Moderate alcohol benefits: only for 15% of population

An alcoholic beverage a day is claimed to keep coronary heart disease at bay, but only for 15% of the population, confirms a new study at Sahlgrenska Academy, University of Gothenburg in Sweden.

Alcoholic consumption (ethanol intake) at "moderate" level, up to 1 drink a day for women (corresponding to 14 g or 0.6 ounces of ethanol) and 2 drinks a day for men is associated with a decreased risk of coronary heart disease.

However, your favorite nightly tipple may only have cardio-protective benefits for people of a particular genotype of the cholesteryl ester transfer protein (CETP) polymorphism. For the other 85% of the population, this is not the case.

A previous study of men found an association between alcohol consumption and coronary heart disease, but the evidence had not been confirmed in further studies, until now.

The new study, published in Alcohol, specifically re-examines the potential association between alcohol consumption and coronary heart disease with the presence of the CETP TaqIB (rs708272) polymorphism.

There were 618 patients included in the study, including both men and women, below the age of 75. They were from three regional hospitals admitted for acute coronary syndrome and diagnosed with myocardial infarction, with a typical history, ECG, and enzyme changes or unstable angina.

Of the 618 participants, 453 were men and 165 women. First-time acute myocardial infarction or unstable angina was present in 209 men and 86 women, while the remaining 323 had an exacerbation of previously diagnosed coronary heart disease.

Study contributors and 2,921 healthy control subjects answered self-administered questionnaires on environmental and lifestyle-related exposure variables, and anthropometric measures and venous blood samples were collected.

All participants were asked about their intake of different types of alcoholic beverage (low-alcohol beer, medium-strong beer, strong beer, wine, dessert wine and spirits) and the serving size and frequency of consumption.

Participants were tested in order to identify if the CETP TaqIB genotype was present - the genotype found to play a role in the health benefits of alcohol consumption in a previous study. The researchers also tested whether the participants carried the B1 or B2 alleles of this genotype.

Moderate drinking alone does not have a strong protective effect

Results show that the distribution of CETP TaqIB genotype was similar in both female and male cases and controls. The researchers found:

• The B2 genotype was associated with a lower coronary heart disease risk, with a similar magnitude in men and women
• 19% of participants were homozygous for the CETP TaqIB B2 allele
• The group with intermediate alcohol intake had the lowest risk compared with low intake, but this was markedly more pronounced in B2 homozygotes than in B1 carriers.

The protective effect of B2 genotype in the categories of intermediate or high ethanol intake was more pronounced when the cases were restricted to the first-time coronary cases.

The results echo that of the previous study and confirm that moderate alcohol helps protect against coronary heart disease for the percentage of people who have the genotype.

Prof. Dag Thelle, Professor Emeritus at Sahlgrenska Academy, University of Gothenburg, says:

"In other words, moderate drinking has a protective effect among only 15% of the general population."

Alcohol consumption advice 'far too sweeping'

The researchers point out that a common attitude toward alcohol focuses on the breadcrumb that "moderate drinking has health benefits for everyone." However, evidence suggests that this advice may be too sweeping and needs reassessing.

"Moderate drinking alone does not have a strong protective effect," comments Prof. Lauren Lissner, who also participated in the study. "Nor does this particular genotype. But the combination of the two appears to reduce the risk of coronary heart disease significantly."

Study authors devised two hypotheses for how the CETP affects the "good" cardio-protective high-density lipoprotein (HDL) cholesterol that assists in the removal of excess lipids from the blood vessels:

1. Alcohol by some means affects the CETP in a way that benefits HDL cholesterol
2. Alcohol contains healthy, protective antioxidants.

One or both of these hypotheses may prove correct, but the mechanisms by which HDL cholesterol or antioxidants might act remain unknown.

Prof. Thelle notes:

"Our study represents a step in the right direction, but a lot more research is needed. Assuming that we are able to describe these mechanisms, it may be a simple matter one day to perform genetic testing and determine whether someone belongs to the lucky 15%."

"That would be useful to know when offering advice on healthy alcohol consumption. But the most important thing is to identify new means of using the body's resources to prevent coronary heart disease," he concludes.

Medical News Today recently reported that individuals over the age of 60 who partake in a little drinking may experience better episodic memory in later life.

Tomado de: medicalnewstoday.com Written by Hannah Nichols  Copyright: Medical News Today

CLASE PARASITOSIS INTESTINALES

CLASE PARASITOSIS INTESTINALES
MODULO GASTROENTEROLOGIA
NOVIEMBRE 2014

APRENDIZAJE BASADO EN UN CASO CLINICO

Paciente de 27 años, con síndrome nefrótico por amiloidosis renal secundaria a Enfermedad de Crohn, remitido a urgencias por malestar general, vómitos y diarrea de 10 días de evolución. 

El paciente mantenía hasta este cuadro función renal estable con Crs: 2-2 5 mg/dL, y mantenía tratamiento crónico con esteroides. 10 días antes de su ingreso el paciente comenzó con síndrome febril y diarrea sanguinolenta (6-7 deposiciones/día), y vómitos ocasionales. A su llegada urgencias el paciente estaba en muy mala situación clínica. Respiración de Kussmaul, mal perfundido y signos de deshidratación. TA: 90/60. Frecuencia: 130 lpm. Intensa palidez cutáneo-mucosa. Hábito asténico. El resto de la exploración física fue anodina 

Las exploraciones complementarias reflejaron:

• Hcto: 16, Hgb: 5.7, VCM: 87,
• Plaquetas: 599.000, Leucocitos: 43.600 (936N, 3L, 1M); 
• Crs: 9 mg/dL, Urea: 246 mg/dL, Na: 137 mEq/L, K: 9 mEq/L, Cl: 120 mEq/L, 
• Proteínas totales: 3.7 g/dL, Calcio: 7.2 mg/dL.
• pH: 7.13, pCO2: 12, HCO3: 4.1, pO2: 92 mm Hg.
  

PREGUNTAS:

1.- ¿Cuál es el trastorno ácido-base? ¿Es adecuada la compensación? ¿Cuáles son las causas más probables del cuadro? ¿Por qué el anión GAP es normal?


2.- ¿Como considera de grave el cuadro clínico?

3.- ¿Cuáles serían las primeras medidas terapéuticas a adoptar?

Tomado de S.E.N 

Questioning Medicine: Prostate Cancer Screening

Andrew Buelt, DO, and Joe Weatherly, DO, are family medicine residents in St. Petersburg, Fla. Together, they co-produce the podcast Questioning Medicine, where they deconstruct issues confronting today's clinicians. In this guest blog, Buelt gives his take on the overuse of prostate cancer screenings

Let the Prostate Be

As prostate cancer awareness month just ended, prostate cancer screening seemed a fitting subject for this week's blog.

Those who know the evidence might think this argument pits European practices against our own domestic actions. Almost like a Ryder Cup for prostate screening. However, I recently saw that almost 50% of patients admit to undergoing lubed finger insertions and blood tests, which we know to be fairly inaccurate, in the last 12 months.

In a Research Letter in JAMA Internal Medicine by Sammon et al., the fact that so many physicians are still screening for prostate cancer makes my evidence-based medicine soul cringe. In a 2012 survey, the authors found that among 114,544 respondents, 37% had undergone screening. Higher socioeconomic status nearly doubled a man's odds of being screened (odds ratio 1.91, 95% CI 2.69-3.34).

Prostate cancer screening has been placed in the no-go category by the U.S. Preventive Services Task Force and the Choosing Wisely campaign, as well as by many other major medical associations.

Even the American Urological Association, which stands to lose the most money from reduced screening, states, "Men ages 55 to 69 ... should talk with their doctors about the benefits and harms of testing ...." In my opinion, they deserve a standing ovation for speaking to the evidence and not to the money, as the American College of Obstetrics and Gynecologists has with pelvic exams.

I suppose some physicians will try to argue that rectal exams are not unpleasant or uncomfortable for the patient, as many did in the comments section of my pelvic exam post. However, if you really believe that, it's probably been a while since your last rectal exam.

The Screening Process

There are two parts to prostate screening: the digital rectal exam (DRE) and the prostate-specific antigen (PSA) blood test. Guided by evidence, here's a look at harms and benefits.

First, is the index finger so sensitive and accurate that it can really detect cancer with the DRE? A little common sense would tell us "no chance," and the evidence seems to support that.

In a study published in the Annals of Surgical Oncology by Richie et al., among 644 asymptomatic men, 241 had an abnormal DRE or elevated PSA. And of the 163 who underwent further ultrasound or biopsy, 77% were found to have normal results.

A retrospective analysis of 14 studies by Hoogendam et al. suggested that the positive predictive value of the DRE was only 28% (95% CI 0.20-0.36), meaning that out of 100 men who were diagnosed by their physician's finger, 72 did not actually have cancer. Plus, according to an analysis by Collins et al., 25% of the time when cancer was found after DRE, the biopsy located it in a different part of the prostate!

So unless your patient has a fecal impaction there is probably very little reason to perform a DRE.

What about the PSA blood test? Its accuracy is also riddled with way too many false positives and false negatives. This is one of those tests that has led to serious rates of overdiagnosis.

Only about 24% of those who undergo prostate biopsy because of elevated PSA actually have prostate cancer (Studer and Collette). The study included 162,243 men, and about 76% of those with a PSA over 3 ng/mL were false positives.

In a study published in the Journal of the National Cancer Institute, which reported the results of The Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, Andriole et al. found barely any benefit with PSA screening and DRE. The cumulative mortality rates in the intervention arm were 3.7 compared to 3.4 per 10,000 person-years in the control arm.

Authors of the European Randomized Study of Screening for Prostate Cancer (ERSPC) found a 20% reduction in prostate cancer deaths with PSA. Yet, when you look at actual numbers, it paints a much different picture. The ERSPC study estimated that 1,410 men would need to undergo screening, and 48 more cases of prostate cancer would need to be treated, for one life to be saved. Meaning 48 men will possibly endure erectile dysfunction or urinary incontinence for life, for every one life saved.

When the USPSTF looked at the evidence, they found for every 1,000 men screened for 10 years, roughly 220 had a positive result. About 110 subsequently get a true diagnosis of prostate cancer, 50 get a complication from treatment, and at most one life is saved.

I'll repeat the most important part of that rant: one out of a thousand is saved! At least 50 men will have a serious complication and about 100 will have to undergo anxiety and sleepless nights for a disease they don't even have.

Just under half of those in a different study with a positive screen and negative biopsy, 40%, admitted to worrying about prostate cancer "a lot" or "some of the time." This could qualify as harmful to a man's mental health.

Better Left Unchecked

Finally, in an estimate by Draisma et al., almost 50% of those diagnosed with prostate cancer would have never developed any symptoms of disease had they been left unchecked. Too often people will argue a 10 to 12 years' increase in survival with those screened for prostate cancer.

The problem is the very small or almost nonsignificant increase in mortality. I do not care if my patient survives longer with a disease, as long as the age of mortality remains the same.

After all, the reason we treat hypertension, high cholesterol, or screen for cancer is to have people live longer; not to die at the same age.

Of course, there are physicians out there with anecdotal evidence of catching life-threatening prostate cancer in early stages during a routine DRE or PSA, and will therefore insist they are great tests, just like the pelvic exam.

What shouldn't be forgotten is all of the men who now wear a diaper, can't get an erection, or can't sleep from high anxiety.

So why even have the test available? Possibly if the patient has a positive family history. It seems to increase the patient's risk two or three times above the standard rate of incidence, according to Whittemore et al.

Thus, instead of one out of 1,000, it is 2.5 out of 1,000. At that point, it might be worth at least a conversation. It is also decent to trend the success of prostate cancer treatment. However, as a screening tool it's like swimming with a shark: rarely will it kill you, but it will likely to leave you mentally or physically scarred, feeling vulnerable, and with high anxiety.

Tomado de: Medpagetoday.com  By Andrew Buelt, DO