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Content 7


The Doctor and the Pharmacist

Radio Show Articles:
February 26, 2011

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Four-Drug or Three-Drug Combo for H. Pylori
Lavender Oil Has Strong Antifungal Properties
Long-Term Bisphosphonate Use Linked to Subtrochanteric and
   Femoral Shaft Fractures in Older Women
Cell Phones Seen Affecting Brain Biochemistry
Weighty Effects on Breast Cancer Outcomes
Predicting Response to Proton-Pump Inhibitors for Dyspepsia
Omega-3s May Reduce Age-Related Muscle Loss
Planned Home Birth: A New View
C-Reactive Protein Level Doesn't Predict Statin Response in High-Risk Patients
Statins Prevent Vascular Events, Independent of Baseline CRP Levels
Statins for Patients with Fatty Liver Disease and Mildly Elevated Transaminases
Atopic Dermatitis and Cataracts: A Cloudy Issue

Lancet 2011; DOI: 10.1016/S0140-6736(11)60020-2.
Four-Drug or Three-Drug Combo for H. Pylori
     Researchers have reported that a four-drug regimen over 10 days has been found to work as well as the three-drug, seven-day regimen that's the standard ulcer treatment. In addition, it may help overcome the growing problem of antibiotic resistance.
     Due to increased resistance to clarithromycin, the standard week-long therapy has become less effective in recent years. Resistance to metronidazole appeared to have no effect, and one of the effects of adding the bismuth salt is to help overcome resistance to metronidazole. Opinions show that bismuth-containing quadruple therapy is effective and acceptable "in regions where resistance to clarithromycin is high."
     In a randomized, open-label phase III trial of 440 patients, the four-drug combo - a proton pump inhibitor plus a single capsule containing bismuth subcitrate potassium, metronidazole, and tetracycline -- was found to be noninferior to clarithromycin (Biaxin), omeprazole, and amoxicillin, according to Peter Malfertheiner, MD, of Otto-von-Guericke-Universtitat in Magdeburg, Germany, and colleagues.
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18 February 2011- J Med Microbiol 2011: Advance online publication
Lavender Oil Has Strong Antifungal Properties
     Portuguese researchers have shown that lavender oil has strong antifungal properties, effectively destroying various dermatophytes and species of Candida when tested. In the last few years, there has been an increase in the incidence of fungal diseases, particularly among immunocompromised patients. Unfortunately, there is also increasing resistance to antifungal drugs.
     The researchers suggest that the antifungicidal effect of lavender oil may be due to its ability to damage fungal cell membranes, eventually causing cell death. An active component, Lavandula oil, shows wide-spectrum antifungal activity and is highly potent, serving as a good starting point for developing this oil for clinical use to manage fungal infections. The results of this study are published in the Journal of Medical Microbiology.
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Long-Term Bisphosphonate Use Linked to Subtrochanteric and Femoral Shaft Fractures in Older Women
     Long-term oral bisphosphonate use is associated with an increased risk for subtrochanteric or femoral shaft fractures, but the absolute risk remains low, according to a JAMA study.
     Researchers examined Canadian provincial databases to identify some 700 Ontario women over age 68 taking oral bisphosphonates who were hospitalized for a subtrochanteric or femoral shaft fracture. Cases were age-matched to 3500 controls — also taking bisphosphonates — without such fractures.
     Women who took bisphosphonates for at least 5 years had an increased risk for subtrochanteric or femoral shaft fractures (adjusted odds ratio, 2.74), compared with women who used bisphosphonates for fewer than 100 days. Among women treated at least 5 years, the absolute risk of developing one of these fractures was low (0.13% within the following year, 0.22% within 2 years).
     The authors note that clinicians should continue prescribing bisphosphonates for appropriate patients. However, "long-term use of these drugs may warrant reconsideration, especially in patients at relatively low risk of fracture. It may be appropriate to consider a drug holiday for selected patients."
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Cell Phones Seen Affecting Brain Biochemistry
You may be getting calls about a preliminary study showing that cell phone usage for about an hour can affect glucose metabolism in the area of the brain closest to the phone's antenna. The study appears in JAMA.
     Some 50 healthy participants had cell phones placed next to both ears for 50 minutes on two occasions. On one occasion the phones were off, and on the other only the right phone was activated, but the sound was muted while it received a recorded message.
     Brain glucose metabolism, as measured by positron emission tomography, was significantly higher in the region of the brain closest to the activated phone's antenna. Whole-brain glucose metabolism, however, did not differ between the active versus inactive phone conditions.
     The authors conclude that the finding's clinical significance is unknown.
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J Clin Oncol 2010 Nov 29
Weighty Effects on Breast Cancer Outcomes
Danish data add to the evidence that high body-mass index negatively affects prognosis.
     Obesity raises risk for incident breast cancer; moreover, high body-mass index (BMI) can worsen prognosis. In a report based on data from nationwide clinical trials of adjuvant treatment for early-stage breast cancer conducted since 1977, Danish investigators assessed obesity's effects on risk for breast cancer recurrence and death among almost 19,000 women who received treatment for early-stage breast cancer between 1977 and 2006.
     Participants with BMIs greater than or equal to 30 kg/m2 were older and had more-advanced disease at diagnosis than those with BMIs <25. Cumulative incidence of distant metastasis at 10 years was 24% versus 20% (adjusted hazard ratio, 1.46; P=0.007), and cumulative risk for death from breast cancer at 30 years was 57% versus 46% (AHR, 1.38; P=0.003). However, high BMI was not associated with excess risk for locoregional recurrence. Chemotherapy as well as adjuvant endocrine therapy with tamoxifen or an aromatase inhibitor were less effective after 10 years of follow-up in women with BMIs greater than or equal to 30.
     Comment: These findings lend further support to the conclusion that obesity is an independent risk factor for developing distant metastatic disease and for dying from breast cancer. Editorialists note that obese patients were less likely to have received chemotherapy than were lean women, possibly reflecting concerns that obese patients might experience excess toxicity when such medications are dosed by body weight. High systemic levels of estrogen, insulin, leptin, and proinflammatory molecules also might contribute to poor prognoses in obese patients. Such patients should be informed of obesity's adverse effects on breast cancer outcomes and should be encouraged to adopt lifestyle changes leading to weight loss.
Andrew M. Kaunitz, MD Published in Journal Watch Women's Health December 22, 2010
     Citation(s): Ewertz M et al. Effect of obesity on prognosis after early-stage breast cancer. J Clin Oncol 2010 Nov 29; [e-pub ahead of print]
     Sinicrope FA and Dannenberg AJ. Obesity and breast cancer prognosis: Weight of the evidence. J Clin Oncol 2010 Nov 29; [e-pub ahead of print]. (http://dx.doi.org/10.1200/JCO.2010.32.1752)
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Aliment Pharmacol Ther 2011 Jan; 33:41
Predicting Response to Proton-Pump Inhibitors for Dyspepsia
The value of a therapeutic index to predict response is unclear.
     Dyspepsia is a common symptom complex with a variety of underlying causes. Proton-pump inhibitor (PPI) therapy for dyspepsia is successful in some but not all patients.
      To identify predictors of response to PPI therapy, investigators in Denmark conducted an industry-sponsored, double-blind, randomized, controlled trial involving 805 primary care patients with uninvestigated, upper gastrointestinal symptoms categorized as acid related by their physicians. Participants were randomized to receive 40 mg of esomeprazole or placebo daily for 2 weeks. The primary endpoint was response to PPI therapy, defined as absence of the patient's key complaint during the last 24 hours of treatment. Researchers used a modeling sample of 484 participants to identify predictors of PPI response and then a validation sample of 321 other participants to test the predictors. Last, researchers applied modeling results to construct a therapeutic index — a scoring system to calculate a patient's predicted response to esomeprazole (excellent, good, fair, or little or no response).
     More PPI recipients than placebo recipients achieved response (68% vs. 44%; P<0.00001). Predictors of positive response to PPI therapy were heartburn and early satiety; predictors of negative response were dulled abdominal pain, pain relieved by bowel movement, and nausea (in women). The therapeutic index showed significantly higher therapeutic gain for a score of excellent than for little or response (55% vs. 22%).
     Comment: The authors concluded that this simple index can reliably identify patients with uninvestigated dyspepsia who are likely to respond to short-term PPI therapy. However, the concept that patients with acid-related symptoms of dyspepsia are more likely to respond to acid reduction is not novel, and the index described does not substantially improve on that concept. In addition, a fundamental problem is that the endpoint (key complaint) is not well defined and is based on only 24 hours of symptom relief rather than sustained relief. The high placebo-response rate casts further doubt on the reliability and durability of the measure. Whether a predictive model is required to justify a short-term therapeutic trial of PPI therapy in these patients is unclear.
David J. Bjorkman, MD, MSPH (HSA), SM (Epid.) Published in Journal Watch Gastroenterology February 11, 2011
     Citation(s): Meineche-Schmidt V et al. Randomised clinical trial: Identification of responders to short-term treatment with esomeprazole for dyspepsia in primary care – A randomised, placebo-controlled study. Aliment Pharmacol Ther 2011 Jan; 33:41. http://www.ncbi.nlm.nih.gov/pubmed/21083590?dopt=Abstract
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February 21, 2011
Omega-3s May Reduce Age-Related Muscle Loss
Small clinical trial in people over 70 is first to show that omega-3s enhance the efficiency of two key metabolic pathways to muscle creation
by Craig Weatherby      
     The results of a small placebo-controlled clinical study from Washington University suggest that omega-3 fish oil may help reduce age-related muscle loss. The trial was designed to test the effects of daily omega-3 pills on sarcopenia … the gradual loss of muscle mass and strength associated with aging.To put things in perspective, a person in their 20s will have muscle that is up to 60 percent fat-free mass, while this proportion drops to less than 40 percent by age 70.
     Almost one in two people over 65 suffer from sarcopenia to an extent that makes them noticeably frail and vulnerable to falls. As the trial’s authors wrote, “A major cause for the loss of muscle mass with advanced age is the inability of aging muscle to adequately increase the rate of muscle protein synthesis in response to nutritional stimuli … e.g., amino acids and insulin.” (Smith GI et al. 2011). These facts may have prompted the test of omega-3s, which influence the body’s production and use of insulin.For example, two rat studies found that dietary omega-3s increase the extent to which insulin binds to muscle cell membranes and the efficiency with which muscle cells use blood sugar (Storlien LH et al. 1991; Liu S et al. 1994).
     Pilot trial is first to link omega-3s to reduced sarcopenia risk
To test whether omega-3s might help keep muscle mass from melting away, a Washington University team recruited 16 healthy adults (average age 71) and randomly assigned them to receive either omega-3 fish oil supplements or corn oil placebo capsules for eight weeks (Smith GI et al. 2011). The study, led by Bettina Mittendorfer, Ph.D., tested the effects of taking four grams of fish oil per day, providing 1.86 grams of omega-3 EPA plus 1.5 grams of omega-3 DHA.
     The authors chose this dose because it is the level approved by the Food and Drug Administration for lowering blood triglyceride levels in heart patients. (It’s higher than the daily dose range recommended for the general public – 250mg to 500mg per day – but there is no evidence that this amount of omega-3s is unsafe for healthy people.)
     Unlike the corn oil group, the omega-3 group had twice as much anabolic (muscle building) activity resulting from two key pathways known to increase lean muscle mass.As Dr. Mittendorfer and her co-workers wrote, “Omega-3 fatty acids stimulate muscle protein synthesis in older adults and may be useful for the prevention and treatment of sarcopenia.” 
     And they pinpointed one way in which the omega-3s helped: “In the present study, we provide novel evidence that dietary omega-3 fatty acid supplementation augments the hyperaminoacidemia- and hyperinsulinemia-induced increase in the rate of muscle protein synthesis in older adults.” (Smith GI et al. 2011)
     What does this jargon mean?
Hyperaminoacidemia-induced muscle building results from high levels of amino acids in the blood (Young VR, Marchini JS 1990) – due to protein-rich diets – while hyperinsulinemia–induced muscle building results when blood insulin levels are high (Fryburg DA et al. 1995; Hillier TA et al. 1998).As a possible explanation for these increases in these two anabolic (muscle-building) pathways, the omega-3 group showed increases in the activation of a “signaling” pathway that’s reported to be, as the authors wrote, an “… integral control point for muscle cell growth” (specifically, a pathway called mTOR-p70s6k).
     Still, the full range of means by which the omega-3s may enhance muscle mass creation remains to be detailed.
     Sources: Clavel S, Farout L, Briand M, Briand Y, Jouanel P. Effect of endurance training and/or fish oil supplemented diet on cytoplasmic fatty acid binding protein in rat skeletal muscles and heart. Eur J Appl Physiol. 2002 Jul;87(3):193-201. Epub 2002 Apr 26.Fryburg DA, Jahn LA, Hill SA, Oliveras DM, Barrett EJ. Insulin and insulin-like growth factor-I enhance human skeletal muscle protein anabolism during hyperaminoacidemia by different mechanisms. J Clin Invest. 1995 Oct;96(4):1722-9.Hillier TA, Fryburg DA, Jahn LA, Barrett EJ. Extreme hyperinsulinemia unmasks insulin's effect to stimulate protein synthesis in the human forearm. Am J Physiol. 1998 Jun;274(6 Pt 1):E1067-74.Liu S, Baracos VE, Quinney HA, Clandinin MT. Dietary omega-3 and polyunsaturated fatty acids modify fatty acyl composition and insulin binding in skeletal-muscle sarcolemma. Biochem J. 1994 May 1;299 ( Pt 3):831-7.Smith GI, Atherton P, Reeds DN, Mohammed BS, Rankin D, Rennie MJ, Mittendorfer B. Dietary omega-3 fatty acid supplementation increases the rate of muscle protein synthesis in older adults: a randomized controlled trial. Am J Clin Nutr. 2011 Feb;93(2):402-12. Epub 2010 Dec 15.Sohal PS, Baracos VE, Clandinin MT. Dietary omega 3 fatty acid alters prostaglandin synthesis, glucose transport and protein turnover in skeletal muscle of healthy and diabetic rats. Biochem J. 1992 Sep 1;286 ( Pt 2):405-11.Storlien LH, Jenkins AB, Chisholm DJ, Pascoe WS, Khouri S, Kraegen EW. Influence of dietary fat composition on development of insulin resistance in rats. Relationship to muscle triglyceride and omega-3 fatty acids in muscle phospholipid. Diabetes. 1991 Feb;40(2):280-9.Young VR, Marchini JS. Mechanisms and nutritional significance of metabolic responses to altered intakes of protein and amino acids, with reference to nutritional adaptation in humans. Am J Clin Nutr 1990;51:270-89
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Obstet Gynecol 2011 Feb; 117:425
Planned Home Birth: A New View
The ACOG acknowledges that women have the right to make informed choices about home birth after thorough counseling about risks and benefits.
     In the U.S., 25,000 births (0.6%) occur at home annually. The American College of Obstetricians and Gynecologists (ACOG) has issued an updated committee opinion on planned home birth. Because data on the safety of home birth are limited (JW Womens Health Mar 7 2006), the statement relies primarily on a meta-analysis of observational studies of planned home births versus hospital births (Am J Obstet Gynecol 2010; 203:243.e1). This study showed that, although absolute risks were low, planned home birth was associated with twofold higher risk for neonatal death than was hospital birth (risk was threefold higher when anomalous newborns were omitted from the analysis).
     The committee recommends that women who are considering planned home birth should adhere to strict selection criteria (e.g., absence of preexisting or pregnancy-related disease, singleton fetus, gestational age >36 weeks). In addition, the following resources should be readily available:

The committee emphasized the need to respect the rights of women to make medically informed decisions about delivery and stressed that women who are planning home births should be made aware of the risks and benefits (particularly to their newborns) through adequate counseling.
     Comment: The American College of Nurse-Midwives notes that a critical aspect of this ACOG statement is the right of women to make informed choices after thorough counseling about home birth. However, more safety studies are needed, especially from the standpoint of certified midwifery- or nurse midwifery-led models of home care. What effect this committee opinion might have on legislation and insurance coverage for home birth is unknown.
     Diane J. Angelini, EdD, CNM, FACNM, FAAN, NEA-BC Published in Journal Watch Women's Health February 24, 2011
Citation(s): ACOG Committee on Obstetric Practice. ACOG committee opinion no. 476: Planned home birth. Obstet Gynecol 2011 Feb; 117:425. http://www.ncbi.nlm.nih.gov/pubmed/21252776?dopt=Abstract
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Lancet 2011 Feb 5; 377:469
C-Reactive Protein Level Doesn't Predict Statin Response in High-Risk Patients
Reanalysis of the largest randomized statin trial to date suggests a cardiovascular risk reduction irrespective of baseline CRP levels.
     Although C-reactive protein (CRP) has become an important blood marker of cardiovascular risk beyond traditional risk factors, whether clinicians should use CRP level to guide patient management remains debated. The partially manufacturer-funded Heart Protection Study (HPS) previously demonstrated a beneficial effect of simvastatin in high-risk patients across all levels of LDL cholesterol (JW Cardiol Aug 9 2002). Now, the HPS investigators have tested whether the effects of statin therapy differ depending on baseline CRP levels. The 20,536 participants (aged 40–80, with a previous diagnosis of any vascular disease or diabetes or taking antihypertensive medication) were randomly assigned to 40 mg of simvastatin daily or placebo for a mean of 5 years. They were divided into six baseline CRP groups: <1.25 mg/L, 1.25–1.99 mg/L, 2.00–2.99 mg/L, 3.00–4.99 mg/L, 5.00–7.99 mg/L, and greater than or equal to 8.00 mg/L.
      Overall, treatment with simvastatin significantly reduced rates of the primary endpoint (a composite of coronary death, nonfatal myocardial infarction, stroke, or revascularization) compared with placebo (19.8% vs. 25.2%). The reduction in this endpoint, or its components, did not differ significantly with baseline CRP level. Moreover, rates of the primary endpoint were significantly reduced with simvastatin even in patients with baseline CRP levels <1.25 mg/L (14.1% vs. 19.4%) and in those with both LDL and CRP levels below the median (15.6% vs. 20.9%).
     Comment: These findings clearly demonstrate that inflammation status, as measured by CRP level, does not affect the cardiovascular risk-reduction effect of statin therapy in high-risk patients. Still, patients on simvastatin who had baseline CRP levels below the median had fewer vascular events than those with levels above the median, regardless of whether LDL was above or below the median. Elevated CRP levels might aid prediction of a statin benefit in asymptomatic individuals with low LDL levels (e.g., the JUPITER population; JW Cardiol Nov 10 2008), but CRP measurement in high-risk patients remains purely academic.
Beat J. Meyer, MD Published in Journal Watch Cardiology February 23, 2011
Citation(s):Heart Protection Study Collaborative Group. C-reactive protein concentration and the vascular benefits of statin therapy: An analysis of 20 536 patients in the Heart Protection Study. Lancet 2011 Feb 5; 377:469. http://www.ncbi.nlm.nih.gov/pubmed/21277016?dopt=Abstract
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Lancet 2011 Feb 5; 377:469
Statins Prevent Vascular Events, Independent of Baseline CRP Levels
Contrary to some claims, statins benefited high-risk patients with low C-reactive protein levels.
     In the 2008 JUPITER trial, healthy adults — with LDL cholesterol levels <130 mg/dL and C-reactive protein (CRP) levels greater than or equal to 2 mg/L — who received rosuvastatin (20 mg daily) for 2 years experienced significantly fewer cardiovascular endpoints than those who received placebo (JW Gen Med Nov 18 2008). JUPITER suggested that statins had particular benefits in patients with high baseline CRP levels whose risk was otherwise low, perhaps through an anti-inflammatory effect.
     In the industry-supported Heart Protection Study, >20,000 U.K. adults at high risk for vascular events received simvastatin (40 mg) or placebo daily for a mean of 5 years. Overall, patients who received simvastatin had 24% fewer first vascular events (myocardial infarction, stroke, or revascularization) than those who received placebo.
     LDL cholesterol and CRP levels were available for 2727 patients. When these patients were stratified into six groups according to baseline CRP levels (from <1.25 to ≥8.0 mg/L), vascular risk was significantly lower for simvastatin recipients than for placebo recipients in all groups, with no relation to CRP levels. When patients were categorized as having high or low CRP levels and high or low LDL cholesterol levels at baseline, simvastatin recipients with low CRP and LDL cholesterol levels had proportional reductions in vascular risk that were similar to those in participants with high CRP and LDL cholesterol levels.
     Comment: Recent evidence suggests that statins produce similar proportional reductions in vascular events regardless of baseline LDL cholesterol levels, and this study suggests that benefits of statins are independent of baseline CRP levels as well, at least in high-risk patients.
Bruce Soloway, MD Published in Journal Watch General Medicine February 17, 201
Citation(s): Heart Protection Study Collaborative Group. C-reactive protein concentration and the vascular benefits of statin therapy: An analysis of 20 536 patients in the Heart Protection Study. Lancet 2011 Feb 5; 377:469. (http://dx.doi.org/10.1016/S0140-6736(10)62174-5) http://www.ncbi.nlm.nih.gov/pubmed/21277016?dopt=Abstract
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Lancet 2010 Dec 4; 376:1916
Statins for Patients with Fatty Liver Disease and Mildly Elevated Transaminases
Benefits seem to outweigh hepatotoxicity risk.
     Patients with hyperlipidemia often have elevated transaminase levels, usually caused by nonalcoholic fatty liver disease (NAFLD), an independent predictor of mortality. Small studies have suggested that statins lower transaminase levels and improve liver histology in patients with NAFLD, but many clinicians are reluctant to start or continue statins in such patients. In two recent studies, investigators examined the effects of statins in patients with NAFLD who were enrolled in trials with cardiovascular primary endpoints.
     In a Greek study, researchers randomized 1600 patients with coronary heart disease and hyperlipidemia to receive either structured care including atorvastatin (titrated to achieve LDL cholesterol level <100 mg/dL) or usual care by their own physicians for an average of 3 years (Angiology 2003; 54:679). Of these patients, 437 had elevated transaminases (less than or equal to 3 times the upper limit of normal) at baseline; most had ultrasound findings consistent with NAFLD and no other apparent cause of transaminitis. In this subgroup, mean transaminases declined significantly from baseline in patients assigned to statins and rose significantly from baseline in those assigned to usual care. Patients with baseline transaminitis who were assigned to statins had 68% lower risk for cardiovascular events than those receiving usual care; patients with normal baseline transaminases exhibited 39% relative risk reduction with statins. Fewer than 1% of patients assigned to statins in the original study had hepatotoxicity related to treatment.
     In a U.S. study, researchers randomized 1000 apparently healthy adults with elevated coronary calcium scores to receive a daily combination of atorvastatin (20 mg), vitamin C (1 g), and vitamin E (1000 IU), or matching placebos for a mean of 3.6 years (JW Cardiol Aug 12 2005). At baseline, all patients had LDL cholesterol levels between 90 and 174 mg/dL and transaminases <1.5 times the upper limit of normal. Among the 455 patients who underwent baseline and follow-up abdominal computed tomography (CT) scans, 80 met radiological criteria for NAFLD at baseline (defined as a ratio of liver to spleen attenuation <1). Follow-up CT scans showed significantly fewer patients with NAFLD in the treatment group than in the placebo group (37% vs. 78% at 2 years). Three patients exhibited transient transaminase elevations during the study.
     Comment: In patients with NAFLD and mildly elevated transaminase levels, the cardiovascular benefits of statins seem to outweigh any risk for hepatotoxicity. Whether statins (with or without antioxidant vitamins) can interrupt the progression from NAFLD to advanced liver disease will require longer-term study. Also, randomized trials of statins in patients with more-severe fatty liver disease are needed.
Bruce Soloway, MD Published in Journal Watch General Medicine January 25, 2011
Citation(s): Athyros VG et al. Safety and efficacy of long-term statin treatment for cardiovascular events in patients with coronary heart disease and abnormal liver tests in the Greek Atorvastatin and Coronary Heart Disease Evaluation (GREACE) Study: A post-hoc analysis. Lancet 2010 Dec 4; 376:1916. (http://dx.doi.org/10.1016/S0140-6736(10)61272-X) http://www.ncbi.nlm.nih.gov/pubmed/21109302?dopt=Abstract
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Arch Dermatol 2011 Jan 17;
Atopic Dermatitis and Cataracts: A Cloudy Issue
Long-term corticosteroid treatment, onset in infancy, and family history of AD increase risks for cataracts in children.
     Ocular complications of atopic dermatitis (AD) include herpes simplex, conjunctivitis, keratoconus, retinal detachment, and subcapsular cataracts (SCs). Both posterior and anterior SCs have been described in AD patients, but the related risk factors and pathogenesis of their formation are largely unknown.
     Authors of this case report and review of the literature describe a 6-year-old girl with asthma and allergic rhinitis who presented with severe chronic AD. She had had multiple hospitalizations and missed school days due to AD despite multiple courses of topical and systemic corticosteroids, antibiotics, and emollients. Her AD improved with UVB and UVA phototherapy administered with appropriate eye protection. At age 7, she awoke with sudden blindness due to bilateral anterior SCs. These were corrected surgically; 4 weeks later, she developed a detached retina.
     Comment: The authors explain that although posterior cataracts are more common in AD patients, anterior cataracts are more specific to the disease. Posterior SCs are known to be associated with systemic corticosteroid use, with or without AD. Improper use of inhaled corticosteroids by children can lead to ocular exposure and thus to posterior SC development. Serum lipid peroxide levels are increased, and inducibility of superoxide dismutase decreased, in AD patients with cataracts. Conflicting data prevent clear correlation of cataract development with AD severity or with repetitive rubbing of the eyes. The authors hypothesize that atopic cataract development is related to chronic inflammation and oxidative damage of the lens. They suggest ophthalmologic screening of patients with infantile onset AD, family history of AD, systemic corticosteroid use, or elevated lipid peroxide levels.
     Risk for cataract development in atopic dermatitis remains a cloudy issue. Ophthalmology consult seems prudent for patients with chronic periocular AD or chronic itchy eyes (e.g., allergic conjunctivitis), particularly in recipients of long-term oral or topical steroids and young patients who may be unable to verbalize ocular complaints. Cataracts in patients younger than 8 years can lead to amblyopia and resultant disability, even after surgical correction of cataracts.
Mary Wu Chang, MD Published in Journal Watch Dermatology February 25, 2011
     Citation(s): Bair B et al. Cataracts in atopic dermatitis: A case presentation and review of the literature. Arch Dermatol 2011 Jan 17; [e-pub ahead of print]. (http://dx.doi.org/10.1001/archdermatol.2010.411)

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