Two studies published in the April issue of Chest journal report serious health effects including reduced lung function and cardiorespiratory conditions due to water pipe smoking (WPS).

Hookah or WPS, is a form of tobacco use that has been practiced for hundreds of years but has recently seen a dramatic increase in popularity, leading to its description as “an emerging deadly trend.” WPS was common mainly in the Middle East, Turkey , India , and Pakistan but with globalization and immigration from these countries, it has spread to Western countries, notably among youth. According to reports more than 100 million people worldwide smoke WPS daily.

“Many adolescents and adults believe that hookah use is less dangerous than cigarette smoking," says Bengt Arnetz, Professor of Social Medicine at Uppsala University and Professor of Occupational and Environmental Medicine at the Wayne State University School of Medicine. "Some fail to understand that hookah use involves tobacco. In fact, smoking a hookah entails much greater exposure to carbon monoxide and other dangerous and carcinogenic substances in tobacco smoke than does smoking cigarettes."

Raad et al from the State University of New York at Buffalo conducted two separate meta-analyses on six eligible cross-sectional studies comparing lung function between water-pipe smokers and non-smokers and water-pipe smokers and cigarette smokers, respectively. Three spirometric measurements (FEV 1 , FVC, and FEV 1 /FVC) were examined, and the standardized mean difference was used to pool results.

A significant decrease in the FEV 1 , equivalent to a 4.04% lower FEV 1 % was found in the WPS group compared with the nonsmokers, as was a trend (nonsignificant) toward a lower FVC and FEV 1 /FVC. No difference was found in FEV 1 , FVC, or FEV 1 /FVC between the WPS and cigarette smoking groups. The significant decrease in FEV 11 among WPS showed clinical relevance.

According to the authors, the results of this study along with reports of elevated levels of parameters for oxidant injury and decreased total antioxidant activity associated with WPS, suggest that it may play a possible role in development of COPD. They also recommend that further prospective studies should be conducted to establish the causal relationship between WPS and clinical outcomes.

In another study, Hakim et al from Israel evaluated the acute effects of WPS on cardiorespiratory system. They analysed the acute effects of a single 30-min session of WPS on carboxyhemoglobin (COHb) levels, pulmonary function test results, vital signs, fractional exhaled nitric oxide (FENO ) levels, and exhaled breath condensate (EBC) cytokine levels in volunteers in a domestic, open-air, group smoking setting.

Forty-five volunteers (30 men and 15 women) smoked 10 g of double apple flavored “moasel” (hookah tobacco) of the same brand at their own pace and pattern using a standard charcoal disk for ignition.

Carboxyhemoglobin levels were significantly raised post-WPS, especially in women

(P <0 .001). Three of 45 subjects demonstrated carboxyhemoglobin concentrations varying between 20% and 26%, high enough levels for consideration of inpatient treatment, oxygen therapy, and hyperbaric oxygen therapy , in susceptible individuals. The researchers suggest that the gender difference found in the results may be because of differences in alveolar ventilation and smoking patterns. Blood pressure, heart rate and respiratory rate were all significantly increased post-WPS with no sex differences apparent.

Acute decreases in FEF 25%–75% levels and PEFRs were observed after 30 min of WPS. However, the marginal statistically significant changes in PEFRs, percentage of eosinophils, and levels of FEF 25%–75%, FENO, and 8-isoprostane became insignificant after applying Bonferroni correction.

Thus the results obtained from both the studies conclude that WPS has important short and long-term adverse effects on health similar or possibly even more harmful than cigarette smoking. The researchers unanimously call for interventions to control the continuing global spread of WPS, especially among youth.

Chest 2011; 139(4):764–774

Chest 2011; 139(4):775–781

A new study presented at the American Academy of Allergy, Asthma and Immunology 2011 Annual Meeting has reported that patients with asthma may have a higher risk of developing diabetes and heart disease.

This is the first population-based study on asthma and associated pro-inflammatory conditions that has shown that patients with asthma have double the risk of diabetes mellitus and a 50% higher risk of coronary artery disease (CAD) compared with non-asthmatics.

Researchers led by Dr Young J. Juhn, of the department of paediatrics and adolescent medicine at the Mayo Clinic in Rochester , Minnesota , used the Rochester Epidemiological Project to study patients diagnosed and treated with asthma between 1964 and 1983 and control subjects. Nearly 2,400 patients with asthma were matched 1:2 by age and gender with 4800 controls. The incidence of heart disease, diabetes mellitus, rheumatoid arthritis and inflammatory bowel disease was compared between the two populations.

Results revealed that the hazard ratio for diabetes mellitus and coronary artery disease among asthmatics was 2.12 and 1.46, respectively (p=0.00002 and p=0.027). Although results for rheumatoid arthritis and inflammatory bowel disease did not reach statistical significance, they showed a clear trend toward increased incidence among asthmatics.

"Our study has clinical implications for those who treat patients with asthma; follow-up care should address early detection of coronary artery disease and diabetes," said senior author Dr Young Juhn (Mayo Clinic, Rochester , MN ).

The researchers point out that proinflammatory cytokines such as interleukin-6 (IL-6) increase during asthma, which may play a role in development of CAD. According to the presenting author Dr Hyun Don Yun (Harbor Hospital Baltimore, MD), the proinflammatory cytokine T helper-17 (TH-17), which has been implicated in asthma progression, also plays a role in increasing risk for rheumatoid arthritis and inflammatory bowel disease

There are certain limitations of the study, viz. possible confounders for use of oral steroids and associated obesity and high blood sugar among asthmatics were not adjusted for. Also the researchers agree that the study was retrospective in nature and the sample size was small, considering rheumatoid arthritis and inflammatory bowel disease, which are not as common as asthma.

“However, this study is an important start; it is our first look at the possible impact of asthma on other proinflammatory conditions,” Dr Juhn said. "In future studies, we will be looking at case-controls with coronary artery disease and asthma and analyzing confounding variables such as obesity”.

American Academy of Allergy, Asthma & Immunology 2011 Annual Meeting; March 20, 2011; San Francisco, CA. Abstract 293

A new expanded analysis of the cardiovascular risks associated with calcium supplements published in the British Medical Journal , on April 19, 2011, reported a 25%-30% increased risk of myocardial infarction and 15%-20% increased risk of stroke in individuals taking calcium supplements, with or without vitamin D.

The Women's Health Initiative Calcium/Vitamin D Supplementation (WHI CaD) Study originally found no risk associated with the supplements after studying more than 36,000 patients over seven years. This prompted millions of people to take combination of calcium and vitamin D supplements to reduce risk of fractures.

However, Dr Mark Bolland ( University of Auckland , New Zealand ) one of the authors of the study noted that 54% and 47% of subjects in the placebo arm of the WHI CaD study were taking their own calcium and vitamin D supplements, respectively, at the time of randomization. This prompted Dr Bolland et al to analyze patient-level data on baseline supplementation use. They found among, almost 17000 women who were not taking personal supplements at the time of randomization, new supplement use was associated with a significant increase in risk of clinical MI (hazard ratio 1.22; p = 0.05) and clinical MI and stroke (hazard ratio 1.16; p = 0.05). Among women already taking supplements at baseline, no such increase in events was seen. Researchers also found no relation between the dose of the supplements and the cardiovascular risk.

The authors suspect that the abrupt change in blood calcium levels after taking a supplement causes the adverse effect, rather than it being related to the total amount of calcium consumed. According to Dr Ian Reid ( University of Auckland ), senior author of the study, increased risk of stroke, a longer-term process was due to calcium accruing in the vessel walls. Also, he accredited increased risk of MI, a more acute response, to blood calcium levels, including changes in platelet function, blood coagualability, or endothelial cell activity.

To further strengthen the evidence, the researchers of the study added the newly-found data from the WHI CaD study, as well as data on concomitant calcium and vitamin-D supplementation from two other studies they'd excluded in their earlier analysis, to their 12 000-patient meta-analysis from last year looking at calcium use only, bringing the sample size up to almost 30,000. All the data was from randomized controlled trials.

The analysis showed that the use of calcium or calcium plus vitamin D was associated with increased risk of MI (patient-level data: hazard ratio 1.26, p = 0.005; trial-level data: hazard ratio 1.24, p = 0.004), stroke (patient-level data: hazard ratio 1.19, p = 0.03; trial-level data: hazard ratio 1.15, p = 0.06) and composite of MI and stroke (patient-level data: hazard ratio 1.17, p = 0.005; trial-level data: hazard ratio 1.15, p = 0.009). According to these calculations, if 1000 people take calcium with or without vitamin D, it would cause six additional MIs or strokes (a number needed to harm of 178), yet prevent only three fractures (a number needed to treat of 302).

In an editorial accompanying the current article, Dr. Bo Abrahamsen ( Gentofte Hospital , Copenhagen ) and Dr. Opinder Sahota ( Nottingham University Hospitals , England ) raised concerns about the cardiovascular adjudication and study design of the underlying trials and emphasized that insufficient evidence is available to support or refute the association. They suggested dire need for further studies to reach a conclusion.

Adapted From: BMJ 2011; DOI:doi:10.1136/bmj.d2040

http://www.theheart.org/article/1214663.do?utm_campaign=
newsletter&utm_medium=email&utm_source=20110419_breaking_new

Last Accessed on: 21st April 2011

Sexually transmitted diseases (STDs) remain a major public health challenge, especially among women, who disproportionately bear the long-term consequences of STDs. For example, each year untreated STDs cause infertility in women, and untreated syphilis in pregnant women results in increased infant mortality. Testing and treatment are keys to reducing disease and infertility associated with undiagnosed STDs.

The reasons why women are more severely affected by STDs compared to men are enumerated below:

1. A woman's anatomy can place her at a unique risk for STD infection, compared to a man.
   • The lining of the vagina is thinner and more delicate than the skin on a penis, so it's easier for bacteria and viruses to penetrate
   • The vagina is a good environment (moist) for bacteria to grow
2. Women are less likely to have symptoms of common STDs — such as chlamydia and gonorrhea — compared to men.
   • If symptoms do occur, they can go away even though the infection may remain
3. Women may not see symptoms as easily as men.
   • Genital ulcers (like from herpes or syphilis) can occur in the vagina and may not be easily visible, while men may be more likely to notice sores on their penis
4. Women are more likely to confuse symptoms of an STD for something else.
   • Women often have normal discharge or think that burning/itching is related to a yeast infection
   • Men usually notice symptoms like discharge because it is unusual
5. Human papillomavirus (HPV) is the most common sexually transmitted infection in women, and is the main cause of cervical cancer.
   • While HPV is also very common in men, most do not develop any serious health problems
6. STDs can lead to serious health complications and affect a woman's future reproductive plans.
   • Untreated STDs can lead to pelvic inflammatory disease, which can result in infertility and ectopic pregnancy
   • Chlamydia (one of the most common STDs) results in few complications in men
7. Women who are pregnant can pass STDs to their babies.
   • Genital herpes, syphilis and HIV can be passed to babies during pregnancy and at delivery
   • The harmful effects of STDs in babies may include stillbirth (a baby that is born dead), low birth weight (less than five pounds), brain damage, blindness and deafness

http://www.cdc.gov/nchhstp/newsroom/docs/STDs-Women-042011.pdf
Last accessed on 20/04/11

New research has shown that rifaximin, a non absorbable antibiotic, reduces gastrointestinal symptoms in patients with IBS. This research published in the April issue of Clinical and Experimental Gastroenterology, shows that rifaximin reduces the symptoms of IBS by at least half.

The author John Jolley from the Department of Medicine, University of California , San Francisco , CA , USA , has shown that rifaximin 1200mg/day for 10 days is effective in patients diagnosed with IBS, according to Rome III criteria. A total of 236 patient charts were reviewed, and 162 were selected for this trial.

Among these individuals, 28% were classified as having diarrhea predominant IBS, 20% were classified as having constipation-predominant IBS, and 15% were classified as having mixed-symptom IBS. Lactulose breath test results indicated that 91 patients 56% were hydrogen positive, 20% were methane positive, and 6% were positive for both hydrogen and methane.

There was a 52% improvement in global IBS symptoms after 10 days of 1200 mg/day of rifaximin treatment. 12% of the patients achieved complete symptom response after this regimen. The predominant symptoms like diarrhea or constipation was relieved in 13% and 12% patients respectively.

81 patients who did not have an adequate response to the initial 1200 mg/day rifaximin were given a high dose of rifaximin 2400 mg/day for 10 days. 47% of patients who received high-dose rifaximin achieved =50% global symptom improvement. Patients with mixed-symptom IBS received the greatest benefit from high-dose rifaximin. Interestingly, patients with mixed-symptom IBS reported larger remission of diarrheal symptoms than constipation symptoms.

8% patients reported adverse events with the initial rifaximin dose (1200mg/day) and 6% reported adverse events with higher dose regimen of rifaximin (2400mg/day). Most of these adverse events occurred in the first 3–4 days of treatment and consisted of flu-like illness with diarrhea and nausea. These symptoms resolved by day 5 and were thought to be secondary to “bacterial kill”.

This retrospective chart review demonstrated that rifaximin 1200 mg/day for 10 days improved global and IBS-related symptoms. Encouragingly the authors noted that patients with incomplete symptom resolution may respond to increased doses of rifaximin. Although one might expect a larger number of adverse events with an increased medication dose, rifaximin 1200 mg/day or 2400 mg/day is well tolerated.

Clinical and Experimental Gastroenterology 2011:4 43–48

Diabetes and its complications are one the major reasons for premature mortality and morbidity in the world today. India hosts one of the highest diabetic populations, with the current figures well over 51 million and expected to touch around 87 million by the year 2030. Diabetic foot disease is one of the gravest complications which often results in amputation. Despite this condition, epidemiological data on diabetic foot, specific to the Indian population has been lacking. The present multicentric study, published in the April Issue of Journal of the Association of Physicians of India, concludes that most amputations associated with diabetes in India are neuropathic and infective in origin.

A total of 1985 type 2 diabetic patients were selected from 31 centers across India . Out of the total, 1295 subjects who had undergone amputation were included in the analysis. Peripheral Vascular Disease (PVD) was confirmed by using Doppler studies and neuropathy was assessed by 10g monofilament and 125 Hz tuning fork. Foot infection was defined as the presence of purulent drainage or two or more signs of inflammation which includes warmth, tenderness, swelling and redness.

Infection was present in almost 90% of patients who underwent amputation. Out of the total amputations, over half of the incident amputations were of toes and rays. Prevalence of neuropathy (82%) was very high in these patients, followed by PVD (35.3%) and retinopathy (34.8%, Graph1). Presence of claw toes was seen in 64% of patients.

The development of foot ulcer is mainly associated with the presence of peripheral neuropathy, PVD, foot deformity and infection.

Studies from the world over have shown that significant reductions in amputations can be achieved by well organized diabetic foot care teams with podiatric specialists, good glycaemic control and by educating patients on foot care. Even in India , a recent study concluded that it is possible to reduce the burden of foot problems by educating patients on foot care and by providing appropriate foot wear.

In conclusion, this study showed that infection is the major cause of amputation. Neuropathy is highly prevalent in these Indian type 2 diabetic patients. The burden of foot problems in a developing country like India can be reduced by educating patients on foot care and importance of proper foot wear.

JAPI . 2011; 59: 148-51.