argue that people who want to buy defibrillators for their homes should be able to do so without needing a prescription from a doctor. Others argue that people won’t maintain the devices so they will be ready when needed, or that most people would be better off spending some of the money on a health club membership and donating the rest to their local emergency response team.

Researchers have collected relatively little evidence on the benefits and risks of wider access to defibrillators. A few studies have examined their use in public places. One, published in the October 17, 2002, Journal of the American Medical Association, showed that 11 of 18 people who collapsed with ventricular fibrillation over a two-year period in Chicago’s three airports were revived, mostly by passers-by who used highly visible and well-marked defibrillators.

But their use at home is uncharted territory. One project, Neighborhood Heart Watch, is putting automated defibrillators in volunteers’ homes in Indianapolis neighborhoods. When there’s a call to 911 about a cardiac arrest in that neighborhood, it’s routed to both the emergency services and the nearest home with a defibrillator.

Another study, the Home Automatic External Defibrillator Trial, sponsored in part by the National Institutes of Health, aims to map out the benefits and risks. It will give home defibrillators to 3,500 heart patients and train their partners to use the devices. The partners of another 3,500 heart patients will get training in CPR, but no home defibrillator. The results aren’t expected until 2007.

Who should have one?

A home defibrillator would probably be a good investment for anyone who has survived a sudden cardiac arrest but who does not have a pacemaker capable of shocking the heart (an implantable cardioverter/defibrillator, or ICD). Owning this device might also make sense for someone with severe heart failure, unstable angina, or other severe forms of heart disease. So far, though, there’s no good evidence that home defibrillators will save lives in this group of people.

Training is a must

If you decide to buy a defibrillator for your home, or if you just want to be prepared for the chance you’ll someday need to use one in a public venue, make the time now to take a class on using this device.

Why bother to go through training when these machines have been designed for virtually mistake-free use? Several reasons. A class can help you use the defibrillator with confidence and speed. It can help you deal with unusual situations, such as where to apply the pads on someone with an implanted pacemaker, a medication patch, or a hairy chest. It will also teach you how to do CPR, an important part of the process.

The American Heart Association has developed a 3 1/2-hour course called “HeartSaver AED for Lay Rescuers and First Responders.” To find the closest training center that offers this course, call the AHA at 800-242-8721.

January 2003 Update

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Medications for postmenopausal osteoporosis prevention

Risk of osteoporosis increases after menopause, when levels of estrogen — which helps preserve bone density — drop. Until recently, most doctors recommended long-term hormone replacement therapy (HRT) to treat postmenopausal women who need medication to prevent bone loss. But things changed after results from a large trial on a common HRT drug showed that estrogen plus progestin (as the medication Prempro) did more harm than good. An increased risk for breast cancer and cardiovascular events outweighed the benefits of less colorectal cancer and fewer fractures. (See the Update from July 2002 for more information on the trial.)

Health experts now encourage most women who have been taking long-term HRT for osteoporosis prevention to consider an alternative. Fortunately there are several options. Each of the FDA-approved treatments (see chart) has potential benefits and risks that women and their doctors should weigh before making a decision. Even with HRT’s proven risks, it may still be a good choice for certain women — especially in lower doses, which recent data have shown to have bone benefits comparable to higher, standard doses.

Approved medications for osteoporosis prevention

Medication

How to take it

Bone benefits

Side effects

Comments

Alendronate (Fosamax)

Orally, once daily in the morning or as a larger dose once a week; take with 6–8 ounces of water and stay upright for 30 minutes.

Increases bone density at the spine and hip; reduces spinal and hip fracture risk. Side effects uncommon.

Heartburn, nausea, inflammation of the esophagus, muscle pain.

Interferes with cells that break down bone. Well-tolerated when taken properly.

Risedronate (Actonel)

Orally, once daily in the morning or as a larger dose once a week; take with 6–8 ounces of water and stay upright for 30 minutes.

Increases bone density at the spine and hip; reduces spinal and hip fracture risk. Side effects uncommon.

Abdominal pain, nausea, constipation, joint pain.

Interferes with cells that break down bone. Well-tolerated when taken properly.

Raloxifene (Evista)

Orally, once daily, any time.

Increases bone density (but less so than alendronate or risedronate); reduces spinal fracture risk. Side effects uncommon.

Hot flashes, leg cramps, deep-vein blood clots.

Acts like estrogen in bone but is an anti-estrogen in breast tissue; may reduce breast cancer risk.

Estrogen (Premarin, Estrace, other brands)

Orally, once daily, any time; or weekly by skin patch.

Increases bone density; some evidence for fracture reduction.

Increases the risk for breast cancer (after 4–5 years) and cardiovascular events when combined with a progestin (as Prempro) and taken orally.

May be recommended if other medications are not tolerable or menopausal symptoms persist.

Sources: Boosting Bone Strength: A Guide to Preventing and Treating Osteoporosis, Harvard Health Publications, Boston, 2000; Managing Osteoporosis, Part 3: Prevention and Treatment of Postmenopausal Osteoporosis, American Medical Association, 2000; Osteoporosis: Guide to Prevention, Diagnosis, and Treatment, Brigham and Women’s Hospital, Boston, 2002

December 2002 Update

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Dietary Antioxidants May Decrease Risk of Alzheimer's Disease

Alzheimer’s disease (AD) is a complex disease that spreads through the brain. It affects some 4 million Americans, causing memory loss, impaired thinking, and changes in personality. Scientists have suspected that substances called antioxidants — vitamin C, vitamin E, and beta carotene, for example — may guard against AD. However, studies testing the relationship between antioxidant supplements and the risk of AD have not found consistent evidence of a benefit. But now two studies published in the Journal of the American Medical Association have found that high intakes of antioxidants from food may reduce the risk of developing AD.

In the first study, researchers recruited 5,395 participants with an average age of 67.7 years, who lived independently. All participants reported their eating habits and went through two mental state examinations to ensure that they were free of dementia at the start of the study.
During six years of follow-up, the researchers re-screened the participants for Alzheimer’s disease. They found that high dietary intake of vitamin C significantly reduced the risk of developing Alzheimer’s disease and that the reduced risk of AD from high dietary intake of vitamin E was also borderline significant. These antioxidants were most effective at preventing AD in current smokers, compared with current non-smokers.

Use of dietary supplements was controlled in this study, so the beneficial effects of vitamins C and E were only from food. Vitamin C is found in large amounts in citrus fruits, kiwi, and broccoli, and good sources of vitamin E include nuts, milk, and egg yolk.

In the second study, participants were also free of Alzheimer’s disease at the beginning and completed a food frequency questionnaire. The questionnaire helped researchers keep track of the intake of certain foods and supplements. The 815 subjects were 65 years and older, and were followed for four years.

After adjusting for age, education, sex, race, and presence of APOE e4 (a genetic characteristic that makes a person more likely to develop AD), the researchers found that those with the highest dietary intake of vitamin E were 70% less likely to develop AD than those with the lowest dietary intake of vitamin E. However, the highest Vitamin E intake for the study was 363.6 International Units (IU) per day, well above the Recommended Dietary Allowance of 22 IU.

The other dietary antioxidants tested in this study, vitamin C and beta carotene, did not reduce the risk of AD. More research will need to be performed to find out why vitamin C proved effective in one study but not in the other. While dietary antioxidants are proving more effective in reducing Alzheimer's risk than antioxidant supplements, these weren't randomized, clinical trials, so these studies won't translate into dietary recommendations.

August 2002 Update

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Physical activity benefits all ages

The frail health often associated with aging is in large part due to physical inactivity, according to a report released by the U.S. Department of Health and Human Services (HHS). It also advises that it’s never too late to benefit from becoming physically active.

The report cites that even moderate levels of activity — such as washing a car or raking leaves — can produce considerable benefits that can be even more noticeable in older adults. Regular exercise improves cholesterol levels, reduces blood pressure, cuts body fat, and lowers blood sugar. Physical activity also improves bone and muscle strength. All in all, people who exercise live longer — and they also live better.

Current guidelines recommend at least 30 minutes of moderate physical activity a day. However, few older Americans reach this level. Lack of physical activity and poor diets are the major causes of obesity, an epidemic that is affecting people of all ages.

In the '70s and '80s, doctors were telling Americans to run; now, they are asking people to walk. Walking can be a moderately intense aerobic activity. But even at a more relaxed pace, walking has huge benefits. The distance actually seems more important than the pace — and it doesn't take heroic distances to get real benefit. In 1993, the Harvard Alumni study found that men who walked just 1.3 miles a day had a 22% lower death rate than those who walked less than 0.3 mile a day.

Strong muscles also improve your health. So set aside 15 minutes two or three times a week for resistance or strength training as well as 10–15 minutes at least three times a week for stretching exercises.

The HHS report provides strategies that individuals, doctors, and even communities can follow to promote physical activity. Individuals are encouraged to take part in activities that they enjoy and to make them a daily part of life. Doctors should help patients start and continue these regimens and overcome any difficulties they encounter. Communities can establish programs tailored to seniors’ physical activity needs and improve walking or bike trails.

The complete report is available at www.ahrq.gov/ppip/activity.htm

August 2002 Update

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Annual PSA Test May Not be Necessary for All Older Men

Prostate cancer is the second leading cause of death for men in the United States. And while the chance of being diagnosed with prostate cancer over a lifetime may be as high as 20%, the chance of dying of prostate cancer is only about 3%. But the risk of prostate cancer increases with age. More than 75% of all cases occur in men over 65, and about 40% of men over 80 have the disease. When it is diagnosed early, prostate cancer is more likely to be treated successfully. Cure rates are excellent for cancer that is discovered and treated when it is still confined to the prostate gland. About 95% of men with localized prostate cancer treated by surgery are alive after five years.

The prostate-specific antigen (PSA) test is a primary test for finding early-stage prostate cancer. PSA is a protein produced by the prostate gland, and PSA levels become elevated in men with prostate cancer. Although some respected groups recommend an annual PSA test for all men over age 50, the annual PSA test remains controversial. That is, in part, because it has a high chance of being falsely negative (20%-40% of men with prostate cancer have normal levels of PSA) or falsely positive (PSA levels may be elevated in men with noncancerous prostate conditions).

At a meeting of the American Society of Clinical Oncology, researchers presented findings that indicated that an annual PSA test may not be warranted in men over 50 with an initial normal PSA (0–4 nanograms/milliliter). For five years, researchers tracked the annual PSA test results of 27,863 men ages 55–74 whose PSA levels were initially normal. . They found that 98.6% of men with a PSA result of less than 1 ng/ml at baseline would remain negative after 4 more annual tests and that 98.8% of men with a baseline PSA of 1–2 ng/ml would have a negative PSA test the following year.

Based on these results, the researchers concluded that performing a PSA test every five years on men with an initial PSA less than 1 ng/ml and every two years for men with a PSA of 1–2 ng/ml would reduce the number of PSA tests performed by 55%. This would save money and help men avoid the anxiety associated with yearly prostate tests.

July 2002 Update

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Healthy Diet Eradicates Need for Trendy Supplements in Elderly

Magazine ads and television commercials tout dietary supplements that claim to be a veritable fountain of youth for seniors. Images of grandparents able to keep up with their grandkids convince older adults that shakes, energy bars, and special vitamins will help boost energy and decrease signs of aging.

Health experts, however, stress that a well-balanced diet rich in fruit and vegetables is just as effective and probably safer. But many older adults skip meals and eat small amounts of fruits and vegetables, citing reasons ranging from rotten teeth to unhappiness with eating alone.

While doctors acknowledge that nutritional shakes and energy bars are helpful for seniors who need to gain weight or have trouble chewing or swallowing, those who eat a balanced diet or stay active do not need them.

In spite of what the experts have said, the savvy advertisements are convincing millions of seniors that they need these expensive supplements, some of which have not even been proven safe.

Herbs are also a source of concern. Saw palmetto, an extracts made from the fruit of the saw palmetto plant, is promoted as a treatment for an enlarged prostate. Many people believe that herbs are natural and therefore safe but this is not the case. In fact, as with most nonprescription herbal products, the composition of the extract and the dosage have not been standardized and the supplement is not regulated by the FDA. If you decide to use saw palmetto, tell your doctor in order to alert him or her to possible interactions between it and other medications you may be taking.

People who are on strict diets — like those prescribed for kidney disease, heart disease, or diabetes — must be especially wary of adding any special supplements to their diet. Regardless of whether health problems are present, you should always consult a physician before starting any dietary regimen.

May 2002 Update

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New Guidelines for Rheumatoid Arthritis Treatment

Rheumatoid arthritis (RA) is a chronic autoimmune disease affecting more than 2 million people in the United States. It causes pain, stiffness, and swelling in the joints, as well as inflammation in organs. Guidelines for the management of the disease were first created in 1996, but significant developments since then prompted the American College of Rheumatology to publish an updated version in the February 2002 issue of its journal, Arthritis & Rheumatism.

A key addition to the new guidelines is the emphasis on early diagnosis and treatment. Recent studies have confirmed that if RA is treated early and aggressively, the course can be altered and the onset of joint destruction can be delayed. The report advises patients to consider nonsteroidal antiinflammatory drugs (aspirin, ibuprofen), glucocorticoid injections, or prednisone to control symptoms once diagnosed. But the new guidelines recommend most people begin treatment with the more potent disease-modifying antirheumatic drugs (DMARDs) within three months of diagnosis. If prognosis is poor, however, DMARDs should be initiated as soon as the diagnosis is confirmed.

The guidelines give information on the efficacy, potential side effects, cost, and administration methods of several new drugs being used in the treatment of RA. These new therapies include three genetically engineered biologic response modifiers (entanercept, infliximab, and anakinra) which target chemicals that cause inflammation. The use of entanercept and infliximab, which work by blocking important inflammation messenger proteins, represent a major advancement in RA treatment. Also presented is a new DMARD, Leflunomide, which slows the structural damage brought on by RA. The guidelines recommend using the aggressive drugs in combination — for example, a biological agent plus a DMARD or two DMARDs.

These new therapeutic options are already being used in the treatment of RA. But for physicians who treat the disorder, the primary value of the new guidelines is the parameters they set for RA therapy and medications.
April 2002 Update

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Advanced Macular Degeneration and Nutritional Supplements

Nutritional supplements may help slow the progression of advanced macular degeneration (AMD), the most common cause of vision loss in people over age 55, a new study suggests.

The Age-Related Eye Disease Study (AREDS), reported in the October 2001 Archives of Ophthalmology, is the largest clinical trial to have tested the impact of nutritional supplements on AMD and cataracts. AREDS involved nearly 5,000 women and men, ages 55-80, at 11 clinical centers nationwide. Participants in the macular degeneration portion of the study were divided into groups depending upon the severity of their condition. They received one of the following daily regimens: 1) antioxidants (500 mg vitamin C, 400 IU vitamin E, 15 mg beta-carotene), 2) zinc (80 mg, plus 2 mg copper to prevent anemia), 3) a combination of the antioxidants and zinc, or 4) a placebo. Participants were evaluated every six months for vision loss and annually for retinal changes.

Over the seven-year study, combined antioxidants and zinc reduced the risk for progression to advanced AMD by 25%, compared with placebo, among those who already had extensive intermediate or large drusen or advanced AMD in one eye. This treatment also reduced the AMD-related loss of visual acuity by about 19%. Antioxidants or zinc alone reduced the risk, but to a lesser extent. AREDS subjects with early or no AMD got no measurable benefit from the supplements. In the companion study of cataract development, antioxidants and zinc (separately or in combination) had no beneficial effect.

Though participants reported no major side effects, the long-term consequences of taking these nutrients at levels above the Recommended Dietary Allowance (RDA), as AREDS participants did, are unknown.
January 2002 Update

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Aggressive Therapy for Older Hearts

There's no question coronary artery bypass grafting and angioplasty can relieve the pain of angina, prevent heart attacks, and add years to the lives of people with blocked coronary arteries. But most studies have excluded people over age 70, so the benefits of aggressive therapy is less clear in the older patient.

Two studies from Switzerland and Canada provide good news for older people who may need bypass surgery or angioplasty. Swiss researchers compared the effects of medical therapy and invasive therapy among more than 300 men and women with angina, all of whom were age 75 or over. They reported the results in the journal Lancet. After six months, the frequency and severity of chest pain had lessened and the quality of life had improved in both groups. But the improvements were substantially greater, and the heart attack rate substantially lower, among those who had undergone bypass surgery or angioplasty.

The Canadian study, which appeared in the Canadian Medical Association Journal, compared the effects of bypass surgery on patients in their 80s and those in their 70s. The investigators found it as safe and effective for octogenarians as it was for septuagenarians and reported that it cost about the same in either group.

Neither of these studies provides blanket assurance that an invasive procedure like bypass surgery or angioplasty is right for every older person with blocked coronary arteries. Older candidates for bypass surgery or angioplasty may want to focus on quality-of-life issues. Recovery, for example, may be a completely different experience for older people.
December 2001 Update

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Statins Associated With Lower Dementia Risk

Most people who develop dementia - poor memory and intellectual functioning that often accompanies old age - have Alzheimer's disease. But a small, yet sizable group of people appear to develop dementia from a narrowing of the arteries supplying the brain. The lack of blood can lead to many small areas of damage to the brain; each too small to be noticeable as a "stroke," but collectively devastating in their effect. This syndrome is called "vascular dementia" to differentiate it from Alzheimer's disease and other types of dementia.

Presumably because high cholesterol levels contribute to the damage of brain's blood vessels, researchers have looked for evidence that people who use statins might have a lower rate of dementia. Statins are the most widely used cholesterol-lowering drugs. In addition to protecting the brain's arteries from atherosclerosis, some scientists believe statins may also help protect the brain against non-vascular forms of dementia, including Alzheimer's disease.

A recent study examined the relationship between statin use and types of dementia among people living in the United Kingdom. The researchers identified 284 people with dementia, and matched them with 1,080 "control" subjects of similar age and sex, but without dementia. After adjusting statistically for a wide range of clinical information, the researchers found statin use was associated with a 71% reduction in dementia risk.

Could statins really cut the risk for dementia by two-thirds or more? It seems unlikely, since other studies haven't suggested protective effects of this size. On the other hand, this study adds to several other laboratory and epidemiological investigations that suggest statins might provide some benefit in the protecting the brain - if for no other reason than lower cholesterol levels lead to healthier brain arteries. No one should start taking statins as a strategy for preventing dementia, but these data do provide another reason for people with elevated cholesterol levels who are on these medications to be sure they take them as prescribed.
October 2001 Update

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Killing H. Pylori Helps Prevent Gastrointestinal Bleeding in Patients Taking Low-Dose Aspirin

Many people take low-dose aspirin on a daily basis to help prevent heart attacks. Others take larger doses of stronger nonsteroidal antiinflammatory drugs (NSAIDs), such as naproxen (Anaprox, Aleve, others), to relieve musculoskeletal pain such as that caused by arthritis. When taken on a regular basis, however, NSAIDs often cause ulcers and gastrointestinal (GI) bleeding. Ulcers, which are raw, crater-like breaks in the mucosal lining of the digestive tract, may also be caused by excess acid production and a bacterium known as Helicobacter pylori (H. pylori).

In a study published in the New England Journal of Medicine, researchers enrolled 400 patients with a history of GI bleeding who were taking aspirin or other NSAIDs to prevent heart disease or to control musculoskeletal pain. They set out to find whether eradicating H. pylori infection reduces the risk of recurrent GI bleeding in these patients. For six months, 250 patients were given an 80 mg "baby" aspirin once per day, while the remaining 150 patients received 500 mg of naproxen twice per day. Within each of the two groups, patients were randomly assigned to take either a daily dose of omeprazole (Prilosec), an acid-suppressing medication, or a one-week antibiotic treatment to eradicate H. pylori infection, followed by placebo for the remainder of the trial.

The researchers found that in patients taking aspirin, those who were treated for H. pylori had a 1.9% risk of GI bleeding while the risk for those taking omeprazole was 0.9%. In other words, for patients on low-dose aspirin, the treatments were almost equal.

The results were very different for patients taking naproxen. 19% of the naproxen patients who had H. pylori treatment suffered from recurrent bleeding. In contrast, only 4% of the omeprazole group did.

The study suggests that patients with a history of GI bleeding who take low-dose aspirin to prevent heart attacks should be tested for H. pylori infection and treated if the infection is found to be present. Patients taking non-aspirin NSAIDs and who have experienced GI bleeding are more likely to benefit from acid-suppressing therapy.
April 2001 Update

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Ipriflavone Not Effective for Osteoporosis

For years, estrogen replacement therapy was the drug of choice for treatment of osteoporosis in postmenopausal women. But the potential risks of HRT sent women searching for alternatives. One option was phytoestrogens — plant-based compounds that bind to estrogen receptors in the body, presumably mimicking the beneficial effects of estrogen without its potential risks. Of the phytoestrogens, the most promising was ipriflavone, a synthetic version of a naturally occurring isoflavone, a type of phytoestrogen.

But a well-designed study published in the March 21, 2001, Journal of the American Medical Association refutes the positive results of previous studies, demonstrating that ipriflavone does not prevent bone loss or reduce the risk of fracture in postmenopausal women. It also cautions that ipriflavone lowers levels of lymphocytes, an effect that could make women more vulnerable to infection.

In the JAMA study, members of the Ipriflavone Multicenter European Fracture Study Group assigned 474 postmenopausal white women with low bone mass aged 45 to 75 to either 200 mg of ipriflavone taken three times per day or a placebo for the three-year duration of the trial.

At the end of the trial, the researchers found no significant difference between the treatment groups in regard to bone mineral density measured at the lumbar spine, total hip, and distal radius; in biochemical markers of bone formation or bone resorption; or in the number of vertebral fractures suffered by the women.

The major difference was that women treated with ipriflavone experienced significant drops in their lymphocyte concentration. 13.2% of the ipriflavone-treated women developed lymphocytopenia, a condition defined as a total lymphocyte concentration below 500/µL. Of these women, 52% returned to normal lymphocyte values within one year of discontinuation of the drug; 81% returned to normal within two years.

In reviewing their findings, the researchers cautioned against the use of ipriflavone to treat osteoporosis.

Women throughout much of the world have used ipriflavone since 1969 to treat osteoporosis. More recently it has been sold over-the-counter in the United States as Ostovone.
April 2001 Update

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Early Cognitive Impairment Following Coronary Bypass May Predict Lasting Cognitive Impairment

More than 500,000 coronary-artery bypass grafting (CABG) surgical procedures are performed in the United States each year to bypass blood around clogged arteries and improve the flow of blood and oxygen to the heart. Advances in anesthesia, surgical procedure, and other areas have made CABG a relatively safe procedure for an expanding group of heart disease patients including older and other high-risk patients. But while the risk of death after CABG has decreased, the risk of cognitive impairment has not. Growing evidence suggests that many patients experience short-term cognitive impairment after CABG.

A recent study in the New England Journal of Medicine confirmed not only the high incidence but also the persistence of cognitive decline following the procedure. It also showed that patients who exhibit signs of cognitive decline immediately following surgery are more likely to continue to suffer from cognitive decline at up to five years after surgery. Researchers from Duke University Medical Center tested the cognitive function of 261 patients before they underwent CABG surgery, and then again before discharge from the hospital and at six weeks, six months, and five years after the CABG procedure. 172 patients, whose average age was 61, completed all of the follow-up.

The researchers found that the incidence of cognitive decline was 53% at discharge, 36% at six weeks, 24% at six months, and 42% at five years. The pattern demonstrated improvement of cognitive functioning within the first six months, and then a decline between six months and five years after surgery.

Even after controlling for age, education level, and baseline test score, patients who experienced cognitive decline immediately following surgery were at a significantly increased risk for long-term cognitive decline and a reduced level of overall cognitive functioning.

It remains unclear why early, postsurgical cognitive decline is associated with a greater risk of long-term cognitive decline.
April 2001 Update

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Sertraline Effectively Treats Depression in Alzheimer's Patients

A large portion of the 4 million Americans with Alzheimer's disease (AD) — a progressive degenerative disease of the brain that results in memory loss, impaired thinking, and personality change — also suffer from major depression. This can make the already devastating condition even more difficult, not only for patients, but also for their caregivers. Until recently, the efficacy of antidepressants in such patients was uncertain. Now, a study from The American Journal of Psychiatry shows that sertraline (Zoloft) a type of antidepressant known as a selective serotonin reuptake inhibitor (SSRI) is more effective than placebo in reducing depression in patients with AD. This study is the first to show both the efficacy and safety of an SSRI in treating depression in patients with AD.

A team of researchers from the Johns Hopkins University School of Medicine and the Copper Ridge Institute in Maryland selected 22 patients with Alzheimer's disease who also met the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for having had a major depressive episode. Over the course of the 12-week double-blind trial, the scientists gave the patients, whose average age was 77, either a placebo or up to 150 milligrams of sertraline per day. All patients and caregivers received illness education, encouragement, and emotional support every three weeks over the course of treatment.

The scientists found that AD patients who had been given sertraline experienced significantly greater improvements in mood than patients who received a placebo. In addition, the sertraline patients experienced less decline than placebo patients in participation in daily activities.

Side effects of the drug included tremor, restlessness, and gastrointestinal complaints. But all were mild, and there was no significant difference in side effects between the sertraline group and the placebo group.
April 2001 Update

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Reducing Your Risk of Deep Vein Thrombosis During Airline Travel

Deep vein thrombosis (DVT), recently featured in the news as "economy class syndrome," is the formation of a blood clot in the deep veins of the legs while sitting — particularly in the cramped seats of an airplane (be it economy class or first class), car, bus, or train — for long periods. You move less in tight quarters, causing circulation to decrease and allowing blood to collect and form a clot. The blood clot may cause pain and swelling in the legs. Serious, even fatal complications can occur if the blood clot breaks loose in the blood stream and travels to the heart or lungs. Older people, and those who are obese or have a family history of DVT tend to be at the highest risk.

While a blood clot can result from a number of causes, some studies suggest an association between blood clots and airplane travel. Many doctors believe this connection is simply a result of being unable to move around, and not from sitting in economy class seats or in an airplane, per se. However, it is possible that pressurized air and dehydration may also play a role in the connection between air travel and blood clots.

Many airlines have already begun to address this health issue by preparing warning pamphlets for their passengers, including articles in their in-flight magazines, posting notices on their Websites, or creating in-flight videos offering exercises aimed at prevention. A member of the parliament in Australia has even called for treadmills to be installed in airplanes that carry passengers for six or more hours.

While treadmills may or may not appear on airplanes in the near future, you can address this issue on your next lengthy flight by taking a few simple measures to help prevent blood clotting.

  • Wear loose-fitting, comfortable clothing during the flight.
  • Eat a small meal and drink plenty of fluids to help increase blood circulation. Avoid alcohol and caffeine, as these contribute to dehydration.
  • Do not cross your legs while seated and make sure you adjust your position every half hour.
  • You may want to wear elastic support hose to increase circulation in your legs.
  • Most importantly, try to walk up and down the aisle at least once an hour. Even standing in front of your seat and gently shaking out your legs or slowly rising up on your toes can help.
  • If you can’t get out of your seat, you can do the following exercises in your seat to increase blood circulation. Perform each exercise for 15 seconds, once an hour.
  • Ankle rotations: Draw a circle with your toes, rotating clockwise and then counterclockwise with both feet.
  • Foot pumps: Slowly alternate between flexing and pointing your toes.
  • Leg lifts: With your knee bent, lift your leg up off the seat and hold for a few seconds. Alternate legs.
  • Head and shoulder rotations: Gently roll your head clockwise and then counterclockwise, keeping your shoulders relaxed. Then gently roll your shoulders forwards and backwards.
  • Toe reach: Slowly bend forward and extend your arms down towards your toes and then gently sit back up.
  • People who are at high risk for blood clotting due to other conditions should speak with their physician for additional advice before traveling.

Studies do not agree on how long a flight needs to be to pose a risk of blood clotting. A few studies even suggest that there is no association between blood clots and air travel. Clearly, more research is necessary. However, while we wait for a definitive answer to these questions, heeding these simple instructions may help prevent problems.
March 2001 Update

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FDA Approves Weekly Dose of Fosamax (alendronate) for Osteoporosis Treatment and Prevention

The FDA recently approved once-a-week doses of Fosamax (alendronate) for the prevention and treatment of osteoporosis. The weekly dose for prevention is 35 mg while the weekly dose for treatment is 70 mg. Fosamax, which was already approved for once-a-day use, works by slowing bone loss.

The main advantage of the once-a-week version is convenience. Doctors recommend that Fosamax be taken first thing in the morning, on an empty stomach, approximately 30 minutes before breakfast, and that patients not lie down for at least 30 minutes after taking the medication. Patients may find that they prefer to adhere to this routine only once a week, rather than every day.

FDA approval was based largely on a two-year clinical trial that showed that for postmenopausal women, a weekly 70 mg dose of alendronate was just as effective at increasing bone mineral density as a 10 mg daily dose. The study included 1,258 postmenopausal women with a mean age of 67. The once-weekly alendronate dose was effective regardless of the women’s underlying condition, age, bone mineral density (BMD), or pre-existing fractures.

Compared with the daily dose, 70 mg of alendronate once a week was better tolerated and produced fewer serious upper gastrointestinal and esophageal problems. The weekly dose also produced similar gains in bone mineral density at the lumbar spine, total hip, femoral neck, hip, and total body sites.
February 2001 Update

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More Evidence That Pumping Iron Is Good for Seniors Too

Two recent studies published in the Journal of the American Geriatrics Society add more data to the mounting evidence that exercise is important at any age and that resistance (or weight) training has considerable benefits for older adults.

It is well known that strength training can improve muscle strength and balance — of particular importance in preventing falls and fractures in seniors. Research on just how much training is required to derive these benefits has been conducted primarily in younger people. The first study looked at how often older people must exercise. Forty-six people (both men and women) between the ages of 65 and 79 years were assigned to a resistance exercise program to be performed one, two, or three days per week. Study results showed that seniors exercising one or two times per week had about the same improvements in muscle strength and coordination as did those who exercised three times per week.

Researchers at the University of Maryland Exercise Science Laboratory conducted the second study, which was designed to look at the effects of strength training on resting blood pressure in older adults (the average age in this study was roughly 69). Eleven men and 10 women who had not been exercising regularly were assigned to a six-month training program using weight lifting machines. Not only did the study volunteers show significant increases in upper- and lower-body strength, but both groups also demonstrated significantly lowered diastolic blood pressure (the bottom number in a blood pressure reading). Interestingly, only the men in the group experienced significantly lowered systolic blood pressures (the top number in a blood pressure reading). Perhaps the best news was that the reduction in blood pressure brought these patients’ readings into the normal range. Investigators also noted that the improvement in blood pressure was not related to weight loss associated with increased exercise.

The bottom line, however, is not news at all. Exercise is important, good for individuals of every age group, and the health benefits are many. Even doing a little is a whole lot better than doing no exercise at all.

Journal of the American Geriatrics Society, Vol. 47, No. 10, pp. 1208–14.
Journal of the American Geriatrics Society, Vol. 47, No. 10 pp. 1215–21.

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Purchasing Prescriptions Online

Your mother always warned you about taking candy from strangers. Now a new study cautions consumers about buying prescription drugs from electronic strangers. The Internet offers unparalleled access to health care information and increasingly unparalleled shopping for prescription pharmaceuticals. However, a survey conducted by researchers at the University of Pennsylvania found these online pharmacies are, at best, expensive alternatives to traditional pharmacies and at worst, potentially dangerous substitutes for your doctor's advice.

The study reviewed Internet sites offering prescription drugs directly to the public. Information examined included the procedures for obtaining medication, prescription and shipping costs, cost of physician consultations, and physician qualifications. Study investigators then compared the prices of consultations and two popular medications — Viagra (for impotence) and Propecia (for hair loss) — with prices at the clinics and pharmacies in their area.

Thirty-seven of the 45 sites required a prescription or online physician approval before purchase. Nine sites, all based overseas, required no physician consent. Most consultations consisted of online medical history forms and limited interaction through e-mail. The resulting medication was 10% more expensive on the Web before adding shipping costs. Consultation costs, too, were higher, averaging 15% above clinic rates.

While the additional costs might not worry those consumers more interested in convenience or privacy, the potential risks should. The dangers associated with sites that do no require any form of physician approval are obvious. However, none of the sites, even those requiring a doctor's approval, revealed the names, specialties, or qualifications of their physicians. The lack of a physical exam likely increases the risk of misdiagnosis, and only five sites listed their business' physical address, should a problem occur.

In June of 1999, the American Medical Association issued a statement condemning doctors who diagnose patients without access to the patient's medical records, a reasonable likelihood of follow-up, or, at least, a physical exam. More regulations will certainly follow. Until then, consumers should think twice before surfing to the online pharmacy. For more information on managing your medications, see page 1,156 of the Family Health Guide.

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