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Update From the Medical Journals: January 2009
January 30, 2009  By Mary Pickett, M.D.
Harvard Medical School What's the latest news in the medical journals this month? Find out what your doctor is reading. Deep Brain Stimulation More Helpful — and More Risky — Than Medication for Parkinson's Disease Parkinson's disease causes the hands and head to gently shake in rhythmic, continuous motion. At the same time, purposeful movements such as walking and reaching can be difficult to initiate. These symptoms can be treated with medicines that provide extra "dopamine" to the brain, such as levodopa (Larodopa, Dopar), bromocriptine (Parlodel), pramipexole (Mirapex) and ropinirole (Requip). Unfortunately, the medicines cause side effects and don't always relieve symptoms completely. A surgical treatment called "deep brain stimulation" can help reduce symptoms. A study in the January 7 issue of the Journal of the American Medical Association (JAMA) is the largest study yet to compare the benefits and risks of deep brain stimulation to those of drug treatments. During deep brain stimulation an electrode on a wire is placed into a specific location in the brain. Electric pulses are generated, similar to a pacemaker, which reset the electric current in the deep brain. This seems to improve overall function for people with Parkinson's. Thirteen medical centers and 255 people with advanced Parkinson's were involved in the study. Patients were randomly divided into two groups. One group received surgery and medications if needed. The other group received close care by a specialized neurologist, medications and physical therapy, but they did not have surgery. After six months, neurologists examined all of the patients. They did not know who had surgery and who did not so their examinations would not be biased. Seventy-one percent of the people in the surgical (deep brain stimulation) group had substantially improved movement scores compared with 32% of people in the non-surgery group, despite treatment with medicine. The patients also reported how much "on" time — time with comfortable mobility — they gained. (Time during which patients had bothersome side effects from their treatment, such as jerking or uncontrolled muscle movements, did not count as "on" time.) People in the surgical group reported an average gain of 4.6 hours each day in "on" time. People in the medication-only group had an average gain of 0 hours. This was partly due to less improvement in their symptoms, and partly to the more frequent side effects from medication. Forty percent of the surgically treated patients had complications or side effects from their treatment compared with 11% of patients in the medication group. The majority of these problems were short-term and resolved by the six-month follow-up time. The most common complication from surgery was infection. In some cases this required removal of the stimulator. Other common side effects included falls, walking or balance difficulty, uncoordinated or uncontrolled movements, and depression. This study provides hope to Parkinson's patients who wish to consider deep brain stimulation as a possible treatment. The treatment seems to offer meaningful improvement with increased quality of life, although complications are fairly frequent. Doctors don't yet know the long-term results for this treatment. Back to top Eight Hours of Sleep May Keep Colds Away If you sleep less than seven hours a night, you are more likely to get a cold. This is the finding of a study published in the January 12 issue of the Archives of Internal Medicine. One hundred and fifty-three healthy adults participated in the study. They kept a diary of how long they slept each night for two weeks. Then, a solution containing live rhinovirus (a common cold virus) was dripped into their nose. The participants were kept in quarantine for five days, so that they would not spread virus to others. If their noses ran, their mucus was weighed; they had nose swabs with cultures and blood tests to check for antibodies. They also reported cold symptoms: nasal congestion, sneezing, runny nose, earache, sinus pain, sore throat, cough, and chest congestion. A person was counted as "having a cold" if they had cold symptoms and if their cultures or antibody test showed evidence of virus infection. Participants who slept an average of more than 7 hours a night in the two weeks prior to receiving the virus were nearly three times as likely to catch the cold, compared with people who slept 8 hours or more. Get plenty of rest, so that you can have these same results! Back to top Should 80% of Middle-Aged and Older Adults Use Statins? Since the results of the JUPITER trial were published last November, doctors have wondered whether expert groups would recommend that more people take statins. (The JUPITER trial looked to see if cholesterol-lowering drugs called "statins" can lower heart attack risk even for people who have normal cholesterol. It found that statins reduce the risk of heart attack, stroke and death in people with elevated C-reactive protein levels, a sign of inflammation.) There have not been any new recommendations. Several public health experts, however, have created a stir by publishing a prediction of just how many people might be affected by expanding the recommendation. They analyzed data that was gathered during the 1999–2004 National Health and Nutrition Examination Survey (NHANES). They published their predictions in the online journal Circulation: Cardiovascular Quality and Outcomes, on January 13. They found that nearly 60% of people (men over 50, and women over 60) had risks that justify statin treatment without testing their CRP levels. Broadening the recommendations to include people who have a high CRP result but normal LDL cholesterol (between 130 and 160 mg/dL) could mean doctors will recommend statins for about an additional "20% of middle-aged to elderly adults." These results suggest that 80% of the population could be treated with statins. Experts need to consider the JUPITER results with some care. Although the drugs can reduce heart risks, treating people who have CRP as their only risk for heart disease would require treating 120 people with a statin for about two years (at a total drug cost of approximately $300,000, plus the cost of doctor visits and blood tests) to prevent one heart attack, stroke or death. This is a high "need to treat" number. Half of the people in the JUPITER study saw their LDL cholesterol levels drop to 55 mg/dL or less. We don't know the long-term effects of doing this. Most doctors prefer to focus on treating high-risk people with statins instead of expanding the medicines to people whose only identifiable risk factor (besides age) is CRP. These folks are still undertreated. Back to top More News in Brief - Caution Urged With High-Dose Steroids for Wheezing Pre-Schoolers. Steroids are commonly used to prevent and treat asthma in children and adults. On January 22, the New England Journal of Medicine published two studies urging caution when giving high dose oral or inhaled steroids to younger children who wheeze, and who may be too young to be diagnosed with asthma. In the first study, 687 hospitalized children under age 6 were given either oral prednisolone or a placebo pill. These children all had respiratory infections and were making wheezing noises while they breathed. The steroid medicine did not shorten their hospital stays. In the second study, 129 asthmatic pre-schoolers who had had a history of wheezing with infection were given either high-dose inhaled steroid (fluticasone) or a placebo to treat a viral upper respiratory infection and prevent an asthma-like episode. Children treated with high-dose steroids had fewer asthma-like symptoms, but the medication appeared to stunt growth. It is important for parents of children with asthma to know that these concerns only apply to pre-school aged children who are given high-dose inhaled steroids and oral steroids. These studies have not raised concerns for the usual low-dose inhaled steroids that are prescribed for daily asthma control and prevention in children who have asthma. Low-dose inhaled steroids are an important treatment for children with asthma, and they continue to be recommended for children who need them.
- Nuts and Oils Are Good For Your Health. A science advisory published January 27 in Circulation: Journal of the American Heart Association recommends that 5% to 10% of our daily calories should come from omega-6 fatty acids. Vegetable oils, nuts and seeds contain omega-6 fatty acids, which are linked to lower rates of heart disease. Most Americans get adequate omega-6 fatty acids in their diet by including nuts, cooking oils, and vegetable oils in salad dressings. Omega-6 fatty acids are similar to omega-3 fatty acids, which are the healthy fats that are found in tuna, mackerel, and salmon.
- Antipsychotic Drugs (Tranquilizers) Increase Risk of Sudden Death. Nearly four years ago, the U.S. Food and Drug Administration issued a warning concerning the safety of antipsychotic drugs. The drugs are used to treat schizophrenia, post-traumatic stress syndrome, and a variety of other mental health problems. The drugs can also relieve symptoms of agitation or paranoid fears that occur in people with dementia. The safety warning was issued after studies in 2005 found that elderly patients with dementia who were treated with antipsychotic medicines died sooner than would otherwise have been predicted. In a new study, published January 15 in the New England Journal of Medicine, the risk of sudden death was approximately doubled for anyone — not just people with dementia — who used the medicines. Antipsychotic drugs include aripiprazole (Abilify), clozapine (Clozaril), olanzapine (Zyprexas), quetiapine (Seroquel), risperidone (Risperdal), ziprasidone (Geodon), haloperidol (Haldol), perphenazine (Trilafon), and fluphenazine (Prolixin). Researchers reviewed the records of 90,000 Medicaid patients who used antipsychotic medicines over a period of 15 years, along with records of 186,600 patients who did not use these medications. Experts believe the medicines make dangerous heart rhythm changes more likely to occur, leading to the unexpected deaths. Based on the study results, these medicines should be reserved for people who will clearly benefit from treatment, given the risk involved.
Back to top Mary Pickett, M.D. is an Associate professor at Oregon Health & Science University where she is a primary care doctor for adults. She supervises and educates residents in the field of Internal Medicine, for outpatient and hospital care. She is a Lecturer for Harvard Medical School and a Senior Medical Editor for Harvard Health Publications.
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