2010 AHA Guidelines: The ABCs of CPR Rearranged to "CAB"

October 20, 2010 — Chest compressions should be the first step in addressing cardiac arrest. Therefore, the American Heart Association (AHA) now recommends that the A-B-Cs (Airway-Breathing-Compressions) of cardiorespiratory resuscitation (CPR) be changed to C-A-B (Compressions-Airway-Breathing). 

The changes were documented in the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, published in the November 2 supplemental issue of Circulation: Journal of the American Heart Association, and represent an update to previous guidelines issued in 2005.

"The 2010 AHA Guidelines for CPR and ECC [Emergency Cardiovascular Care] are based on the most current and comprehensive review of resuscitation literature ever published," note the authors in the executive summary. The new research includes information from "356 resuscitation experts from 29 countries who reviewed, analyzed, evaluated, debated, and discussed research and hypotheses through in-person meetings, teleconferences, and online sessions ('webinars') during the 36-month period before the 2010 Consensus Conference."

According to the AHA, chest compressions should be started immediately on anyone who is unresponsive and is not breathing normally. Oxygen will be present in the lungs and bloodstream within the first few minutes, so initiating chest compressions first will facilitate distribution of that oxygen into the brain and heart sooner; starting with "A" rather than "C" adds another 30 critical seconds.

"For more than 40 years, CPR training has emphasized the ABCs of CPR, which instructed people to open a victim's airway by tilting their head back, pinching the nose and breathing into the victim's mouth, and only then giving chest compressions," noted Michael R. Sayre, MD, coauthor and chairman of the AHA's Emergency Cardiovascular Care Committee, in an AHA written release. "This approach was causing significant delays in starting chest compressions, which are essential for keeping oxygen-rich blood circulating through the body," he added.

The new guidelines also recommend that during CPR, rescuers increase the speed of chest compressions to a rate of at least 100 times a minute. In addition, compressions should be made more deeply into the chest, to a depth of at least 2 inches in adults and children and 1.5 inches in infants.

Persons performing CPR should also avoid leaning on the chest so that it can return to its starting position, and compression should be continued as long as possible without the use of excessive ventilation.

9-1-1 centers are now directed to deliver instructions assertively so that chest compressions can be started when cardiac arrest is suspected.

The new guidelines also recommend more strongly that dispatchers instruct untrained lay rescuers to provide Hands-Only CPR (chest compression only) for adults who are unresponsive, with no breathing or no normal breathing.

Other Key Recommendations

Other key recommendations for healthcare professionals performing CPR include the following:

    * Effective teamwork techniques should be learned and practiced regularly.
    * Quantitative waveform capnography, used to measure carbon dioxide output, should be used to confirm intubation and monitor CPR quality.
    * Therapeutic hypothermia should be part of an overall interdisciplinary system of care after resuscitation from cardiac arrest.
    * Atropine is no longer recommended for routine use in managing and treating pulseless electrical activity or asystole.

Pediatric advanced life support guidelines emphasize organizing care around 2-minute periods of continuous CPR. The new guidelines also discuss resuscitation of infants and children with various congenital heart diseases and pulmonary hypertension.

Toothbrushing Less Than Twice a Day Linked to Increased Cardiovascular Risk

June 7, 2010 — Individuals who do not brush their teeth twice a day have an increased risk of heart disease, a new study shows.

The study was published online May 27, 2010 in BMJ; corresponding author is Prof Richard Watt (University College London, UK).

The researchers note that while it has been established that inflammation in the body (including mouth and gums) plays an important role in the buildup of atherosclerosis, this is the first study to investigate whether the number of times individuals brush their teeth has any bearing on the risk of developing heart disease.

They analyzed data from more than 11 000 adults who took part in the Scottish Health Survey, in which individuals were asked about lifestyle behaviors such as smoking, physical activity, and oral health routines. Questions asked included how often they visited the dentist and how often they brushed their teeth (twice a day, once a day, or less than once a day). Information was also collated on medical history and family history of heart disease and blood pressure. Blood samples were taken from a subgroup of participants and tested for C-reactive protein (CRP) and fibrinogen levels. The data gathered from the interviews were linked to hospital admissions and deaths.

Results showed generally good oral hygiene practices, with 62% of participants saying they visited the dentist every six months and 71% reporting that they brushed their teeth twice a day. After adjustment for established risk factors, it was found that participants who reported less frequent toothbrushing had an increased risk of heart disease compared with people who brushed their teeth twice a day. Participants who had poor oral hygiene also had increased levels of CRP and fibrinogen.

Hazard Ratio for Cardiovascular Events (Fatal and Nonfatal) Relative to How Often Teeth Are Brushed Each Day
Frequency of toothbrushing HR* (95% CI)
Twice a day 1.0
Once a day 1.3 (1.0–1.5)
Less than once a day 1.7 (1.3–2.3)
p for trend 0.001

*Adjusted for age, sex, socioeconomic group, smoking, physical activity, visits to dentist, body-mass index, family history of cardiovascular disease, hypertension, and diabetes

The researchers say: "To the best of our knowledge, this is the first study to show an association between a single-item self-reported measure of toothbrushing and incident cardiovascular disease in a large representative sample of adults without overt cardiovascular disease."

They add: "Our study suggests a possible role of poor oral hygiene in the risk of cardiovascular disease via systemic inflammation. Raised inflammatory and homoeostatic responses as well as lipid metabolism disturbance caused by periodontal infection might be possible pathways underlying the observed association between periodontal disease and the increased risk for cardiovascular disease."

But they note that further studies are needed to confirm whether the observed association between oral health behavior and cardiovascular disease is in fact causal or merely a risk marker.

References

1. de Oliveira C, Watt R, and Hamer M. Toothbrushing, inflammation, and risk of cardiovascular disease: Results from Scottish Health Survey. BMJ 2010; DOI:10.1136/bmj.c2451. Available at: http://www.bmj.com.

Additional Information

Information about oral hygiene and cardiovascular risk is available online on the National Institute of Dental and Craniofacial Research Web site
Clinical Context

Systemic inflammation plays a role in cardiovascular events, and a previous study by Danesh and colleagues, which was published in the July 22, 2000, issue of the BMJ, found that certain serum markers of inflammation were independent predictors of the risk for coronary heart disease events. Specifically, CRP and serum amyloid A protein were significantly associated with the risk for nonfatal myocardial infarction or coronary heart disease death, even after a multivariate analysis. The serum white blood cell count and albumin levels were not significantly associated with coronary heart disease risk.

Periodontal disease is associated with a moderate systemic inflammatory response. The current study explores the relationship between oral hygiene behavior and inflammatory response as well as the risk for cardiovascular disease.
Study Highlights

* Data were drawn from the Scottish Health Survey administered in 1995, 1998, and 2003. The survey is a broad questionnaire of health behaviors and outcomes among adults 35 years and older.
* Participants who were edentulous (no natural teeth) or had existing cardiovascular disease were excluded from the current analysis.
* Researchers of the current study specifically examined oral hygiene behaviors and their relationship to a composite of cardiovascular diagnoses, which were derived from hospital discharge and death certificate databases. These diagnoses included myocardial infarction, coronary artery bypass surgery, percutaneous coronary angioplasty, stroke, and heart failure.
* The main study outcome was adjusted to account for other cardiovascular risk factors.
* Researchers also examined the relationship between oral hygiene and 2 serum markers of systemic inflammation: CRP and fibrinogen.
* 11,869 individuals provided study data. The mean age was 50 years old, and 46.1% of participants were men.
* 62% of participants reported visiting a dentist at least every 6 months, and 71% said they brushed their teeth twice a day.
* Participants who brushed their teeth less than twice a day were more likely to be older and have a higher number of cardiovascular risk factors.
* There were 555 cardiovascular events during an average of 8.1 years of follow-up.
* Compared with participants who brushed their teeth twice daily, individuals who brushed less often than once a day experienced a significant multivariate hazard ratio of 1.7 for cardiovascular events. The adjusted hazard ratio among patients who brushed once a day was 1.3, a result of borderline significance.
* The risk for cardiovascular disease related to poor oral hygiene was similar among men and women, and it also did not differ by age or smoking status.
* Mean levels of CRP among participants who brushed twice daily, once daily, and less than once daily were 3.07, 3.51, and 4.18 mg/L, respectively. The respective fibrinogen levels were 2.86, 2.95, and 2.98 mg/L.
* Further analyses indicated that these markers of systemic inflammation at least partly mediated the risk for cardiovascular events associated with poor oral hygiene.

Clinical Implications

* A previous study found that serum levels of CRP and amyloid A protein, but not the white blood cell count or albumin level, were positively and independently associated with the risk for coronary heart disease events.
* The current study suggests that toothbrushing less than twice daily might independently increase serum markers of systemic inflammation as well as the risk for cardiovascular disease.


From Heartwire CME © 2010 Medscape, LLC

Super Foods for Men and Women

Guess what? You have different nutritional needs than the opposite sex. Discover the best foods for you both.

One in five women have a history of painful urinary tract infections. "I had three in one year," says Patty Buxton*, a Colorado middle-school teacher. Reading that cranberry juice may help prevent these infections, Buxton went on a regimen a year ago, and since then she's been infection-free. She thinks cranberry juice did the trick.


Cranberry juice isn't the only food that offers protection from specific illnesses. Here's a list of disease-fighting foods for men and women.

Foods for Men

1. Tomato Sauce.
Men who eat a lot of tomatoes, tomato sauce, or pizza smothered with the stuff may be giving themselves a hedge against prostate cancer. So say researchers at Harvard, who studied the eating habits of more than 47,000 male health professionals. They found that men who ate tomato sauce two to four times per week had a 35 percent lower risk of developing prostate cancer than men who ate none. A carotenoid called lycopene, which tomatoes contain in abundance, appeared to be responsible. But scientists were puzzled: tomato juice didn't seem to have a protective effect. Other research showed why. For best absorption, lycopene should be cooked with some kind of fat. So pizza may be just what the doctor ordered.

2. Oysters.
Myth has it that oysters are the food of love. Science may agree. Just two to three oysters deliver a full day's supply of zinc, a mineral critical for normal functioning of the male reproductive system. Scientists are divided over reports that sperm counts have declined over the last 50 years and that environmental factors are to blame. Nutritional deficiencies do seem to be the cause of certain cases of low testosterone. Getting adequate zinc is sometimes the answer (11 mg per day is recommended for men; more than 40 mg can pose risks). In one trial, 22 men with low testosterone levels and sperm counts were given zinc every day for 45 to 50 days. Testosterone levels and sperm counts rose.


3. Broccoli.
A recent Harvard study finds that cruciferous vegetables, like broccoli, may protect against bladder cancer. It's one of the most common cancers in this country, and affects two to three times as many men as women. Scientists analyzed the diets of nearly 50,000 men and discovered that those who ate five servings or more per week of cruciferous veggies were half as likely to develop bladder cancer over a ten-year period as men who rarely ate them. And broccoli and cabbage were singled out as the most protective foods.

4. Peanut Butter.
If you want a healthy heart, spread your morning toast with peanut butter. Heart disease is the leading killer of men and women, but men fall victim at an earlier age. Researchers from Pennsylvania State University compared the cholesterol-lowering effect of the American Heart Association's Step II Diet with a higher-fat diet based on peanuts. The AHA plan included more carbohydrates. The peanut regimen was 36 percent fat. After 24 days both diets lowered "bad" LDL cholesterol. But the peanut plan also caused a drop in blood fats called triglycerides and did not decrease HDL, the "good" cholesterol. The AHA diet raised levels of triglycerides and lowered levels of HDL.

"Peanut butter is a little higher in fat," says Penny Kris-Etherton, Ph.D., the lead author of the Penn State study. "But it's the type that's good for you -- monounsaturated fat." Researchers have predicted that the peanut diet could reduce heart-disease risk even more than could the AHA diet. Just don't go nutty plastering on the tasty spread, since it is high in calories.


5. Watermelon.
Until the age of 55, more men suffer from high blood pressure than do women. Research suggests that foods rich in potassium can reduce the risk of high blood pressure and stroke. The evidence is so convincing that the Food and Drug Administration recently allowed food labels to bear a health claim about the connection between potassium-rich foods and blood pressure. "There isn't a dietary requirement for potassium," says Kathleen Cappellano, nutrition-information manager at Tufts University in Boston. "But a good goal is about 2000 milligrams or more a day." Watermelon, a rich source of this mineral, has more potassium -- 664 mg -- in one large slice than the amount found in a banana or a cup of orange juice. So cut yourself another slice and enjoy the taste of summer.

Foods for Women

1. Papaya.
This tropical fruit packs about twice the vitamin C of an orange. Add it to your arsenal against gallbladder disease, which afflicts twice as many women as men.

After analyzing the blood of over 13,000 people, scientists from the University of California, San Francisco, found that women who had lower levels of vitamin C were more likely to have gallbladder illnesses. One medium papaya (about ten ounces), with its 188 mg of vitamin C and a mere 119 calories, is a refreshing source of the vitamin. The once exotic fruit now can be found in most supermarkets.

2. Flaxseed.
Bakers use this nutty-flavored seed mainly to add flavor and fiber. But scientists see the tiny reddish-brown seed, rich in estrogenlike compounds called lignans, as a potential weapon against breast cancer. An exciting report at last year's San Antonio Breast Cancer Symposium showed that adding flaxseed to the diet of women with breast cancer effectively slowed tumor growth. You can flavor your muffins with flaxseed, but the easiest way to get the beneficial lignans is to sprinkle a few tablespoons of ground flaxseed on your morning cereal. Look for the seeds in health food stores or in supermarkets on the flour aisle. They're easy to grind in a blender or coffee grinder. But get seeds -- there are no lignans in the oil.


3. Tofu.
Foods high in soy protein can lower cholesterol and may minimize menopausal hot flashes and strengthen bone. Isoflavones, plant chemicals in soybeans that have a structure similar to estrogen, may be the reason. Though animal studies form the bulk of the evidence, a human study found that 90 mg of isoflavones was beneficial to bone (specifically the spine). And two other studies suggest that 50 to 76 mg of isoflavones a day may offer some relief from hot flashes. A half-cup of tofu contains about 25 to 35 mg of isoflavones.

4. Buffalo Meat.
Due largely to menstruation, women tend to be anemic more than men. And low iron levels in blood can cause severe fatigue. To get a good dose of iron, try bison. Bison, or buffalo, meat is lean and has what diet-conscious women want -- lots of iron and less fat than most cuts of beef. "The iron content is about 3 milligrams in a 3 1/2-ounce uncooked portion," says Marty Marchello, Ph.D., at North Dakota State University. "That portion contains less than 3 grams of fat." Buffalo meat can help boost energy and lower weight. And you don't have to have a home on the range to get some bison anymore. You can pick it up at many supermarkets across the United States, or through mail order or on the Internet.


5. Collard Greens.
This humble vegetable may help fight osteoporosis, which afflicts many women late in life. In addition to getting adequate amounts of calcium and vitamin D, some studies suggest that vitamin K may have a bone-protective effect as well. Based on data from one of the largest studies of women, the Nurses' Health Study, researchers discovered that women who ate enough vitamin K-rich foods (at least 109 micrograms of the vitamin daily) were 30 percent less likely to suffer a hip fracture during ten years of follow-up than women who ate less. Researchers point out that dark-green leafy vegetables -- Brussels sprouts, spinach, broccoli -- are all good sources of the vitamin. But collard greens, with about 375 micrograms per half-cup, are among the best.

There you have it: five great foods for women and for men that can keep both of you well fed and healthy too.

By Maureen Callahan of Yahoo Shine

New Physicians at Increased Risk for Depression During Internship

From the Arch Gen Psychiatry. Published online April 5, 2010.

April 7, 2010 — The percentage of new clinicians who develop depressive symptoms increases significantly during medical internship, new research suggests.

A large prospective study showed a marked increase in depressive symptoms among new clinicians — from 3.9% at baseline to an average of 25.7% (P < .001) during internship — as reflected by increases in the 9-item Patient Health Questionnaire (PHQ-9).

Srijan Sen, MD, PhD, University of Michigan, Ann Arbor, and colleagues also found that 41.8% of participants met criteria for major depression at one or more quarterly assessments.

On stepwise linear regression analysis, neuroticism (P < .001), personal history of depression (P < .001), lower baseline depressive symptoms (P < .001), female sex (P = .03), US medical education (P = .005), and a difficult early family environment (P = .04) significantly correlated with a change in depressive symptoms.

"When myself and coinvestigator Constance Guille were interns 4 years ago, we noticed that people who were well adjusted and happy a few months before were having trouble sleeping and problems with their relationships and just struggling to adjust, so it struck us that these problems were very common during internship," Dr. Sen told Medscape Psychiatry.

"And while I think internship will always be a stressful time, there are things that we may be able to do to make it better for interns, including working fewer hours and using electronic records to reduce the risk of errors and making sure interns have some resources in place before they become depressed to reduce the effects of stress," he added.

The study was published online April 5 in the Archives of General Psychiatry.

No Link to Medical Specialty or Age

For the study, investigators recruited a total 1271 interns entering traditional and primary care internal medicine, general surgery, pediatrics, obstetrics-gynecology, and psychiatry residency programs during the 2007-2008 and 2008-2009 academic years. Depressive symptoms were measured using the depression module of the PHQ-9, where the total score ranges from 0 to 27. The PHQ-9 scores of 10 to 14 correspond to moderate depression, scores between 15 and 19 to moderately severe depression, and scores of 20 or greater to severe depression.

Mean PHQ-9 scores increased significantly from 2.38 at baseline to 6.70 at 3 months, 6.48 at 9 months, and 6.26 at 12 months (all P < .001 vs baseline). The percentage of subjects meeting criteria for moderately severe depression increased from 0.7% at baseline to 6.6%, 6.2%, 7.8%, and 7.6% at 3-, 6-, 9-, and 12-month points of the internship, respectively, the investigators add.

Similarly, the percentage of interns who met criteria for severe depression increased from 0% at baseline to 2.3%, 1.6%, 1.8%, and 0.8% at 3, 6, 9, and 12 months of internship, respectively. Investigators also assessed factors during internship that were associated with a change in depressive symptoms.

The 3 key variables that were associated with a significant increase in the risk for depressive symptoms were work hours (P < .001), reported medical errors (P < .001), and noninternship stressful life events (P < .001).

Interestingly, medical specialty and age were not associated with the development of depression.

5-HTTLPR Moderates Stress and Depression Response

Investigators also used internship as a model to explore the relationship between a serotonin transporter promoter polymorphism and stress in the development of depression.

"We found evidence that this variant moderates the response to stress in European American subjects, with subjects carrying at least one low-functioning 5-HTTLPR allele reporting a 43% greater increase in depressive symptoms than subjects with two low-functioning alleles," the study authors write.

European American participants with 2 high-functioning 5-HTTLPR alleles who met criteria for depression increased from 5.1% before internship to 36.2% at its highest during internship. Investigators also found that the association between 5-HTTLPR and the development of depressive symptoms under stress was moderated by neuroticism and work hours, although not with medical errors or stressful life events.

"Medical internship provided us with the unique situation where we know that a group of people currently under low stress will enter a period of high stress, and we showed that 5-HTTLPR had no effect on depression under the low stress conditions but was strongly associated with depression under high stress," Dr. Sen told Medscape Psychiatry. "So in my view, this provides strong evidence that 5-HTTLPR moderates the relationship between stress and depression, [although] the effect of this one genetic variant is relatively small compared with other factors, such as work hours, gender, and prior history of depression."

Stressful Experience

Gregory Dalack, MD, University of Michigan, Ann Arbor, agreed that internship is clearly a stressful experience, "as all of us who went through it know."

"Nevertheless," he said, "depressive symptoms detected in this cohort of interns were self-reported, which is different than detecting symptoms with a clinical diagnosis, because with a clinical diagnosis, physicians can rule out ongoing substance abuse problems or other medical conditions that may be contributing to symptoms such as sleep disturbances, which on self-reported questionnaires may be mistakenly attributed to depression."

Dr. Dalack also noted that a number of organizations have already put forward suggestions that are intended to reduce stress among interns, including limitations of hours worked. Currently, interns are still allowed to work 80 hours per week.

"They are following these recommendations prospectively to make sure hospitals are putting systems in place so that residents are not overworked, and while there may be transgressions from the rules under some circumstances, there is a higher level of scrutiny now in place to make sure people stay within those limits so as to reduce interns’ fatigue and depression and maintain a high level of quality care for patients," he said.

The study was supported by a Donaghue Foundation Clinical and Community Grant, an American Psychiatric Association Substance Abuse and Mental Health Services Administration grant, a Veterans Administration Research Enhancement Award Program award, and an American Foundation for Suicide Prevention Young Investigator grant.

Soft Drink Consumption Linked to Pancreatic Cancer

February 16, 2010 — The regular consumption of sugar-laden soft drinks could boost a person's risk of developing pancreatic cancer. The results of a new study found that individuals who consumed 2 or more soft drinks per week had an 87% increased risk for pancreatic cancer, compared with those who did not.

Even after taking factors such as smoking, caloric intake, and type 2 diabetes mellitus into account, the authors found that consuming soft drinks might play an independent role in the development of pancreatic cancer.

The finding is reported in the February issue of Cancer Epidemiology, Biomarkers & Prevention.

Both soft drinks and fruit juices have a high glycemic load relative to other foods and drinks, and it has been hypothesized that both are risk factors for pancreatic cancer. The high levels of sugar can increase levels of insulin in the body, and this can contribute to pancreatic cancer cell growth, the researchers explain.

Association Not Seen With Fruit Juice

However, this study did not find an association between consumption of juice and an increased risk for pancreatic cancer.

"There are several plausible explanations why fruit juice was not significantly associated with pancreatic cancer," said first author Noel Mueller, MPH, a research associate at Georgetown University Medical Center in Washington, DC.

One reason is that the finding was based on a relatively small number of cases, so there might have been too few cases to detect an effect with fruit juice, he explained. Another is that there are differences between soft drinks and fruit juice — fruit juice is lower in sugar, includes many nutrients, and is typically served in smaller portion sizes.

A third explanation is that fruit juice intake is associated with healthier lifestyle characteristics than soft drink intake, he said.

The consumption of soft drinks coincided with a number of other unhealthy lifestyle characteristics, making it somewhat difficult to separate smoking, caloric intake, body weight, and type 2 diabetes mellitus from soft drink consumption. "But the findings from our study suggest that soft drinks may play an independent role in the development of pancreatic cancer," Mr. Mueller told Medscape Oncology.

"The influence of soft drink intake on the risk of pancreatic cancer remained virtually unchanged after adjustment for smoking status, energy intake, body weight, and type 2 diabetes mellitus," he added.

Results Statistically Significant for Soft Drinks

The current study examined the association between the consumption of soft drinks and juice and the risk for pancreatic cancer among Chinese people residing in Singapore. The data came from the Singapore Chinese Health Study (n = 60,524), and information regarding the consumption of soft drinks, juice, and other dietary items, along with lifestyle factors and environmental exposures, was collected at recruitment to the study. The participants were followed for up to 14 years.

At the start of the study, 9.7% of the participants consumed at least 2 soft drinks per week and 10.2% consumed at least 2 servings of juice per week. The authors note that, compared with those who did not consume soft drinks, those who consumed 2 or more soft drinks per week were younger, were more likely to be men, and were more likely to smoke cigarettes. They also had higher levels of education, alcohol consumption, and total energy intake; lower levels of physical activity; and consumed more total carbohydrates, fat, added sugar, and red meat.

Individuals who reported consuming 2 or more juice drinks a week had lifestyle and dietary habits that were similar to those who consumed soft drinks. However, there was no association between juice intake and cigarette smoking, and body mass index (BMI) was comparable across different categories of soft drink and juice consumption.

At 14 years and a cumulative 648,387 person-years of follow-up, 140 incident pancreatic cancers developed in people who were cancer free at baseline. After adjustment for confounders such as BMI, type 2 diabetes mellitus, and fruit juice intake, the authors found that those consuming 2 or more soft drinks per week experienced a statistically significant increased risk for pancreatic cancer (hazard ratio [HR], 1.87; 95% confidence interval [CI], 1.10 - 3.15).

Although people who consumed 2 or more juice drinks a week had an increased risk for pancreatic cancer of approximately 30%, elevated HR was not statistically significant after adjustment for variables.

However, in an age-adjusted analysis, smoking was also a risk factor. After excluding former smokers, the authors found that current smokers had a 49% increased risk for pancreatic cancer, compared with never smokers (HR, 1.49; 95% CI, 0.98 - 2.27). This risk factor remained unaffected after adjustment for diabetes and BMI.

Can Be Extrapolated to United States and Europe

Singapore is a highly industrialized nation with lifestyle and nutritional patterns reminiscent of many westernized countries. In that sense, these findings could be extrapolated to the United States and Europe, explained Mr. Mueller. Soft drinks are the leading source of added sugar in the American diet, the authors note.

"However, there are inherent differences between Singaporean Chinese and Caucasians, which is why one must be cautious when generalizing these results to the United States and Europe," he said. "But it is important to note that other studies in Caucasian populations have suggested that soft drink intake may increase risk for pancreatic cancer."

Because pancreatic cancer is a relatively rare disease, the number of cases in this study was relatively small, the authors point out. This limited the statistical power of the study. Another limitation was the inability to collect repeated dietary measurements during the course of the study; therefore, they could not account for changes in consumption of soft drinks and juices.

However, this study adds to the evidence that soft drink consumption plays a role in the development of pancreatic cancer, they conclude, and that "clinical studies examining biomarkers for glycemia and insulinemia and taking a mechanistic approach to the question of soft drink consumption and pancreatic cancer are warranted."

There is "still much to understand on the link between sugar-sweetened beverages and pancreatic cancer," the authors write.

The study was supported by a grant from the National Cancer Institute. The researchers have disclosed no relevant financial relationships.

Chocolate Linked to Lower Stroke and Stroke Mortality Risk

February 12, 2010 — Just in time for Valentine's Day, a new systematic review from Canadian researchers suggests higher chocolate consumption may be associated with a lower risk for incident stroke and stroke-related mortality.

Results of 2 prospective cohort studies showed, respectively, a 22% reduction in stroke risk for those who had 1 serving of chocolate per week and a 46% reduction in stroke mortality from weekly consumption of flavonoids in 50 g of chocolate vs no consumption. A third study showed no association between chocolate intake and stroke or death.
However, the number of studies looking at this relationship was small, senior author Gustavo Saposnik, MD, from St. Michael's Hospital and the University of Toronto, Canada, told Medscape Neurology. "We need more prospective studies that specifically identify the type of chocolate and the amount, including the amount of flavonoids included in the composition of the chocolate, to make more valid conclusions," he said.
The results were released February 11 in advance of their planned presentation at the upcoming American Academy of Neurology 62nd Annual Meeting in April. The abstract will post to http://www.aan.com on February 17.

Varying Effects
Chocolate contains cocoa butter, flavonoids, carbohydrates, and vitamins. Previous studies, most of them epidemiological, have shown varying effects of chocolate consumption on the risk for cardiovascular disease, the researchers, with first author Sarah Sahib, BScCA, from McMaster University in Hamilton, Ontario, Canada, write. "Less is known about the risk of stroke in association with flavonoid intake," they note.
To examine this association, the authors carried out a systematic review of studies published between 2001 and 2009, using search terms including flavonoids, flavanols, isoflavones, and anthocyanidins, as well as stroke and mortality.

"We found 88 publications, among them 3 prospective studies, and another retrospective study providing some information on the effect of chocolate consumption on the incident risk of stroke," Dr. Saposnik said. "Two of these studies show a reduction in the incident risk of stroke, and the other 2 didn't show any substantial difference."

For example, of the 3 prospective studies, 1 found no association between flavonoid intake and the risk for stroke or death when 3% of catechin intake came from chocolate (relative risk [RR], 0.92; 95% confidence interval [CI], 0.51 - 1.68).

However, a second study found a reduction in incident stroke for chocolate consumption once per week vs no consumption (RR, 0.78; 95% CI, 0.65 - 0.94).

The third study looked at the association between flavonoid intake and stroke mortality and found a suggestion of protection against stroke mortality from 50 g of chocolate (hazard ratio, 0.54; 95% CI, 0.30 - 0.96).

The authors conclude that further prospective studies are needed "to assess whether the benefit of chocolate-based flavonoid consumption truly lowers stroke risk, or whether the apparent benefit is biased by a healthy user effect."

Investigation a Challenge
However, although more data on this link would be helpful, Dr. Saposnik pointed to several challenges to doing these kinds of studies. First, it is important to document the actual content of flavonoids or other substances thought to be active in the chocolate being consumed.
"There are some studies that compare the content of flavonoids for different food elements and antioxidant capacity," he said. Dark chocolate is one with the highest flavonoids and procyanidins, which have been associated with lower cardiovascular risk, and in addition, dark chocolate has the highest antioxidant capacity.
Still, there are varying types of chocolate, and the amounts that are required to affect stroke risk may bring a load of sugar and fats that may work counter to the beneficial effects. "50g of chocolate per day is a significant amount," Dr. Saposnik notes.

Finally, large longitudinal studies are also expensive, and funding for them scarce, which may explain why much of the evidence is coming from epidemiologic studies, he added. One alternative may be to conduct smaller studies, looking the effects of consuming controlled amounts of chocolate on some intermediate biomarker of stroke risk.

The study received no commercial support. The authors have disclosed no relevant financial relationships.
 
American Academy of Neurology 62nd Annual Meeting. April 10-17, 2010. Published online February 11, 2009.

American Diabetes Association Revises Diabetes Guidelines

December 29, 2009 — The American Diabetes Association (ADA) revised clinical practice recommendations for diabetes diagnosis promote hemoglobin A1c (A1c) as a faster, easier diagnostic test that could help reduce the number of undiagnosed patients and better identify patients with prediabetes. The new recommendations are published December 29 in the January supplement of Diabetes Care.

"We believe that use of the A1c, because it doesn't require fasting, will encourage more people to get tested for type 2 diabetes and help further reduce the number of people who are undiagnosed but living with this chronic and potentially life-threatening disease," Richard M. Bergenstal, MD, ADA president-elect of medicine & science, said in a news release. "Additionally, early detection can make an enormous difference in a person's quality of life. Unlike many chronic diseases, type 2 diabetes actually can be prevented, as long as lifestyle changes are made while blood glucose levels are still in the pre-diabetes range."

The A1c test, which measures average blood glucose levels for a period of up to 3 months, was previously used only to evaluate diabetic control with time. An A1c level of approximately 5% indicates the absence of diabetes, and according to the revised evidence-based guidelines, an A1c score of 5.7% to 6.4% indicates prediabetes, and an A1c level of 6.5% or higher indicates the presence of diabetes.

For optimal diabetic control, the recommended ADA target for most people with diabetes is an A1c level no greater than 7%. It is hoped that achieving this target would help prevent serious diabetes-related complications including nephropathy, neuropathy, retinopathy, and gum disease.

Unlike fasting plasma glucose testing and the oral glucose tolerance test, A1c testing does not require overnight fasting. Compliance with screening may therefore be improved through use of the A1c test, which can be determined from a single nonfasting blood sample.

Recommendation Changes for 2010
Specific changes in the 2010 Clinical Practice Recommendations are as follows:

• A section on diabetes related to cystic fibrosis has been added to "Standards of Medical Care in Diabetes." New evidence has shown that early diagnosis of cystic fibrosis-related diabetes and aggressive treatment with insulin have narrowed the gap in mortality between patients with cystic fibrosis with and without diabetes and have eliminated the sex difference in mortality rates. New recommendations for the clinical management of cystic fibrosis-related diabetes, based on a 2009 consensus conference, will be published in 2010 in a consensus report.
• Revision of the section "Diagnosis of Diabetes" now includes the use of the A1c level for diabetes diagnosis, with a cutoff point of 6.5%.
• The section formerly named "Diagnosis of Pre-diabetes" is now named "Categories of Increased Risk for Diabetes." Categories suggesting an increased risk for future diabetes now include an A1c range of 5.7% to 6.4%, as well as impaired fasting glucose and impaired glucose tolerance levels.
• Revisions to the section "Detection and Diagnosis of GDM [Gestational Diabetes Mellitus]" now include a discussion of possible future changes in this diagnosis, according to international consensus. Screening recommendations for gestational diabetes are to use risk factor analysis and an oral glucose tolerance test, if appropriate. Women diagnosed with gestational diabetes should be screened for diabetes 6 to 12 weeks postpartum and should have subsequent screening for the development of diabetes or prediabetes.
• Extensive revisions to the section "Diabetes Self-Management Education" are based on new evidence. Goals of diabetes self-management education are to improve adherence to standard of care, to educate patients regarding appropriate glycemic targets, and to increase the percentage of patients achieving target A1c levels.
• Extensive revisions to the section "Antiplatelet Agents" now reflect evidence from recent trials suggesting that in moderate- or low-risk patients, aspirin is of questionable benefit for primary prevention of cardiovascular disease. The revised recommendation is to consider aspirin treatment as a primary prevention strategy in patients with diabetes who are at increased cardiovascular risk, defined as a 10-year risk greater than 10%. Patients at increased cardiovascular risk include men older than 50 years or women older than 60 years with at least 1 additional major risk factor.
• Fundus photography may be used as a screening strategy for retinopathy, as described in the section "Retinopathy Screening and Treatment." However, although high-quality fundus photographs detect most clinically significant diabetic retinopathy, they should not act as a substitute for an initial and dilated comprehensive eye examination. Retinal examinations should be carried out annually or at least every 2 to 3 years among low-risk patients with normal eye examination results in the past.
• Extensive revisions to the section "Diabetes Care in the Hospital" now question the benefit of very tight glycemic control goals in critically ill patients, based on new evidence.
• Extensive revisions to the section "Strategies for Improving Diabetes Care" are based on newer evidence. Successful strategies to improve diabetes care, which have resulted in improved process measures such as measurement of A1c levels, lipid levels, and blood pressure, include the following:
  • Delivery of diabetes self-management education.
  • Adoption of practice guidelines developed with participation of healthcare professionals and having them readily accessible at the point of service.
  • Use of checklists mirroring guidelines, which help improve adherence to standards of care.
  • Systems changes, including providing automated reminders to healthcare professionals and patients and audit and feedback of process and outcome data to providers.
  • Quality improvement programs, in which continuous quality improvement or other cycles of analysis and intervention are combined with provider performance data.
  • Practice changes, which may include access to point-of-care A1c testing, scheduling planned diabetes visits, and clustering dedicated diabetes visits into specific times.
  • Tracking systems with either an electronic medical record or patient registry to improve adherence to standards of care.
  • Availability of case or (preferably) care management services using nurses, pharmacists, and other nonphysician healthcare professionals following detailed algorithms under physician supervision.

"The most successful practices have an institutional priority for quality of care, involve all of the staff in their initiatives, redesign their delivery system, activate and educate their patients, and use electronic health record tools," the guidelines authors conclude. "It is clear that optimal diabetes management requires an organized, systematic approach and involvement of a coordinated team of dedicated health care professionals working in an environment where quality care is a priority."

Source: Medscape.com