Vitamin E and Cardiac Disease
Brown GB, Crowley J: Is there any hope for vitamin E? JAMA 2005;293(11):1387-90 (editorial).
The HOPE and HOPE-TOO Trial Investigators: Effects of long-term vitamin E supplementation on cardiovascular events and cancer: a randomized controlled trial. JAMA 2005;293(11):1338-47.
Although experimental studies have supported the hypothesis that antioxidants protect against atherosclerosis, recent randomized placebo-controlled clinical trials have consistently shown that commonly used antioxidant vitamin regimens do not significantly reduce overall cardiovascular events or cancer. The HOPE-TOO trial extends the 9,541 patient HOPE Vitamin E trial 2.5 years beyond its previously reported follow-up. After over 7 years of follow-up, vitamin E did not significantly reduce the risk of total cancer incidence, of cancer death, or of a composite of cardiovascular events for these 50- to 75-year-old men and women with established cardiovascular disease or diabetes. In fact, 400 units of vitamin E daily was associated with significant increases in heart failure (RR = 1.4; 95% CI 1.13 to 1.73; p = 0.02) and subtle but not statistically significant trends toward more ischemic complications of atherosclerosis. Brown and Crowley suggest that the vitamin E, C, and beta carotene combination actually reduces levels of cardioprotective high-density lipoprotein 2 cholesterol levels, which may lead to more atherosclerosis. The HOPE investigators advise that vitamin E should not be used in patients with vascular disease or diabetes due to its potential for harm and failure to show benefit.
Very Low LDL Cholesterol Levels
LaRosa JC, Grundy SM, Waters DD, et al: Intensive lipid lowering with atorvastatin in patients with stable coronary disease. N Engl J Med 2005;352(14):1425-35.
Pitt BP: Low-density lipoprotein cholesterol in patients with stable coronary heart disease-is it time to shift our goals? N Eng J Med 2005;352(14):1483-84 (editorial).
Previous trials have shown that very low levels of low-density lipoprotein (LDL) cholesterol benefit patients with acute coronary syndromes. This trial enrolled over 10,000 patients with stable coronary artery disease who already had LDL cholesterol levels < 130 mg/dL and assigned them randomly to receive either 10 mg or 80 mg of atorvastatin daily. During the pretrial run-in phase, 131 patients were excluded because of abnormal liver function tests or myalgia. After 5 years of follow-up, mean LDL cholesterol levels were 77 mg/dL in the group that received 80 mg of atorvastatin compared to 101 mg/dL with the 10 mg dose. Aminotransferase elevation occurred in 0.2% of the 10 mg group compared to 1.2% of the 80 mg group (P <0.001). A primary event of a first major cardiovascular event occurred in 8.7% of the patients receiving 80 mg atorvastatin compared to 10.9% of those receiving 10 mg (HR = 0.78; 95% CI 0.69 to 0.89; P <0.001). Although the risk of coronary heart disease events was reduced by intensive lipid-lowering therapy with 80 mg of atorvastatin per day, the overall risk of death was not. Additional long-term safety data is needed before this approach can be recommended for all patients with stable coronary heart disease.
Pediatric/Adolescent Care
The Common Cold
Pfeiffer WF: A multicultural approach to the patient who has a common cold. Pediatr Rev 2005;26(5):170-5.
Saying "She has a 'catarro' and she needs hot lemonade" may be the only advice an examiner need give a parent from Guatemala who has a child with an upper respiratory infection. This handy 2-page list of over 45 countries provides the examiner with the term for the common cold and the remedies used in that country. This database was obtained from a Kaiser Permanente Honolulu Pediatric Clinic, which has one of the most multicultural populations in the world. Studies have shown that most parents are interested in education about the condition rather than just medication, although over 40% of patients with the diagnosis of upper respiratory infection receive an antibiotic on request. Upper respiratory infection is a self-limited process and medications are expensive and have shown little or no benefit in reducing the symptoms. Home remedies help decrease the discomfort and this list includes multiple choices from barley soup to sniffing red onion. This list should be in any examination room where culturally diverse children are treated for common illnesses.
Pertussis in Teens and Adults
Lee GM, LeBaron C, Murphy TV, et al: Pertussis in adolescents and adults: Should we vaccinate? Pediatrics 2005;115(6):1675-84.
This study uses a complex statistical model to evaluate vaccination of adolescents with pertussis vaccine. The study evaluates potential health benefits, risks, and costs of a national vaccination program. Using a hypothetical cohort of 4 million adolescents, over 85,000 cases would occur if no vaccination program existed. Six protocols are examined: no vaccination, onetime adolescent vaccination, onetime adult vaccination, adult vaccination boosters, adults and adolescent vaccination with boosters, and postpartum vaccination. The onetime adolescent vaccination would prevent 36% of the pertussis cases and cause some adverse events. Results suggest this protocol would provide significant net health benefits and be reasonably cost-effective. There is some suggestion that childhood immunity decreases by adolescence and may be a risk for nonvaccinated infants. Statistics show an increase in the number of cases and deaths of young (under 4 months of age) infants from pertussis. At this time, there is limited information about the frequency of pertussis transmission from one age group to another.
Ear Piercing and Keloid Formation
Lane JE, Waller JL, Davis LS: Relationship between age of ear piercing and keloid formation. Pediatrics 2005;115(5):1312-4.
Hypertrophic scars or keloids can appear following a cutaneous injury such as ear piercing. For this study, 32 patients completed a survey about ear piercing and keloid formation. Following the first piercing, one-half of the patients developed keloids and 20 patients continued piercing and developed additional keloids. If the piercing was at or after 11 years of age, 80% of those piercings developed keloids. Treatments for keloids include topical corticosteroid treatment, intralesional corticosteroid treatment, pressure earrings, laser surgery, and surgical excision. Keloids commonly reoccur following surgery and are typically larger than the original keloid.
Milk and Weight Gain
Berkey CS, Rockett HR, Willett WC, et al: Milk, dairy fat, dietary calcium, and weight gain. Arch Pediatr Adolesc Med 2005; 159(6):543-50.
To assess the associations between milk, food, and beverage calcium, dairy fat, and weight, this study reviews multiple questionnaires from over 12,000 children, 9 to 14 years of age in all 50 states. Results suggest that children who drink more than 3 servings of milk (whole, 1%, or skim) gain more in body mass index (BMI) than those who drink less than 2 glasses a day. No dairy, vegetable, or other fat intake was significantly associated with weight gain after energy adjustment. Dietary calcium intake was positively correlated with weight gain. Dairy products contain the hormone estrone (found in whey protein), which may promote increases in body weight. While increases in milk consumption are promoted as a way to control weight gain, long-term studies are suggesting that high intakes of milk, including skim and 1%, may provide children with excess energy and increased body weight.