Physician's First Watch: Archives

Vitamin D Supplementation Linked to Decreased Risk for Falls

High doses of supplemental vitamin D may lower the risk for falls in older adults, reports a BMJ meta-analysis.

Researchers examined data from eight randomized controlled trials of supplemental vitamin D (vitamin D2 or D3) in roughly 2400 adults aged 65 or older. Among the findings:

• Supplemental vitamin D at 700 to 1000 IU/day (but not lower doses) was associated with a significant, 19% reduction in falls relative to no supplementation.
  
• Serum vitamin D concentrations of 60 nmol/L or higher were associated with a 23% drop in falls (lower concentrations showed no significant association).
  

Researchers also looked at two trials of some 600 older adults and active vitamin D, a metabolite that may be more readily available for people with diminished kidney function. The reduction in falls was similar to that seen with supplemental vitamin D. However, patients taking the active form were more likely to experience hypercalcemia than controls.

As a potential underlying mechanism, the authors note that vitamin D has direct effects on muscle strength.

LINK(S):

BMJ article (Free)

Journal Watch General Medicine summary of 2005 study showing that vitamin D supplementation reduces risk for falls (Your Journal Watch registration required)

Published in Physician's First Watch October 5, 2009

FDA Approves Intrauterine Device for Heavy Menstrual Bleeding

The FDA approved the levonorgestrel intrauterine system (Mirena) for treatment of excessive menstrual bleeding in women who use intrauterine contraception, the agency announced. The device was first marketed in 2000 for contraception in women who already have had a child.

The new indication was approved following a clinical trial of 160 women with confirmed heavy menstrual bleeding, the manufacturer said. After six menstrual cycles, Mirena was found to be more effective than medroxyprogesterone acetate in reducing monthly blood loss to less than 80 mL and by more than 50% from baseline.

Common side effects in the trial included uterine bleeding or spotting, headache, ovarian cysts, vaginitis, pelvic pain, dysmenorrhea, and breast tenderness.

LINK(S):

FDA news release (Free)

Manufacturer news release (Free)

Journal Watch Women's Health summary on levonorgestrel intrauterine system and menorrhagia (Your Journal Watch subscription required)

Published in Physician's First Watch October 5, 2009

Surgical Masks as Efficient as N95 Respirators Against Flu

Standard surgical masks are as effective as fit-tested N95 respirators in protecting healthcare workers against influenza, according to a JAMA report published online.

Some 450 Ontario nurses working in emergency departments, medical units, and pediatric units were randomized to use either a fit-tested N95 respirator or a surgical mask when caring for patients with febrile respiratory illnesses during the 2008-2009 flu season. By study's end, roughly 23% of each group had suffered a laboratory-confirmed influenza infection, showing the noninferiority of surgical masks for protection.

The authors warn that their results "should not be generalized to settings where there is a high risk for aerosolization, such as intubation or bronchoscopy, where use of an N95 respirator would be prudent."

Editorialists say that masks and respirators should be considered the "last line of defense" in infection control in influenza, with the first being annual vaccination of healthcare personnel.

LINK(S):

JAMA article (Free)

JAMA editorial (Free)

Physician's First Watch coverage of the IOM's recommendation of N95 respirators (Free)

Published in Physician's First Watch October 2, 2009

H1N1 Update: 'Substantial Flu Illness in Most of the Country'

There is "substantial flu illness in most of the country," according to a CDC news briefing Thursday.

Dr. Anne Schuchat, director of the CDC's National Center for Immunization and Respiratory Diseases, also announced that some 300,000 courses of pediatric liquid Tamiflu (oseltamivir) had been released to the states. She said that some lots had exceeded their expiration dates, but that those dates had been extended after careful testing.

In addition, Dr. Schuchat said that the first doses of vaccine against 2009 H1N1 flu — in nasal spray formulation — would be available early next week. She said that, contrary to myth, "most health care workers who are under 50 and don't have [certain] chronic conditions can receive the nasal spray." (The conditions are pregnancy, asthma, diabetes, chronic heart or lung disease, and immunosuppression.)

In response to a question suggesting that many parents feel that the H1N1 vaccines haven't been thoroughly tested, she responded that "no corners have been cut at all."

LINK(S):

Transcript of CDC news briefing (Free)

Published in Physician's First Watch October 2, 2009

'No Clear Evidence' That Chantix Increases Risk for Self-Harm

There's "no clear evidence" that the smoking-cessation drug varenicline (Chantix) increases the risk for self-harm compared with other smoking-cessation therapies, BMJ reports.

Using a national database, U.K. researchers studied more than 80,000 adults prescribed varenicline, bupropion (Wellbutrin), or nicotine-replacement products over a 21-month period. Compared with nicotine-replacement therapy, varenicline had a hazard ratio for self-harm of 1.12 (confidence interval, 0.67-1.88), even after adjustment for confounders such as previous psychiatric consultation. Although the association was not statistically significant, the authors write that "limited study power means [they] could not rule out either a halving or a twofold increase in risk" with varenicline. (The hazard ratio with bupropion was 1.17.)

Varenicline was not significantly associated with depression or suicidal thoughts.

The authors conclude that their results "provide some reassurance concerning [varenicline's] association with suicidal behavior."

LINK(S):

BMJ article (Free)

Physician's First Watch coverage of boxed warning on smoking cessation drugs (Free)

Published in Physician's First Watch October 2, 2009

Benefits of Treating Mild Gestational Diabetes

Treating mild gestational diabetes, although ineffective in lowering perinatal mortality, confers other benefits to both baby and mother, according to a New England Journal of Medicine study.

Nearly a thousand women with mild gestational diabetes underwent randomization to active treatment (counseling, dietary therapy, and insulin if necessary) or to usual care. "Mild" gestational diabetes was defined as a fasting glucose under 95 mg/dL and abnormal results on an oral glucose-tolerance test.

Babies in both treatment and control groups showed roughly the same levels of perinatal mortality and severe complications, such as hyperbilirubinemia and hypoglycemia. However, those in the treatment group were less likely to be large-for-gestational-age or present with shoulder dystocia, and their mothers were less likely to deliver by cesarean section or to have pre-eclampsia or gestational hypertension.

In Journal Watch Women's Health, Dr. Ann Davis writes that "these results provide compelling evidence in favor of treating women who have mild [gestational diabetes]."

LINK(S):

NEJM article (Free abstract; full text requires subscription)

NEJM editorial (Subscription required)

Journal Watch Women's Health summary (Free)

Published in Physician's First Watch October 1, 2009

Maternal Smoking During Pregnancy Linked to Psychotic Symptoms in Children Years Later

Children whose mothers smoked during pregnancy are at increased risk for psychotic symptoms by age 12, according to a longitudinal study in the British Journal of Psychiatry.

Researchers gathered information on women's use of tobacco, alcohol, and cannabis during pregnancy and then evaluated their offspring for psychotic symptoms 12 years later. Of nearly 6400 children assessed, about 12% had suspected or definite psychotic symptoms.

In adjusted analyses, maternal smoking was associated with increased risk for psychotic symptoms in offspring, with a dose-response effect (odds ratio for trend, 1.2). A link between alcohol use and psychotic symptoms was limited to mothers who consumed more than 21 units a week. Cannabis use was not associated with symptoms.

The authors say their findings are "consistent with accumulating evidence from animal models of adverse effects on brain development from in utero nicotine exposure."

LINK(S):

British Journal of Psychiatry article (Free)

Published in Physician's First Watch October 1, 2009

H1N1 Update: Bacterial Coinfection in H1N1-Related Deaths

Bacterial pneumonia is contributing to deaths related to 2009 H1N1 influenza, according to a report released online in MMWR. The CDC reiterates the importance of high-risk patients receiving the pneumococcal vaccine.

Researchers analyzed autopsy tissue specimens from 77 patients who died of H1N1-related illness. Of those, 29% had evidence of bacterial coinfection. Streptococcus pneumoniae was the most common bacteria found. (These cases may not be an accurate representation of concurrent bacterial infections in H1N1 fatalities, according to an editorial note, because this was not a systematic sample.)

The CDC says the findings "underscore both the importance of pneumococcal vaccination for persons at increased risk for pneumococcal pneumonia and the need for early recognition of bacterial pneumonia in persons with influenza."

LINK(S):

MMWR article (Free)

CDC guidance for use of pneumococcal vaccine during H1N1 outbreak (Free)

Physician's First Watch coverage of bacterial coinfection in children (Free)

NEJM/Journal Watch H1N1 Influenza Center (Free)

Published in Physician's First Watch September 30, 2009

Two-Drug Combo Appears Better Than Monotherapy for Neuropathic Pain

A combination of the anticonvulsant gabapentin and the antidepressant nortriptyline relieves neuropathic pain more effectively than either drug alone, Lancet reports.

In a crossover study, 56 adults with chronic pain due to diabetic polyneuropathy or postherpetic neuralgia were assigned to the following treatment regimens: gabapentin alone, nortriptyline alone, and a combination of the two. All patients were to receive each regimen, for 6 weeks each, but the sequence of the regimens was randomized. Drug doses were titrated to the maximal tolerable dose.

Overall, mean daily pain intensity was significantly lower with combination therapy than with monotherapy. Adverse events were similar with the three treatments, although significantly fewer patients reported dry mouth with gabapentin than with the other regimens.

The authors discuss several study limitations but conclude: "We recommend combined gabapentin and nortriptyline for patients who have a partial response to either drug alone and seek additional pain relief."

LINK(S):

Lancet article (Free abstract; full text requires subscription)

Lancet comment (Subscription required)

Published in Physician's First Watch September 30, 2009

Beneficial Effect of Weight Loss on Obstructive Sleep Apnea in Patients with Diabetes

Participation in an intensive lifestyle intervention leading to weight loss is associated with improvements in obstructive sleep apnea among patients with diabetes, reports Archives of Internal Medicine.

Researchers studied some 260 overweight older patients (mean age, 61) with type 2 diabetes and obstructive sleep apnea (average apnea-hypopnea index, 23 events per hour) for 1 year. Patients were randomized either to an intensive lifestyle intervention using restricted caloric intake and moderate exercise, or to a series of three group sessions focusing on diet, exercise, and social support.

By year's end, intensive-intervention patients had lost significantly more weight and showed a significant improvement in sleep apnea, compared with controls. In the control group, patients showed a worsening in their sleep apnea, despite maintaining stable weight. The greatest improvements in the apnea-hypopnea index were among patients with the highest initial values and the greatest weight loss.

LINK(S):

Archives of Internal Medicine article (Free abstract; full text requires subscription)

Published in Physician's First Watch September 29, 2009