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American Academy of Neurology 2010 Annual Meeting

The American Academy of Neurology (AAN) held its 2010 annual meeting from April 10 to 17 in Toronto. The features below highlight some of the news emerging from the AAN meeting. » New Driving Recommendations for Dementia Patients » New Gene Implicated in AD » A Potential New Treatment for Pseudobulbar Affect » Guillain-Barré Syndrome Risk Low After H1N1 Vaccination » Alcohol, Smoking, and Stroke New Driving Recommendations for Dementia Patients [Back to Top] The Particulars:Although some people with dementia or Alzheimer’s disease (AD) can drive safely for a time, nearly all of these patients will eventually have to forego driving. Evidence shows that driving skills deteriorate with increasing dementia severity. Physicians should discuss this inevita­bility with patients and caregivers soon after their diagnosis as it is likely to affect quality of life and may lead to other health concerns, such as depression. The American Academy of Neurology issued a new guideline to help determine when people with AD or another type of dementia should stop driving. Data Breakdown: Physicians are recommended to use the Clinical Dementia Rating scale to identify people with dementia or AD who are at an increased risk of unsafe driving. It is recommended that caregivers be encouraged to trust their instincts; caregivers who rate driving as “marginal” or “unsafe” were often correct when patients took on-road driving tests. However, patients who rate their own driving appear to be less accurate in their own assessments. Caregivers and family members play a role in identifying warning signs from unsafe drivers with dementia, including decreased miles being driven; collisions; moving violations; avoiding certain driving situations (eg, driving...

A New Consensus on PAH

Pulmonary arterial hypertension (PAH) is a complex, multidisciplinary disorder resulting from restricted flow through the pulmonary arterial circulation; this results in increased pulmonary vascular resistance and, ultimately, right heart failure. PAH has been thought of as a rare disease, but recent evidence suggests that the incidence may be higher than what has been previously reported. The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) issued their first expert consensus document on PAH. Published in both the April 28, 2009 issues of Circulation and the Journal of the American College of Cardiology, the guideline is intended to inform practitioners about the evolving areas of clinical practice and/or technologies widely available. The document also includes a table on prognostic factors for PAH in addition to diagnostic and treatment algorithms. The Details of PAH The prognosis of PAH is poor, with about a 15% mortality rate within 1 year on modern therapy. The ACCF/AHA guideline outlines predictors of a poor prognosis, including advanced functional class, poor exercise capacity, high right atrial pressure, significant right ventricular (RV) dysfunction, RV failure, low cardiac index, elevated brain natriuretic peptide, and the scleroderma spectrum of diseases. Idiopathic PAH (IPAH) appears to be the most common type of PAH; it’s more common in younger women who tend to present with nonspecific symptoms (eg, shortness of breath or fatigue). Familial PAH is often the result of a mutation in the BMPR2 gene, which is found in up to 25% of patients with IPAH. PAH is also associated with: Congenital heart disease. Connective tissue diseases. Drugs and toxins. HIV. Portal hypertension. Hemoglobinopathies. Patients with a...

Cryosurgery for Localized Prostate Cancer

Most men currently diagnosed with localized prostate cancer are likely to have the disease eradicated by one of the available treatment modalities, but the focus on health-related quality of life associated with treatment has intensified. In 2007, the American Urological Association (AUA) released guidelines for the management of clinically localized prostate cancer. This guideline, however, did not address the role of cryosurgery for treatment of the disease because of insufficient long-term efficacy data on metastasis-free, prostate-cancer specific or overall survival. In the November 2008 Journal of Urology, the AUA released a new best practice statement on cryosurgery for the treatment of localized prostate cancer. “This is the first time the AUA has released official guidance on this treatment modality,” says Richard J. Babaian, MD, who chaired the panel that published the statement. According to the AUA guidelines, several investigations have reported the efficacy and morbidity of cryosurgery for the disease. “Prostate cryosurgery has been found to result in acceptable outcomes with regard to health-related quality of life,” says Dr. Babaian. “It has been associated with reduced costs when compared with other local therapeutic options.” Studies have also shown that short-term PSA relapse-free survival outcomes following cryoablation of the entire prostate are comparable to that of radiation therapy in men with intermediate- and high-risk disease. Cryosurgery Options According to the AUA best practice statement, cryosurgery can be used as primary therapy or salvage therapy (Table 1). The minimally invasive treatment involves freezing cancerous tissue. As a result of this process, tumors are destroyed. Therma probes are placed into the prostate, where a controlled freezing-thawing process ensues. Clinicians must monitor patients...

Reducing Cardiovascular Events After PCI

Research has shown that when compared with moderate-dose statins, intensive statin therapy can reduce major adverse cardiac events among patients with acute coronary syndrome (ACS). However, the results of intensive-versus-moderate lipid-lowering therapy after PCI for ACS are not well established. Furthermore, no studies have compared the effect of different statin dosages on target vessel revascularization (TVR) and non-TVR. In this patient subgroup, clinicians often focus on treating the stent rather than the whole patient. Stenting only treats one focal spot, not the whole bed of the coronary tree. Clopidogrel and aspirin are often used to keep the stent open, but the role of intensive lipid-lowering therapy in PCI is frequently undervalued. Support for Intensive Lipid Lowering In the December 8, 2009 Journal of the American College of Cardiology, my colleagues and I conducted a study in which we compared outcomes in 2,868 patients who underwent PCI for ACS just prior to enrollment in the PROVE IT–TIMI 22 (Pravastatin or Atorvastatin Evaluation and Infection Therapy–Thrombolysis In Myocardial Infarction 22) trial. The PROVE IT–TIMI 22 randomized ACS patients to either 80 mg atorvastatin or 40 mg pravastatin daily. Of the original cohort, 69% had undergone PCI just prior to randomization. The incidence of the primary composite end point of all-cause mortality, myocardial infarction, unstable angina leading to hospitalization, and revascularization after 30 days and stroke was evaluated. We also assessed the incidence of TVR and non-TVR during follow-up. Treatment with 80 mg atorvastatin reduced the incidence of the composite end point (21.5% vs 26.5%) and lowered the incidence of TVR (11.4% vs 15.4%) and non-TVR (8.0% vs 10.5%) when compared with...

Emerging Drug Options: High Blood Pressure

Hypertension affects approximately 70 million Americans and is a major risk factor for cardiovascular disease. It has been estimated that up to 65% of patients with hypertension do not have their blood pressure (BP) under control. Other studies have demonstrated that as many as 85% of hypertensive patients may need multiple medications to control their BP, underscoring the need for effective combination treatments. In 2009, the FDA approved aliskiren/valsartan (Valturna, Novartis) as a single-pill combination for the treatment of high BP in patients not adequately controlled on aliskiren or valsartan monotherapy. It was also approved as initial therapy in patients likely to need multiple drugs to achieve BP goals. Aliskiren/valsartan targets two key points within the renin-angiotensin aldosterone system (RAAS), which is believed to be an important regulator of BP. Valsartan blocks the action of angiotensin II, a component of the RAAS that causes blood vessels to tighten and narrow. Aliskiren directly inhibits renin, an enzyme that initiates the processes that lead to formation of angiotensin II. By targeting these two points within the RAAS, the agent helps blood vessels relax and widen so BP is lowered. Analyzing Clinical Trial Data A pivotal 8-week randomized, double-blind, placebo-controlled clinical trial involving about 1,800 patients helped lead to the FDA’s approval of aliskiren/valsartan. This trial analyzed use of aliskiren 150 mg and 300 mg and valsartan 160 mg and 320 mg alone and in combination. Initial doses of aliskiren and valsartan were 150 mg and 160 mg, respectively, and were increased at 4 weeks to 300 mg and 320 mg, respectively. BP reductions with the aliskiren/valsartan combination were significantly greater than...

The Changing Face of HIV

According to the CDC, about 1.1 million people in the United States are living with HIV infection, 21% of whom are currently undiagnosed. In 2008, the CDC estimated that approximately 56,300 people were newly infected with HIV in 2006. Over half (53%) of these new infections occurred in gay and bisexual men. African-American men and women were also strongly affected; these groups were estimated to have an incidence rate seven times as high as the incidence rate among Caucasians. Since the mid-1990s, there have been substantial reductions in the number of deaths and AIDS diagnoses thanks largely to increased screening efforts and use of effective antiretroviral therapy. Despite these advances, the incidence of HIV and new diagnoses in the United States has remained stable. Social, ethnic, and cultural population subgroups are increasingly affected by HIV. “When HIV was first identified, it was primarily occurring among gay men,” explains Kathleen E. Squires, MD. “More recently, we’ve seen a marked evolution in the groups of people being affected by HIV. The single largest affected group has been African Americans [Figure 1], especially those who are younger and living in urban areas or the rural South.” More than 50% of new HIV diagnoses reported each year are among African Americans. Other ethnic groups also bear a disproportionate disease burden. In 2002, HIV was the third leading cause of death among Hispanic men aged 35 to 44, and the fourth leading cause of death among Hispanic women in the same age group. The population of HIV-infected Asian and Pacific Islanders is also increasing in the United States. Considering Sexual Orientation The most common...

A Modest Reform Proposal

The past few decades have been difficult for many doctors in the United States. Physician anxiety is increasing in many ways, attributable to workplace violence, pressure to provide healthcare to a sicker population with fewer resources, and/or grueling work hours with little opportunity for a satisfying work-life balance. As a result, many physicians are unhappy and stressed out. This has important implications for U.S. physicians as well as for patients, their families, and society as a whole. Concerns Continue to Grow Extreme stresses, such as violence against physicians—particularly psychiatrists—are a growing concern, but more mundane pressures are also taking their toll. Surveys have shown that constraints on time spent with patients are the leading source of dissatisfaction among physicians. Other sources of dissatisfaction include: Loss of autonomy and control due to increased cost pressures. Fear of medical errors and litigation. The psychological burden of dealing with daily illness and death. Studies estimate that as many as 40% of surgeons report feeling burned out; for oncologists, that number jumps to as high as 60%. Career dissatisfaction is not just the province of middle-aged physicians—nearly half of all third-year medical students report burnout, and some studies have linked medical student burnout with suicidal tendencies. Dissatisfied doctors are more likely to leave clinical practice or relocate, disrupting continuity of care and adding to physician shortages. Existing physician shortages are expected to worsen, with huge implications for costs and access to care, especially in rural and poor areas. Healing the Profession An important step toward overcoming these issues is to help doctors reconnect with the human dimension of medicine, a reason many physicians...

Important Concepts in Non-Hodgkin Lymphoma

Non-Hodgkin lymphoma (NHL) is a heterogeneous group of diseases that together accounts for 66,000 new cases each year in the United States, making it the fifth most common cancer. Over four dozen discrete NHL subtypes are now recognized, each characterized by unique biology with implications for diagnosis and therapy. Clinically, NHLs can be generally classified by their cell of origin (B-cell or T-cell), as well as by clinical behavior, which may be considered indolent (eg, follicular lymphoma), aggressive (eg, diffuse large Bcell lymphoma) or highly aggressive (eg, Burkitt lymphoma). Aggressive and highly-aggressive NHLs are often curable diseases; the goal of therapy is complete disease eradication. In contrast, indolent NHLs are usually incurable with standard therapies, but given long natural histories that may be measured in years to decades, treatment is used as needed to control symptoms while prolonging overall survival. Over the past decade, diagnostics and therapies for NHL have evolved rapidly and have been at the vanguard for the development of novel targeted anti-cancer therapies that can improve outcomes for lymphoma patients and ultimately minimize broad toxicities of chemotherapy. Addressing Diagnosis, Treatment, & Supportive Care Lymphoma subtypes may be difficult to diagnose, but accurate classification is critical in selecting appropriate therapy. Clinicians must therefore collaborate closely with pathologists, ideally with expertise in hematopathology. Once patients are diagnosed, treatment will further depend on...

Assessing Follow-Up Screenings in Childhood Cancer Survivors

Research has shown that women who are treated with chest radiation for a pediatric malignancy have a significantly increased risk of developing breast cancer at a young age. The risk of breast cancer is greatest among female pediatric cancer survivors who have been treated for Hodgkin lymphoma with high-dose mantle radiation. By age 45, it is estimated that 12% to 20% of women treated with moderate-to-high dose chest radiation will be diagnosed with breast cancer. For perspective, women with a BRCA gene mutation have an estimated cumulative incidence of breast cancer that ranges from 1% to 5% at age 30 and from 10% to 19% at age...
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