JAMA

doi: 10.1001/jama.296.14.1693pmid: N/A

Myocardial Infarction Risk in Patients With Psoriasis Some data suggest that patients with psoriasis have a higher prevalence of cardiovascular disease, including myocardial infarction (MI). In a population-based cohort study, Gelfand and colleagues investigated whether psoriasis is an independent risk factor for incident MI. The authors found that compared with patients without psoriasis, patients with psoriasis had an increased risk of MI. This risk was attenuated with advancing age and remained high after controlling for traditional cardiovascular risk factors. Article Respiratory Effects of a Smoking Ban in Public Places Despite accumulating evidence of an association of secondhand smoke exposure with adverse health consequences, many public spaces are not smoke-free. Menzies and colleaguesArticle report results of a prospective study of nonasthmatic and asthmatic nonsmoking bar workers, in which the investigators measured respiratory and sensory symptoms, pulmonary function, and markers of inflammation 1 month before and 1 and 2 months after Scotland had implemented a smoking ban in confined public places. Compared with preban measures, the authors found that both nonasthmatic and asthmatic bar workers experienced significant improvements in respiratory and sensory symptoms and in pulmonary function, and reductions in systemic inflammation in the first 2 months following implementation of the smoking ban. In an editorial, EisnerArticle discusses the benefits of smoking bans in public places. Outcomes After Reperfusion for ST-Elevation MI Acute reperfusion with fibrinolytic drugs has been the primary treatment of ST-segment elevation myocardial infarction (STEMI) since the late 1980s. However, some clinical trial data suggest that primary percutaneous coronary intervention (PCI) is associated with better outcomes than fibrinolytic therapy. To assess whether superior outcomes with PCI can be achieved in unselected patients and outside the clinical trial setting, Stenestrand and colleagues analyzed 1999-2004 data from 26 205 consecutive STEMI patients in Sweden who were treated with primary PCI, prehospital thrombolysis, or in-hospital thrombolysis. In analyses that adjusted for age and comorbidities, the authors found that patients who received PCI had lower 30-day and 1-year mortality, less reinfarction, shorter hospital stays, and fewer readmissions than patients receiving prehospital or in-hospital thrombolysis. Article Nonmedical Exemptions to Required Immunizations State policies allowing nonmedical exemptions for school immunizations may influence the incidence of some vaccine-preventable diseases, such as pertussis. Omer and colleagues analyzed 1991 through 2004 state-level data on rates of nonmedical exemptions at school entry and 1986 through 2004 data on pertussis incidence to assess the relationship of exemption policy characteristics to pertussis incidence. The authors found that states permitting personal belief exemptions compared with religious exemptions and states with easily obtained vs medium or difficult to obtain exemptions had higher and increasing nonmedical exemption rates during the period of study. In addition, the authors report that states with personal belief and easily obtained exemptions had increased pertussis incidence compared with states with religious or harder to obtain exemptions. Article A Piece of My Mind “[Randy] had the classic dilemma of the working poor—an injury or condition that wasn't a life-threatening emergency but still clearly needed treatment.” From “The Imaginary Safety Net.” Article Medical News & Perspectives Researchers have identified a genetic variant that weakens amniotic membranes and increases the risk of premature delivery. Article Clinician's corner Opiate analgesia in patients with acute abdominal pain may alter physical examination findings but does not increase the likelihood of errors in management. Article Plan B Contraceptive Pregnancy prevention from the Plan B contraceptive occurs prior to fertilization. Article Chronic Diseases in Childhood Authors may submit manuscripts for an upcoming JAMA theme issue. Article Audio Commentary Dr DeAngelis summarizes and comments on this week's issue. Go to http://jama.ama-assn.org/misc/audiocommentary.dtl. JAMA Patient Page For your patients: Information about acute abdominal pain. Article

Southgate, M. Therese

doi: 10.1001/jama.296.14.1696pmid: 17032974

To hasty readers or hurried museum visitors, as they rush past the jumble of blues and yellows known as An October Day (cover ), it may seem that they have glimpsed yet another of the myriad Impressionist works of the 19th century, albeit not one easily pulled from memory. Monet? Perhaps: something between his yellow haystacks and his ghostly cathedrals, vaguely between sunshine and fog, a landscape image, light-filled, sparkling, ephemeral, timeless, passing. And, a painting most certainly beautiful. An attentive pause, even the briefest, might reveal the transected yellow verticals to be trees that are shedding (unleaving, as Gerard Manley Hopkins would say). A longer pause might even evoke a distant echo of the Bard: “[ . . . ] yellow leaves, or none, or few, do hang/Upon those boughs which shake against the cold,/Bare ruined choirs, where late the sweet birds sang.” (Sonnet 73) Winslow Homer (1836-1910), An October Day, c 1889, American. Watercolor. 35.2 × 50.2 cm. Courtesy of the Sterling and Francine Clark Art Institute (http://www.clarkart.edu/), Williamstown, Mass. Photograph © Sterling and Francine Clark Art Institute. But of course, the painting is not a Monet, nor is it even a work by any of his colleagues, nor is it even French, or an oil. It is American, a watercolor as delicate as a mountain breeze, yet a plain-spoken, unsentimental comment on the realities of life and death. In the midst of a beauty and grandeur that is beyond words to describe, a deer swims for its life; at the left, hidden among the shadows and reflections, is a hunter about to shoulder his rifle. Disarmingly titled An October Day, it is one of nearly 90 watercolors Winslow Homer (1836-1910) executed over a period of 20 years during numerous painting and fishing vacations in the Adirondack Mountains of upstate New York. Many of the works in the series portray deer-hunting, which in the late 19th century was more for purposes of “putting food on the table” than for sport. Homer is neither sentimental nor romantic; he is a realist and that is moral enough. He pictured all aspects of the hunt, from stalking to kill, including the even then controversial method of “hounding.” Dogs were loosed to pick up the deer track, whereupon the pursued deer often took to one of the numerous lakes in the mountain wilderness where its scent would be lost. Ironically, the fleeing deer then became easy prey to the hunter. It is probably just such an episode that is portrayed in An October Day. In 1889, when Homer painted An October Day, he was at the height of his powers, easily considered to be America's best watercolorist. Gone were the subjects of the earlier years, of children, beaches and sand pails, country schoolyards, red one-room schools, rowdy boys, prim but charming teachers—even the soldiers he had pictured at the front during the Civil War. They had been but prelude to the future. Whether oil or watercolor, seascape or landscape, Homer's later paintings had but a single theme: mortality and the struggle for survival against the forces that control it. His subjects became metaphors for the struggle among the mostly unequal forces of nature, whether between humans and animals or humans and the elements or, ultimately, against Nature herself. Although Homer lived a secluded life in Prout's Neck for nearly three decades, he was by no means a recluse. An avid outdoorsman, he went almost every year if not to the Adirondacks then to Quebec, Bermuda, Florida, or the Bahamas to indulge his two passions: fishing and painting. If financial success seems to have eluded him, then neither did he seem to be especially troubled by its absence. His was the satisfaction of knowing that museums and other public collections owned more of his work than that of any other artist then living. Homer died at his studio in Prout's Neck on September 30, 1910. He was 74 and had last visited the Adirondacks just months earlier. He had indeed loved well that which too soon he left.

Thompson, Don

doi: 10.1001/jama.296.14.1698pmid: N/A

As the slow drift of galactic dust Settles around your thoughts, we see In this intracranial planetarium An end to cherished mystery. So this is real. Can we adjust? How can a see-through skull keep its decorum? Or is it all just smoke and ash? And there—right there!—a blackened coin Without a date, minted in the Realm of Fear? May it be a worthless token, And may the docs bank all the cash While we have life to burn this time next year.

Kilgore, David B.

doi: 10.1001/jama.296.14.1701pmid: 17032975

The nursing note for my next patient stated simply, “Follow-up of nose injury.” Randy (not his real name) was a young man, new to the clinic, so there was no background information available from the chart. I knocked on the door, stepped into the small examination room, and introduced myself to a short, unshaven young man with a bandage covering the end of his nose. I learned he was involved in a fight three nights ago and that his assailant had “bitten him on the end of his nose.” He had been treated at the local emergency department and had been referred to a plastic surgeon for follow-up. Upon calling the surgeon's office for an appointment the next day, however, he was told that because he had no medical insurance, he would need to bring $500 cash up front just to be seen for the first appointment. When he called the ED back to complain, they gave him the number of our community clinic. Randy looked at me angrily. “I make minimum wage, Dude—no way I have that kind of money lying around. What am I supposed to do?” I’ve cared for underserved populations my entire professional life, and his is an all too familiar story. The safety net for uninsured patients, such as it exists in the United States, stretches paper thin between emergency departments and community clinics. The buck stops with us, if it stops at all. When poor people have nowhere else to turn, they come to us. After almost 20 years of seeing the results of poverty and lack of access to care, I still never know what to expect behind the next exam room door. I reached forward and gently began to peel back the bandage. Many times patients are referred to plastic surgeons for fine-tuning of cosmetically important wounds, like facial lacerations. Surgeons have the extra training to do subtle wound improvements or scar revisions to help obtain the best cosmetic results. This young man seemed like a rough-and-tumble sort of guy—when I reviewed his basic medical history, he proudly regaled me with his various physical exploits that resulted in several broken bones, three amputated fingers, and various bodily scars. I was a little surprised he would be concerned about having a plastic surgeon attend to a scar on his nose, but then again, it was his face and he had a right to the same level of care as his insured brethren. His problem, however, wasn't with a scar across his nose. His problem was that he no longer had a nose. Pulling back the last layer of bandage, I stifled a gasp. In the middle of his face, between his eyes and mouth, was a jagged wound. There was a small remaining upper bridge of nose jutting down, but the fleshy end was traumatically missing—bitten off. As horrific as it was, the wound at least showed no signs of infection. I rebandaged it, instructed him about further wound care, then promised him that the clinic's outreach worker would get to work on trying to find a plastic surgeon who would see him—for what? For free? Not likely. He had the classic dilemma of the working poor—an injury or condition that wasn't a life-threatening emergency but still clearly needed treatment. His low-income job offered no health insurance but paid him just enough to disqualify him for Medicaid coverage. Our outreach worker sighed when I gave her the referral request. She added his chart to the towering pile on her desk, muttering her suspicions out loud. “What was he doing that night anyway? Did he provoke the fight?” In other words, what was his responsibility for his current predicament? Is he simply paying for his poor choices? I often struggle with these kinds of questions. I struggle first with myself, to acknowledge how easy it is to pass judgment on those whose lives and backgrounds I can scarcely imagine. I struggle with how judgments of the health care community can sometimes make it more difficult to render compassionate care, whether subtly with sarcastic comments and nonverbal behavior, or overtly with substandard or denied care. And this is a slippery slope to start down. Who among us has not done something stupid that resulted in an injury, however small? Are injuries that happen to insured people somehow immune to judgment and more worthy of society's dollars? The choices of many to overeat and not exercise are resulting in an epidemic of diabetes, hyperlipidemia, and vascular disease with very expensive consequences: Are these patients therefore to blame and not deserving of coverage for their medical treatments? During a follow-up visit, Randy asked me to check his shoulder, also injured in the fight, and I noticed persistently elevated blood pressure readings as well. I diagnosed a torn muscle in his shoulder and new-onset hypertension—problems that at least I could treat, although in limited ways due to his lack of insurance. An MRI scan would have been helpful to confirm his torn shoulder muscle, but he simply laughed at the $800 he would have to come up with. Physical therapy would have been helpful in his recovery, but instead I printed out self-guided exercise instructions in lieu of the $600 bill he again couldn't afford. I had samples of blood pressure medication I could give him, but he insisted on postponing important baseline laboratory tests of his kidney function and electrolytes until he covered his rent that month. On his third visit, I learned we had succeeded in getting Randy an appointment at the county surgical clinic 60 miles away, at some distant time in the future. He still wore a gauze bandage over his wound, even though it was healing well, to shield himself from stares from passersby. His blood pressure was down, and his shoulder was feeling better. As I prepared to leave the room, he reached out and vigorously shook my hand. “Thanks, Doc. You’ve done more for me than any of them fancy hospitals.” I was initially embarrassed by his effusive gratitude, but later, as I sat finishing his chart, I found myself feeling sad and angry. I reflected on all the care he would have received had he been insured. As community clinic physicians, we do what we can but know it's often not enough. We know that some care is better than no care, but we carry the burden of knowing what care and treatment someone with insurance would have received. At times, and especially early in my career, I have been proud of carrying that burden, of being part of a safety net for the neediest. At other times, and more so lately, I wonder if my very participation in this system plays a darker role—a complicit role—of enabling the disparity of care to persist, of helping to provide false reassurance that we actually have a safety net that provides adequate care to all in need.

Hampton, Tracy

doi: 10.1001/jama.296.14.1713pmid: 17032976

Researchers have identified a genetic variant in black women that increases the risk of preterm premature rupture of membranes (PPROM)—a leading cause of preterm birth (Wang H et al. Proc Natl Acad Sci U S A. doi: 10.1073/pnas. 0603676103 [published online ahead of print August 21, 2006]). “This is probably the most convincing study to date that specific, fairly common, genetic variants will increase risk,” said Nancy Green, MD, medical director of the March of Dimes. A genetic variant found in approximately 12.4% of black women can cause weakened amniotic membranes during pregnancy, increasing the risk of preterm birth. (Photo credit: Tina Stallard/http://www.sciencesource.com) In addition to helping explain why black women in the United States are nearly twice as likely to have a baby born prematurely as white women, the new findings could help physicians identify those women who are at risk and guide researchers in developing therapeutic interventions. Genetic predisposition Genetic predisposition A number of factors are associated with an increased risk of preterm birth, including smoking, a history of preterm delivery, infection, and low body mass index. But about half of the cases have no known cause, and researchers have been searching the human genome for genes that may increase a woman's likelihood of preterm delivery. Genetic predisposition This latest study has identified a possible culprit: a variant in a region of the SERPINH1 gene that codes for a protein called heat shock protein 47 (Hsp47). Heat shock protein 47 stabilizes collagen and gives strength to the amnion. Presence of the variant leads to decreased production of Hsp47 and weakened amnionic membranes that are more likely to rupture prematurely and lead to preterm birth. The genetic polymorphism is present in approximately 12.4% of black women compared with 4.1% of white women. Genetic predisposition In 2 separate case-control studies involving 244 black women experiencing PPROM and 358 matched controls, the investigators found that the genetic variant occurred almost 3 times more frequently in neonates born from pregnancies complicated by PPROM than in controls. The findings suggest that the genetic variant is responsible for approximately 12% of preterm births. “So it's not the major cause,” said principal investigator Jerome Strauss III, MD, PhD, dean of Virginia Commonwealth University's School of Medicine, in Richmond. “It's one cause and it is a beginning,” he noted. Continued search Continued search According to the March of Dimes, which helps support Strauss' research, more than a half million babies are born too soon each year, and the preterm birth rate has increased more than 30% since 1981, from 9.4% in 1981 to 12.5%, an all-time high. The increase is due to a variety of factors, including delayed childbearing, more multiple births, and more obstetrical interventions to deliver early in cases of maternal or fetal problems. Continued search “Preterm birth is a major obstetric and pediatric challenge in the United States,” said Green. Care of premature infants costs the US health care system more than $14 billion each year, and long-term disabilities that can be associated with prematurity (including cerebral palsy, mental retardation, chronic lung disease, and vision and hearing loss) add additional costs. Continued search There is an accumulating literature on genetic variants that are associated with spontaneous preterm labor and preterm birth. For example, polymorphisms in a number of genes that code for inflammatory cytokines may cause abnormal responses to inflammation and infection, leading to preterm birth (Varner MW and Esplin MS. BJOG. 2005;112(suppl 1):28-31). And genetic predispositions to thrombosis have been reported to be associated with recurrent pregnancy loss and preterm birth, although the link is under debate (Hartel C et al. Thromb Hemost. 2005;94:88-92). “These kinds of studies may help identify specific genetic risk factors and women at risk,” said Green. Continued search In terms of genetic predispositions, “down the road one could envision a molecular screening paradigm where individuals would undergo a genetic screening for a battery of genes that could contribute to poor obstetrical outcomes in preterm birth,” said Strauss. Lifestyle changes, such as stopping cigarette smoking, or therapeutic interventions, might be warranted for high-risk individuals, he said. For example, ingesting sufficient vitamin C, a cofactor for collagen synthesis, has been shown to lessen the incidence of premature rupture of membranes (Casanueva E et al. Am J Clin Nutr. 2005;81:859-863). Continued search Strauss and colleagues speculate that the PPROM-associated gene variant they identified may be important for enhanced wound healing. While the variant reduces production of Hsp47 in fibroblast cells within the amnion, it increases it in dermal fibroblasts. “So it's possible that there was selective pressure to retain this allele,” said Strauss. Continued search The research team is also searching for other genetic variants that may be linked to preterm birth. They have identified a gene deletion nearby that appears to mitigate the effects of the Hsp47 variant within cells in the amnion. “We're doing a little genetic archeology,” said Strauss. “This could be informative with respect to the evolution of genetic traits.”

Zeller, John L.

doi: 10.1001/jama.296.14.1716pmid: 17032977

Chicago—Traditional treatment regimens and limited interventional therapies for patients with head and neck cancer (HNC) have led to unanticipated social and psychological problems for such individuals, including a dramatic increase in the risk of suicide, according to experts gathered at the American Head and Neck Society's annual meeting here in August. In work presented by Stephanie Misono, MD, and Bevan Yueh, MD, from the University of Washington, in Seattle, researchers found that the suicide rate in patients with HNC was substantially higher than that of either the general population or the overall population of patients with cancer. The study population included patients with single primary cancer sites entered into the national network of US population-based cancer registries in the National Cancer Institute's Surveillance Epidemiology and End Results (SEER) program between 1973 and 2002. A scan reveals cancer in the base of the tongue and in the neck (arrow). A new study has found that patients with head and neck cancer may have a markedly increased risk of suicide. (Photo credit: Arch Otolaryngol Head Neck Surg. 2003;129:14-25) In the retrospective chart study, the investigators identified 4732 suicides among 2 860 156 people followed for 14 190 218 person-years. They calculated that the suicide rate among patients with HNC was 50.5 per 100 000 person-years, markedly higher than the overall cancer suicide rate of 33.6 per 100 000 person-years and more than 4 times the rate in the general US population (12.0 per 100 000 person-years, according to the CDC Report on Regional Variations in US Suicide Rates, 1998-2002). The researchers also found that in HNC patients, advanced disease was associated with an even higher suicide rate. Contributing factors Contributing factors Despite the increased risk of suicide among patients with cancer, there has been no national study of this population to examine factors that play a role in this phenomenon. And while cancers of the head and neck are uncommon, it seems plausible that they have a disproportionate impact on quality oflife. Since head and neck cancers often distort such unique human characteristics as voice and appearance; impair tasting, breathing, and hearing; prevent chewing or swallowing; and cause unrelenting fatigue, they have a profound psychological impact, noted Yueh. “Coupled with lifestyle behaviors that include smoking, heavy alcohol use, and concomitant substance abuse, these patients are at particular risk for depression,” he said. Contributing factors Yueh and William Lydiatt, MD, of the University of Nebraska Medical Center, in Omaha, both advocate a second look at the current treatment paradigm of organ preservation coupled with extensive chemoradiation and an examination of associated factors that contribute to psychological distress in patients with HNC. Together, they have called for a multicenter cohort study to prioritize quality-of-life issues, examine survival rates for various treatment options dependent on tumor staging, and acquire more meaningful data about voice quality, appearance, general health, and other important patient-based outcomes. Quality of life Quality of life Although preservation of the ability to speak was once considered the primary quality-of-life factor for patients with HNC, newer surveys indicate that protecting and preserving the ability to swallow may be even more important. Unimpaired swallowing allows patients to eat firmer-textured foods and dine unencumbered in restaurants, and it complements efforts to encourage patient socialization. Further documentation and recognition of preservation of swallowing as a top priority could affect the current treatment regimens, which rely on protracted use of chemoradiation. Studies indicate that this approach has a high complication rate (including a 62% complication rate of esophageal strictures, which can cause swallowing difficulties) without the benefit of increased survival rates. Quality of life “Our preconceived notions about what is best for our patients can be very naive and perhaps inaccurate,” said Lydiatt. “I don't think the question of which therapy is best is at all settled at this time. Quality-of-life, functional, and psychological studies are required to help answer these questions and to refocus our attention.” Addressing depression Addressing depression Studies from the University of Nebraska provide evidence suggesting that depression can be significantly ameliorated with prophylactic interventions, especially when such programs use antidepressant medications. Unfortunately, in a related paper presented at the meeting, researchers from the M. D. Anderson Cancer Center in Houston, Tex, noted that only 32% of HNC patients now participate in any long-term, interventional treatment protocols. Addressing depression There are several reasons why cancer patients in general and HNC patients in particular often fail to receive needed psychiatric intervention. “Medical and surgical oncologists are often not taught the importance of taking a complete psychiatric history, and time constraints often contribute to avoiding this time-consuming task,” explained Lydiatt. He added that patients may be less than honest or forthcoming about such personal issues. Addressing depression “This failure on all sides to recognize depression and its effects should be addressed early on and aggressively treated during the entire course of cancer therapy,” said Lydiatt.

Friedrich, M. J.

doi: 10.1001/jama.296.14.1717pmid: 17032978

Boston—Known best for its role in the body as a regulator of blood glucose levels and fatty acid storage, insulin also acts in the brain to aid memory and thinking. Thus, when insulin regulation is disrupted, as it is in many common medical conditions including obesity and diabetes, the risk for cognitive impairment rises. Insulin dysregulation sets the stage for certain neurodegenerative disorders, particularly Alzheimer disease (AD), said Suzanne Craft, PhD, professor of psychiatry, University of Washington, Seattle. Craft and colleagues have been studying the link between insulin and memory for the past decade, and their research is suggesting potential approaches to treat, delay, or even prevent AD. She recently presented some of their findings at the annual meeting of the Endocrine Society. Insulin acts in certain areas of the brain to enhance memory and cognition. (Photo credit: Molecule source: PDB ID 1ZNJ) In normal physiology—and also when insulin is administered peripherally at optimal doses—insulin can enhance memory, noted Craft. But when insulin levels are poorly controlled, as is the case in millions of older adults with type 2 diabetes who have insulin resistance accompanied by persistently high levels of insulin, problems in the brain can ensue. For example, in a study of 16 healthy individuals, Craft's team found evidence that hyperinsulinemia is associated with inflammation in the brain and also triggers an accumulation of the 42-peptide form of β-amyloid, the precursor of amyloid plaques that are found in certain brain regions and are a hallmark of AD (Fishel MA et al. Arch Neurol. 2005;62:1539-1544). Evidence implicating insulin resistance, type 2 diabetes, and inflammation as risk factors for AD has been building for some time. The hormone appears to boost β-amyloid levels by competing with the peptide for insulin-degrading enzyme, which degrades and clears both insulin and β-amyloid. But insulin-degrading enzyme seems to prefer insulin to β-amyloid, so when high levels of insulin are present, β-amyloid peptides aggregate into plaques. Increases in β-amyloid are known to raise the risk of neurodegenerative disease and impair memory. Craft hypothesizes that treating insulin resistance might improve memory and even avert cognitive decline in people with mild cognitive impairment. To this end, her team has been investigating insulin-sensitizing agents called PPAR-gama agonists that lower insulin levels in the body and have potent anti-inflammatory effects. She described unpublished preliminary findings from a randomized, placebo-controlled trial which compares the effects of the PPAR-gama agonist pioglitazone with nateglinide, a drug from a different class of antidiabetic agents. Both drugs produce comparable levels of hyperglycemic therapy, noted Craft, but they work through two different mechanisms—nateglinide increases insulin levels, whereas pioglitazone reduces them. In the study, 71 adults older than 55 years who were newly diagnosed as having impaired glucose tolerance or type 2 diabetes were randomized to receive pioglitazone, nateglinide, or placebo for 4 months. All participants underwent cognitive testing at baseline, 2 months, and 4 months; 21 patients with insulin resistance and 9 healthy controls also had positron emission tomography (PET) scans at the beginning and end of the study. Performance on memory tasks improved in participants who received pioglitazone but not in those who took nateglinide or placebo. The degree of improvement with pioglitazone was proportional to patients' metabolic responses to treatment (measured by a 2-hour oral glucose tolerance test); the higher the response to treatment, the more improvement in memory. Craft said that a resting PET scan revealed significant differences between those with insulin resistance compared with controls. Those with insulin resistance showed a reduction in glucose metabolism in areas known to be affected in the earliest stages of AD—the left temporal cortex and the right parietal region—as well as in an unanticipated area of hypometabolism, the frontal cortex. Controls who performed a word memory task while in the PET scanner showed increased glucose metabolism in the frontal cortex. Participants with increased glucose tolerance showed diminished activity in glucose metabolism; those with frank diabetes showed an even greater reduction in activity in that area, said Craft. In other unpublished work, Craft's team has been studying the effects of intranasal insulin, which has been demonstrated to produce a quick boost in memory in healthy adults who receive insulin through this route (Benedict C et al. Neuropsychopharmacology. doi:10.1038/sj.npp.1301193 [published online ahead of print August 16, 2006]. (The advantage of delivering insulin intranasally rather than intravenously is that it avoids causing undesirable systemic adverse effects such as hypoglycemia.) In a small trial, 46 older adults with memory impairment and 22 healthy controls received either a nasal dose of saline or nothing or one of 4 different insulin doses; all participants underwent cognitive testing before and after the intervention. While all individuals who received insulin showed improved performance when retested 15 minutes after receiving the hormone, its effects on memory in those with memory impairment were “dramatic,” said Craft. Further investigation is under way to better understand the links between insulin and cognition as well as to examine whether the potential treatment methods arising from the research are effective for AD or age-related memory impairment.

Mitka, Mike

doi: 10.1001/jama.296.14.1718pmid: 17032979

Last year marked the 50th anniversary of the introduction of the Salk vaccine, which signaled the end of the poliomyelitis epidemic. In the half-century that followed, polio has been virtually eliminated worldwide. With such positive news, it is perhaps unsurprising that the experience of 920 000 polio survivors in the United States, plus the millions more worldwide, has disappeared from society's view. But many people who survived an initial acute attack of polio are still living, and they continue to face old and new problems associated with the virus along with issues related to aging. A persistent concern in the polio survivors' community is postpolio syndrome. The condition, first noted in the early 1970s, is marked by a weakening in muscles previously affected by the polio infection as well as in muscles that seemingly were unaffected. New research suggests that functional decline in polio survivors is equivalent to that seen in the general population due to aging. (Photo credit: Alan Pestronk, MD/http://www.neuro.wustl.edu/neuromuscular) Awareness of the syndrome grew rapidly in the 1980s, raising anxieties among survivors who had fought off polio in their youth but now were told new symptoms awaited them as they aged. This awareness also spurs research, as scientists try to determine why the syndrome exists, to assess the severity of symptoms, and to discover therapies for those affected. Such research is also important because while the number of US polio survivors should naturally decline as they age, people are still getting polio, especially in parts of Africa, and scientific insights learned today will help when these patients reach older age by the middle of this century. Less decline than feared? Less decline than feared? In August, some potentially good news came out of the Mayo Clinic in Rochester, Minn, where researchers argued that most polio survivors do not experience declines in physical function as a result of postpolio syndrome and that any drop-off mirrors functional change associated with aging. The researchers also found that polio survivors who had the most deficit from their childhood encounter tended to see the most functional decline, but that the rate of change was no different than that seen in the general population (Sorenson EJ et al. J Peripher Nerv Syst. 2006;11:241-246). Less decline than feared? “No one needed to make lifestyle modifications,” said Eric Sorenson, MD, Mayo Clinic neurologist and lead author of the study. “The prognosis for these people was very good.” Less decline than feared? Sorenson and colleagues followed up 38 polio survivors living in Olmsted County, Minn, for 15 years. At the beginning of the study, in 1987, the average age of participants was 53 years, and an average of 40 years had passed since their initial contact with polio. At the beginning of this period and then again 5 and 15 years later, the researchers measured strength and loss of neurons with electrophysiological testing, strength testing, and timed tests of performing basic functions. Sorenson described the cohort from which the participants in his study came from as being composed roughly of 40% with mild symptoms, 40% with moderate symptoms, and 20% with major symptoms. Less decline than feared? “What we found was a very slight decline in their strength,” Sorenson said. “They did progress and got worse. But the magnitude of the change was modest. Very few needed canes, orthotics, or new equipment.” Less decline than feared? Taking a more cautious read of the results is Lauro S. Halstead, MD, director of the postpolio program at the National Rehabilitation Hospital in Washington, DC, and a polio survivor. Halstead said the findings ran counter to previous research that suggested a greater presence of postpolio syndrome with greater deficits. Less decline than feared? “There are 3 viruses in the polio family, and they're all different,” Halstead said. “It could be possible that that part of the country saw the mild form of polio.” Hypothesizing causes Hypothesizing causes Other researchers are trying to understand the cause of postpolio syndrome, said Marinos C. Dalakas, MD, chief, Neuromuscular Disease Section of the National Institute of Neurological Disorders and Stroke in Bethesda, Md. The most prominent theory is that the initial attack of polio centers on motor neurons, and that the few remaining neurons are then overworked as they are called on to interact with muscle fibers (Dalakas MC et al. N Engl J Med. 1986;314:959-963). Hypothesizing causes “These nerve cells overfunction for many years and finally give out—like a premature aging process,” Dalakas said. Hypothesizing causes Sorenson speculated that the drive of polio survivors to overcome their hardships may ultimately hinder them as they reach advanced age. “They are stricken by a virus in the formative years of their lives, and when they recover they push themselves harder and harder to prove they are a success,” he said. “But driving that hard catches up with them.” Hypothesizing causes Other theories also are being raised. One suggests that the poliovirus somehow remains hidden in the body, only to be released again after several decades of dormancy. Hypothesizing causes Another theory holds that postpolio syndrome is the result of inflammation. Scientists have found increased levels of inflammatory cytokines in the cerebrospinal fluid of polio survivors. To counteract the inflammation, researchers at the Karolinska Institute in Stockholm, Sweden, are studying the effects on polio survivors who receive high-dose intravenous immunoglobulins. The researchers have found that use of intravenous immunoglobulins leads to a lessening of the inflammatory process, followed by an increase in muscle strength and physical activity as well as improved quality of life and reduced pain over 6 months (Gonzalez H et al. Lancet Neurol. 2006;5:493-500). Muscle strength increased by 4.3% over baseline in patients receiving intravenous immunoglobulins, while those receiving placebo had a 5.8% decline in strength, the researchers said. Turning the radar on Turning the radar on Dave Heagerty of San Jose, Calif, is pleased researchers continue to study postpolio syndrome. Heagerty, a 78-year-old polio survivor and chair of Rotary International's Polio Survivors and Associates, worries that physicians may have forgotten how to treat his cohort as they move through old age. Turning the radar on “Because we’ve been immunizing people here for 50 years, polio has fallen off the radar screen among medical people,” Heagerty said. “When I see my physician and tell him about my little difficulties in getting up from a chair, he nods his head and goes, ‘Mhmm.’” Turning the radar on Halstead said physicians may be getting better at appreciating concerns surrounding postpolio syndrome as patients in support groups have been encouraged to bring journal articles about the condition to their physicians. Turning the radar on Halstead noted that any one practitioner may see only one or two polio survivors a year, “so if they don't have a good idea about the problems, that's understandable. But this situation has gradually changed over the years, and some physicians seem to have a better understanding.” Turning the radar on Halstead added that it is also up to polio survivors to make physicians aware of their condition. Turning the radar on “These [patients] are strivers and achievers who you would not necessarily know had polio just by looking at them,” Halstead said. “So there's a bit of a psychological hurdle they must overcome to communicate better with their physicians.”

Mitka, Mike

doi: 10.1001/jama.296.14.1720-dpmid: N/A

National Institutes of Heath (NIH) officials have not adequately disciplined agency scientists for violating ethics rules regarding outside consulting agreements, House members charged on September 13. At a hearing of the House Energy and Commerce Subcommittee on Oversight and Investigations, NIH officials were asked why only 2 of 44 NIH scientists found to have violated ethics rules on outside consulting agreement face possible prosecution for criminal activity and remain employed by the agency. NIH Deputy Director Raynard Kington, MD, told the committee that administrative actions against 34 of the 44 scientists were under way and that cases against the other 10 had been sent to the agency's Office of Inspector General for possible prosecution. At a June hearing, one NIH scientist, Trey Sunderland, MD, chief of the Geriatric Psychiatry Branch, invoked his Fifth Amendment right against self-incrimination. Sunderland was accused by the subcommittee of shipping human tissue samples to Pfizer Inc, New York City, in exchange for $600 000 in outside consulting and speaking fees from 1998 to 2004 (http://energycommerce.house.gov/108/News/06142006_1946.htm).

Mitka, Mike

doi: 10.1001/jama.296.14.1720-apmid: N/A

Advocacy groups are urging Congress to pass legislation protecting Medicare beneficiaries by waiving late enrollment premium penalties for Medicare prescription drug coverage. In letters sent to Senate and House leadership on September 13, more than 40 groups, including the National Council on Aging, Easter Seals, and the Alzheimer Association, argue that people enrolling in Medicare Part D in November or December will pay up to a 7% monthly penalty on premiums for the rest of their lives. The penalty, which could affect up to 1 million enrollees, is equal to a 1% increase in premiums for each month of delayed enrollment. Bills pending in the Senate and House (S 2810 and HR 5399, respectively [http://thomas.loc.gov/]) would waive the penalty and would also provide $18 million for efforts to get more beneficiaries to sign up.