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April 22, 2004


20-Year Estrogen Effects Studied [Ob/Gyn News; 24-Mar-04]
International Journal of Obstetrics and Gynaecology 2004; 111: 335-9

The reduction in bone loss achieved with short-term estrogen therapy in postmenopausal women is maintained in the long-term, for up to 23 years, research shows. Several randomized controlled trials have demonstrated that menopausal bone loss can be reduced by estrogen therapy, Henrik Ahlborg (Malmö University Hospital, Sweden) and colleagues note. However, "few studies have evaluated the effect of estrogen therapy for more than 3 years, none for more than 10 years of treatment, so the long-term effect of estrogen therapy on bone loss is still unclear."

To investigate, the team assessed the rate of forearm bone loss among 28 patients receiving long-term estrogen therapy and 196 untreated women from the age of 48 to 72 years. Analysis showed that women receiving estrogen had an 8.7 percentage point lower rate of bone loss at follow-up than those not taking estrogen throughout the study period. Specifically, each year of treatment equated to a 0.8 percentage point reduction in the rate of bone mineral density loss. "In conclusion, estrogen therapy in women during the peri- and postmenopausal years seems to reduce the rate of bone loss over a period of 23 years, and the longer the duration of the therapy, the lower is the bone loss," Ahlborg's team comments.(© Science Press Internet Services)


2004 Kidney function indicates HF prognosis
Am J Med 2004; 116: 466-473

Blood levels of urea nitrogen, a measure of kidney health, offer a simple clinical variable that can indicate prognosis in patients admitted to hospital with decompensated heart failure (HF), say researchers. "Our data suggest that renal function as assessed during this unstable phase is predictive of mortality," write Doron Aronson (Rambam Medical Center, Haifa, Israel) and colleagues in the American Journal of Medicine. "It should be emphasized, however, that increases in blood urea nitrogen level and blood urea nitrogen/creatinine ratio probably represent renal response to systemic hypoperfusion in the context of decompensated HF rather than intrinsic renal dysfunction."

Importantly, the study showed that both measures of kidney function appeared to be more accurate than serum creatinine or creatinine clearance - already shown in other studies to provide independent prognostic information on mortality from progressive HF. Aronson's team explains that chronic HF involves a complex interaction between the heart and kidneys.

Specifically, they assessed four measures of renal function - blood urea nitrogen, serum creatinine, blood urea nitrogen/creatinine ratio, and estimated creatinine clearance - before initiation of the drugs. All 541 HF patients (mean age=63 years, 70% men) included in the current study were admitted to hospital for clinical decompensation, and had a previous diagnosis of HF - 96% with New York Heart Association class III or IV symptoms. During a mean follow-up of 343 days, 33% of the patients died. Multivariable Cox regression models revealed that the risk of all-cause mortality increased with each quartile of blood urea nitrogen levels, with an adjusted relative risk of 2.3 for patients in the upper quartile (>45 mg/dl) compared with the lower three (p=0.005). Blood urea nitrogen/creatinine ratio offered similar prognostic information to blood urea nitrogen. In contrast, after adjusting for other covariates, creatinine and estimated creatinine clearance were not significant mortality predictors.

The researchers suggest that activation of the renin-angiotensin-aldosterone system, increased catecholamine production, and elevated endothelin levels in decompensated HF all contribute to renal arteriolar vasoconstriction. "The result is a reduction in renal perfusion pressure, with increased sodium and water reabsorption, and therefore enhanced urea reabsorption," they write. "Elevated vasopressin levels in HF are likely to contribute to the increased blood urea nitrogen/creatinine ratio, owing to distal nephron urea reabsorption without creatinine absorption." The authors conclude: "Our results suggest that simple measures of renal function can contribute to better stratification of patients admitted with severe decompensated HF." (© Science Press Internet Services)


2004 Superior protection against MI remodeling with ARBs
Hypertension 2004; 43: 1-7

A study from Wake Forest University Health Science Center in Winston-Salem, North Carolina, USA, indicates that angiotensin II receptor blockers could offer greater protection against cardiac remodeling after myocardial infarction (MI) than standard treatment with ACE inhibitors. The findings, in rats, provide further insights into the role of angiotensin II and the renin-angiotensin system (RAS) in the development of heart failure after MI, and the way in which ACE 2, a novel ACE-related carboxypeptidase that degrades angiotensin II into angiotensin-(1-7), can prevent this. In a previous study, Yuichiro Ishiyama and colleagues characterized the actions of angiotensin-(1-7) and found that the RAS consists of two arms: one that generates angiotensin II via the action of ACE on angiotensin I, and the other that generates angiotensin-(1-7) via enzymes other than ACE.

"The discovery of ACE 2 and the demonstration that its catalytic efficiency is approximately 400-fold higher with angiotensin II as a substrate than with angiotensin I strengthened our hypothesis that this second arm of the system acts as a counter-regulator for the first arm," says the team. To substantiate their theory, Ishiyama et al examined the effect of myocardial ischemia on the expression of cardiac ACE and ACE 2 in 78 rats, both in the absence and in the presence of systemic angiotensin II Type 1a (AT1a) receptor blockade with losartan or olmesartan. Three groups of animals underwent coronary artery ligation, and afterwards received olmesartan, or the vehicle (isotonic saline) via osmotic minipump for 28 days. A fourth group underwent a sham operation, and received no treatment. The researchers report in the journal Hypertension that ligation caused left ventricular dysfunction and compensatory cardiac hypertrophy, and stimulation of the RAS. Furthermore, the chronic phase of MI-induced cardiac remodeling decreased cardiac AT1a messenger (m)RNA, without cardiac ACE or ACE 2 mRNA changes. While MI induced increases in plasma levels of angiotensin I, angiotensin II, and angiotensin-(1-7), there was a higher concentration of circulating angiotensin II compared with angiotensin-(1-7). Both angiotensin II antagonists attenuated cardiac hypertrophy, with olmesartan also increasing cardiac contractility after ligation. The agents also reversed the reduction in AT1a receptor mRNA, and caused large increases in ACE 2 mRNA of approximately 3-fold compared with vehicle or sham treatment. "We believe that ACE 2 may be a natural mechanism for protecting the heart," said senior author Carlos Ferrario. "It seems to limit levels of angiotensin II by degrading it into angiotensin-(1-7). "This research was the first demonstration to show that by blocking the receptor for angiotensin II, we can stimulate production of ACE 2." ACE inhibitors, in contrast, merely block the production of angiotensin II. Ferrario said that the study also reveals more of the complex system of enzymes and hormones that regulates the cardiovascular system. "We believe that this new knowledge could lead to more effective drugs with fewer side effects," he said. (© Science Press Internet Services)


2004 Cancer Research UK

Most people are unaware that being overweight increases their risk of developing cancer, a UK survey has revealed. The poll, carried out on behalf of the charity Cancer Research UK, revealed that few of those surveyed realised that excessive weight gain could increase an individual's chances of developing cancer of the breast, womb, kidney, bowel and oesophagus. Indeed, only 3% of the 1000 adults questioned knew that being overweight increased the risk of cancer development compared with 70% who were aware of the link with heart disease.

Dr Lesley Walker, Director of Cancer Information at Cancer Research UK, said: "The results of this survey are extremely worrying especially as being overweight is the major preventable risk factor for cancer in non-smokers. "Post-menopausal women who are overweight have a greater risk of developing breast cancer and there is also evidence of a link between being seriously overweight and cancer of the womb, kidney, bowel and oesophagus." Professor Jane Wardle, Director of Cancer Research UK's Health Behaviour Unit, added that "excess body fat is not harmless extra padding", but is active tissue producing hormones that can increase the risk of cancer development. "In order to lose weight and then maintain a healthy body weight you need to eat less and be more active. Even small weight losses have been shown to have a beneficial effect on health," she said. (© Science Press Internet Services)



Leading brand breakfast cereals high in fat, sugar and salt were named yesterday by the Consumers Association, supporting its anti-obesity campaign to improve food labelling. The association found that, despite being marketed as healthy, 85 of the 100 products contained high levels of unhealthy ingredients, after assessing the cereals against Food Standards Agency thresholds. In total, 85 cereals were found to contain "a lot of sugar", defined as 10 g or more per 100 g. Forty of the products contained at least 1.25 g of salt per 100 g, and nine had levels of saturated fat as high as 20 g per 100 g. Nick Stace, director of communications at the association, said: "Breakfast cereals have a healthy image, yet our research shows that big brand manufacturers are lacing their cereals with such high levels of sugar and salt that it is no wonder that we have a public health crisis on our hands."

Cereals targeted at children were found to be the worst offenders, with nine of these consisting of at least 40% sugar. In particular, Nestlé Lion Cereal, Kellogg's Frosties Turbos and Nestlé Cookie Crisp were found to be the worst. For those who grab a cereal bar in the morning because they have too little time to prepare breakfast, the findings were worse....

The 11 cereal bars examined by the Consumer's Association had a lot of saturated fat, providing less energy and fibre than an equivalent bowl of cereal. In addition, they discovered that one serving of Kellogg's All Bran, Quaker Oat Krunchies or Nestlé Golden Grahams contained four times the amount of salt found in a 25 g packet of roasted peanuts. However, Martin Paterson, deputy director general of the Food and Drink Federation, said the industry had already started a programme to reduce the salt content of breakfast cereals. He commented: "The programme showed a 16% reduction in sodium achieved since 1998 in the sector, and an expectation that new products coming to market will continue the trend for products with lower sodium levels." The Consumers Association is pushing for a system of "traffic light" labelling to be introduced, enabling shoppers to easily assess the levels of fat, sugar and salt in manufactured food products. Public Health Minister Melanie Johnson agreed that improved food labelling could be the best way to improve the nation's diet. She said: "What many people consider a health-conscious diet is often high in salt. "Despite claims by the industry that they've taken substantial action, we need to see real steps forward to cut salt levels." She added: "If we don't see progress then action on food labelling could be the answer."( © Science Press Internet Services)



2004 Anger Can Provoke Sudden Cardiac Death Mental Stress Can Trigger Sudden Dangerous Heart Rhythm
By Jeanie Lerche Davis WebMD Medical News
Reviewed By Charlotte Grayson, MD on Monday, March 22, 2004

Anger, frustration, and other mental stress can trigger abnormal heart rhythms that may lead to sudden death, new research shows. In the first study of its kind, a group of researchers has demonstrated that mental stress alone can provoke these dangerous heart rhythms. Their study appears in the April 13 issue of Circulation: Journal of the American Heart Association.

Certain irregular heart rhythms (or arrhythmias) put people at high risk for sudden death. The unpredictable nature of these arrhythmias has posed a major challenge in preventing sudden cardiac death, writes researcher Willem J. Kop, PhD, with the Uniformed Services University of the Health Sciences in Bethesda, Md. In recent years, however, doctors have been able to more clearly identify people who are at risk for these arrhythmias -- as well as the activities that can trigger sudden cardiac death.

For example, researchers have identified an abnormal heart rate pattern called T-wave alternans (TWA) that are proving to be a new marker of heart rhythm instability that precedes potentially dangerous arrhythmias. They can be measured via electrocardiogram (EKG). This heart rate pattern has been identified in people with implantable cardiac defibrillators (ICDs) and heart attack survivors during exercise testing. Other studies show that periods of emotional upset -- such as anger -- can trigger life-threatening arrhythmia and other heart irregularities. This study is the first to look at TWA patterns during times of severe mental stress.

In this study, 23 patients with heart disease and ICDs and 17 people with no heart disease participated in two days of mental stress and exercise tasks. In one mental stress test, the volunteer was asked to give a four-minute speech about a recent anger-provoking incident. The other test was a challenging mental arithmetic test; each volunteer was interrupted and urged to improve performance throughout the test. The exercise test involved 25 minutes of bicycling; volunteers were stopped before they developed any heart-related problems. During both the mental stress and exercise tests, the defibrillator patients all had increases in the abnormal TWA heart rhythm pattern than the healthy people did. However, there was one significant difference: Mental stress provoked in the defibrillator patients' a dramatic increase in the abnormal heart rate pattern at a significantly lower heart rate than did the exercise. This is important, Kop says, because exercise testing has been the traditional method used to measure risk for unstable heart rhythms.

This study showed that exercise testing may miss some patients at risk for serious arrhythmias; mental stress can provoke a potentially fatal instability in heart rhythm in people who have heart disease at much lower heart rates than is caused with exercise testing. If the findings can be replicated in a larger study, they may affect the evaluation and management of many patients, especially older and more sedentary heart patients, and to those with heart disease, he says. Other studies show that anger and mental stress create arrhythmias that trigger an ICD discharge, Kop points out.( SOURCE: Kop, W. Circulation: Journal of the American Heart Association, rapid access issue, April13, 2004; vol 109. © 2004 WebMD Inc.)


Chicken Taco Salad For 4 servings

• 3/4 cup bottled salsa

• 3 tablespoons white wine vinegar

• 1 teaspoon sugar

• 1/2 teaspoon ground cumin

• 1/4 teaspoon dried thyme

• 1/4 teaspoon bottled minced garlic

• Dash of ground red pepper

1/2 pound skinned, boned chicken breast, cut into 1-inch strips

• 1 cup halved cherry tomatoes (about 12 tomatoes)

• 1 cup canned kidney beans, rinsed and drained

• 1/4 cup minced fresh cilantro

• 1 tablespoon olive oil

• Cooking spray

• 4 cups coarsely chopped iceberg lettuce

• 1 cup (4 ounces) shredded reduced-fat cheddar cheese

• 32 low-fat baked tortilla chips

Taco salad was made for the crunch and texture of iceberg lettuce--or maybe vice versa--but in a pinch, romaine could stand in.

1. Combine the first 7 ingredients in a bowl. Combine 1/2 cup of salsa mixture and chicken in a zip-top plastic bag; seal and marinate in refrigerator 30 minutes. Add the tomatoes, beans, cilantro, and oil to remaining salsa mixture; cover and marinate in refrigerator 30 minutes.

2. Place a medium nonstick skillet coated with cooking spray over medium-high heat until hot. Add chicken mixture; saute 5 minutes or until chicken is done.

3. Place 1 cup lettuce on each of 4 plates; top each serving with 1/2 cup bean mixture and one-fourth of chicken mixture. Sprinkle each serving with 1/4 cup cheese. Serve each salad with 8 tortilla chips.

Yield: 4 servings. CALORIES 391 (25% from fat); FAT 11g (sat 3.9g, mono 2.8g, poly 1g); PROTEIN 30.4g; CARB 43.8g; FIBER 6g; CHOL 51mg; IRON 4mg; SODIUM 767mg; CALC 320mg



ICDs Reduce Death From Heart Failure

Heart Failure Patients May Benefit From ICDs, but Cost Is an Obstacle By Peggy Peck WebMD Medical News Reviewed By Brunilda Nazario, MD on Tuesday, March 09, 2004 >

A tiny implantable defibrillator may be the best treatment for a broad range of patients with disabling heart failure -- saving lives when drugs alone can't do the job, says Gust H. Bardy, MD, president of the Seattle Institute for Cardiac Research. And Bardy, who just completed overseeing the largest study ever of these devices, says he has the number to prove his point -- the devices commonly called ICDs reduced death by 23% compared with the best medical treatment. He unveiled those numbers at the American College of Cardiology Scientific Session 2004.

Heart failure often follows injury such as the scarring caused by heart attacks or damage caused by infections that attack heart muscle. Heart failure means the heart begins to pump less efficiently and gets larger and weaker, which causes the fatigue, breathlessness, and swelling that are hallmarks of heart failure. New Candidates for ICDs According the American Heart Association, about 5 million Americans are living with this condition, with 550,000 new cases diagnosed each year. But one of the most dangerous complications of heart failure is sudden cardiac death, which is caused by an electrical failure in the heart that causes it to beat irregularly or suddenly stop beating. Defibrillators give an electric shock to the heart, helping to re-establish normal rhythms.

ICDs are programmed to detect the irregular heartbeats that often precede sudden cardiac arrest. Perhaps the most famous recipient of an ICD is vice president Dick Cheney, who has a history of heart disease and who was implanted with an ICD shortly after taking office. ICDs are often used in people who have a history of irregular heartbeats. In recent years, however, they have been implanted in patients who don't yet have arrhythmias but who are considered "at risk" because they have had heart attacks. And now, people with heart failure may be added to the list of patients who are eligible for ICD treatment.

But a big obstacle to ICD use is cost -- many models cost as much as $30,000, with physician and hospital fees on top of that. So researchers and payers, most notably Medicare and Medicaid, have been trying to decide which patients should get ICDs. Bardy's new study suggests that heart failure patients, especially those who are sick but not completely disabled, are good candidates for ICDs. But he tells WebMD that expanding ICD coverage to include these patients could mean that as many as 1 million Americans could be implanted with ICDs. Michael Cain, MD, president of the NASPE-Heart Rhythm Society and director of the cardiovascular division at Washington University in St. Louis, tells WebMD that he estimates "400,000 to 1.5 million people [with heart failure] could benefit from ICD implant."

Better Than Medication? The new study enrolled more than 2,500 patients who were randomly chosen to receive either ICD, treatment with a drug used for arrhythmias called amiodarone, or dummy pills and then followed for almost four years. Bardy says the patients treated with amiodarone did no better than patients receiving dummy pills. At a news conference, Bardy said the study was specifically designed to have a "broad public health impact" and he contended that results deliver that impact. But when asked about real-world economic impact of those results -- for example, if the Centers for Medicare and Medicaid would loosen current restrictions on Medicare reimbursement for ICDs, Bardy declined to comment. Sidney C. Smith Jr., MD, professor of medicine and director of the Center for Cardiovascular Science and Medicine, tells WebMD that the results of the study may help the ICD proponents overcome the "resistance" from third-party payers. "My feeling is that the issue is science. When the science shows a patient benefit, cost should not be a barrier. So it may be that we need to find a way to produce cheaper ICDs." Smith was not involved in the study. The study was sponsored by Medtronic Inc., Wyeth Pharmaceuticals, and the National Heart, Lung and Blood Institute. Medtronic and Wyeth are WebMD sponsors. (SOURCES: American College of Cardiology Scientific Session 2004, New Orleans, March 7-10, 2004. Late breaking clinical trials. Gust Bardy, MD. Michael Cain, MD. Sidney Smith, MD. American Heart Association. © 2004 WebMD Inc.)


Today's Tip from Dr. Weil

Practicing Breath Work In Buddhist and yogic traditions, people claim to have reached an enlightened state by doing nothing more than paying attention to the rising and falling of their breath. What easier way could there be to reach such a state? Especially since breathing - following the ebb and flow of your breath - is an intrinsic part of meditation. By paying attention to your breath, you will rapidly change your state of consciousness, begin to relax, and slowly detach from ordinary awareness. Try to focus on the point between your inbreath and outbreath that is dimensionless, and glimpse the elements of enlightenment in that space.




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Last Modified on April 22 2994

News information is courtesy of Medscape, Medpulse and HeartCenterOnline & MedLinx, Intelihealth & Ivanhoe, Reuters, CNN, plus others as noted.