Are interferon-gamma release assays useful for diagnosing active tuberculosis in a high-burden setting?

Ling DI, Pai M, Davids V, et al. Eur Respir J. 2011 Sep;38(3):649-56. Epub 2011 Feb 24.

Although interferon-gamma release assays (IGRAs) are intended for diagnosing latent tuberculosis (TB), we hypothesised that in a high-burden
SETTING: 1) the magnitude of the response when using IGRAs can distinguish active TB from other diagnoses; 2) IGRAs may aid in the diagnosis of smear-negative TB; and 3) IGRAs could be useful as rule-out tests for active TB. We evaluated the accuracy of two IGRAs (QuantiFERON(R)-TB Gold In-tube (QFT-GIT) and T-SPOT(R).TB) in 395 patients (27% HIV-infected) with suspected TB in Cape Town, South Africa. IGRA sensitivity and specificity (95% CI) were 76% (68-83%) and 42% (36-49%) for QFT-GIT and 84% (77-90%) and 47% (40-53%) for T-SPOT(R).TB, respectively. Although interferon-gamma responses were significantly higher in the TB versus non-TB groups (p<0.0001), varying the cut-offs did not improve discriminatory ability. In culture-negative patients, depending on whether those with clinically diagnosed TB were included or excluded from the analysis, the negative predictive value (NPV) of QFT-GIT, T-SPOT(R).TB and chest radiograph in smear-negative patients varied between 85 and 89, 87 and 92, and 98% (for chest radiograph), respectively. Overall accuracy was independent of HIV status and CD4 count. In a high-burden setting, IGRAs alone do not have value as rule-in or -out tests for active TB. In smear-negative patients, chest radiography had better NPV even in HIV-infected patients.

http://erj.ersjournals.com/content/38/3/649.abstract

Prolonged therapy may help smokers quit.

USA Today (11/29, Lloyd) reports, "Better, prolonged therapy for smokers helps them kick the habit, even smokers who have no desire to quit, according to" research published in the Nov. 28 issue of the Archives of Internal Medicine. Researchers noted that "if you treat smoking like other health conditions and diseases like high blood pressure and diabetes, you're more likely to be successful," citing a need not to "view relapse as failure," but instead, "to build in interim goals until success is achieved."

        The Los Angeles Times (11/29, Stein) "Booster Shots" blog reports that the first study "focused on using a practice quit-attempt program and nicotine therapy for smokers who weren't motivated to quit" while the second study "compared an eight-week usual care stop-smoking program with a year-long telephone-based chronic disease management program." The study had a success rate of 85% for people "assigned to a six-week practice quit-attempt program" and 82% for those who also received nicotine therapy. A second study found that "at 18 months, rates of six-month smoking abstinence were 23.5% in the usual care group and 30.2% in the long-term care group," and smokers "in the long-term group" who didn't quit skill smoked less than those in the usual care group.

        HealthDay (11/29, Reinberg) reports that Dr. Norman Edelman, chief medical officer for the American Lung Association, "doesn't think this study went on long enough to draw any definitive conclusions. 'The study had no long-term follow-up, thus lacking what I consider to be the gold standard of smoking-cessation experimentation,' he said."

        MedPage Today (11/29, Bankhead) reports that the research was supported by the National Institute on Drug Abuse. The Minneapolis Star Tribune (11/29, Lerner) and St. Paul Pioneer-Press (11/29, Snowbeck) also cover the story.

Survey Finds Americans' "Ideal Weights" Have Risen.

The Los Angeles Times  (11/29, Healy) "Booster Shots" blog reports, "In Gallup's annual Health and Healthcare Survey, the nation's leading polling organization has asked Americans yearly how much they weigh and what their ideal weight would be. Compared to Americans' answers to those questions in 1991, both numbers -- actual weight and ideal weight -- have risen, although 'ideal' weights have not quite kept pace with actual weight gains." Interestingly, "as our actual weight drifts upward, so do our perceptions of what our 'ideal; weight would be," with men and women averaging 15 and 22 pounds more than their respective ideal weights. The blog adds, "Gallup's findings help paint a grim picture of mass delusion in the United States about its rising weight and the spate of health problems that come with it."

HbA1c Must Be Just Right in Diabetic Kidney Disease

By Todd Neale, Senior Staff Writer, MedPage Today Published: November 28, 2011 Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

Among patients with diabetes and stage 3 or 4 chronic kidney disease, glycated hemoglobin levels that are too low are associated with worse clinical outcomes, just as are levels that are too high, an observational study showed. Higher glycated hemoglobin (HbA1c) levels at baseline were associated with greater risks of death, progression of kidney disease, new end-stage renal disease, cardiovascular events, and all-cause hospitalization (P<0.001 for all trends), according to Marcello Tonelli, MD, of the University of Alberta in Edmonton, and colleagues. Action Points   Among patients with diabetes and stage 3 or 4 chronic kidney disease, higher glycated hemoglobin (HbA1c) levels at baseline were associated with greater risks of death, progression of kidney disease, new end-stage renal disease, cardiovascular events, and all-cause hospitalization. Low HbA1c levels of less than 6.5% were also associated with an increased mortality risk. But for mortality in particular, an HbA1c level that was too low -- less than 6.5% -- also was associated with an elevated risk, they reported in the Nov. 28 issue of Archives of Internal Medicine. Those findings are largely consistent with two observational studies reported earlier this month at the annual meeting of the American Society of Nephrology, which showed that HbA1c values outside a 6% to 9% range were associated with increased mortality in diabetic patients with end-stage renal disease. Noting the limitations of observational data, however, Tonelli and colleagues said that randomized controlled trials are needed to confirm whether overly intensive therapy worsens outcomes in patients with diabetes and chronic kidney disease. Targeting HbA1c levels lower than 7% has been shown to slow the progression of diabetic kidney disease, and the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) suggests that goal for all diabetic patients, regardless of kidney function. But patients with chronic kidney disease have been mostly excluded from glycemic control trials and a co-chair of the KDOQI work group on diabetes and chronic kidney disease suggested at the ASN meeting that the upcoming revision of the guidelines -- based on research reported since the last update in 2007 -- will include higher targets for these patients. The ACCORD trial showed that intensive glycemic control to a target less than 6% increased mortality in higher-risk patients with type 2 diabetes. That trial excluded patients with elevated creatinine levels, and thus, most patients with chronic kidney disease. "As with participants in the ACCORD trial, it is plausible that patients with diabetes and chronic kidney disease who are treated to an HbA1c level lower than 6.5% might experience iatrogenic harm owing to serious hypoglycemic events or too precipitous a fall in average glucose," Tonelli and colleagues wrote. Using hospitalization and claims data from Alberta, the researchers identified 23,296 patients with stage 3 or 4 chronic kidney disease and type 1 or 2 diabetes. They were stratified by glycemic control based on the first HbA1c measurement completed during the study period. The median HbA1c at baseline was 6.9%. About one in every 10 patients (11%) had a value greater than 9%. Through a median follow-up of nearly four years, 16% of the patients died, 49% were hospitalized, 16% had a cardiovascular event, 6% had a progression of kidney disease defined by a doubling of serum creatinine, and 2% developed end-stage renal disease. After adjustment for age, sex, baseline kidney function, individual and neighborhood income, comorbidities, and residence location, higher HbA1c values were associated with an elevated risk of all five outcomes. The association with mortality was U-shaped, however, with greater risks at HbA1c levels lower than 6.5% and higher than 8%. And the relationship with incident end-stage renal disease was significantly stronger in patients with milder chronic kidney disease at baseline (P<0.001 for the interaction), which "may represent a 'point of no return' for kidney function -- beyond which better glycemic control may simply not be enough to prevent progressive kidney function loss," Tonelli and colleagues wrote. But, in an accompanying editorial, David Goff Jr., MD, PhD, of Wake Forest University in Winston-Salem, N.C., pointed out that severity of renal dysfunction was not a significant modifier of the relationship between glycemic control and a doubling of serum creatinine levels. "The lack of internal consistency for these two renal outcomes [incident end-stage renal disease and disease progression] raises some uncertainties regarding the clinical importance of the differential association of HbA1c level with end-stage renal disease between stage 3 and stage 4 chronic kidney disease," he wrote. Goff also called for randomized controlled trials to better inform the discussion about the best approaches for managing risk factors in patients with advanced kidney disease. But, he added, "in the absence of strong evidence specific to patients with advanced chronic kidney disease and diabetes, prudent practice may be to pursue at least moderately intensive risk factor management while minimizing the potential for serious adverse effects of the treatment regimens." Tonelli and colleagues acknowledged some limitations of their analysis, including the retrospective design, the inability to control for several potential confounders, the use of a single measurement of serum creatinine to define chronic kidney disease, and the inability to distinguish between type 1 and 2 diabetes. The study was funded by an operating grant from the Heart and Stroke Foundation of Canada, and by an interdisciplinary team grant from the Alberta Heritage Foundation for Medical Research (AHFMR). Tonelli and three of his co-authors were supported by career salary awards from the AHFMR. Tonelli was also supported by a Government of Canada Research Chair. Four of the study authors were supported by a joint initiative between Alberta Health and Wellness and the Universities of Alberta and Calgary. The authors reported that they had no conflicts of interest. Goff is an ACCORD investigator. He has received compensation as a member of the Operations Committee for a trial of a glucose-lowering medication marketed by Merck. He serves as a Data and Safety Monitoring Board member for a trial of a glucose- lowering medication marketed by Takeda.

Primary source: Archives of Internal Medicine Source reference: Shurraw S, et al "Association between glycemic control and adverse outcomes in people with diabetes mellitus and chronic kidney disease: a population-based cohort study" Arch Intern Med 2011; 171: 1920-1927. Additional source: Archives of Internal Medicine Source reference: Goff D Jr. "Glycemic control and cardiorenal outcomes in patients with advanced chronic kidney disease: relative or absolute risks?" Arch Intern Med 2011; 171: 1927-1928. ------------------------------------ Higher, Lower HbA1c Levels Associated With Worse Outcomes In CKD With Diabetes. MedPage Today  (11/29, Neale) reports, "Among patients with diabetes and stage 3 or 4 chronic kidney disease, glycated hemoglobin levels that are too low are associated with worse clinical outcomes, just as are levels that are too high," according to a study  in the Nov. 28 issue of Archives of Internal Medicine. "Higher glycated hemoglobin (HbA1c) levels at baseline were associated with greater risks of death, progression of kidney disease, new end-stage renal disease, cardiovascular events, and all-cause hospitalization (P<0.001 for all trends)." However, "for mortality in particular, an HbA1c level that was too low -- less than 6.5% -- also was associated with an elevated risk." An accompanying editorial  "called for randomized controlled trials to better inform the discussion about the best approaches for managing risk factors in patients with advanced kidney disease."

Exercise may improve sleep quality.

The Los Angeles Times (11/24, Stein) "Booster Shots" blog reported a study of 3,000 adults published online in the journal Mental Health and Physical Activity suggesting that "getting 150 minutes a week of moderate to vigorous exercise paid off in a 65% improvement in quality of sleep." Researchers suggested that "the scientific evidence is encouraging as regular physical activity may serve as a non-pharmaceutical alternative to improve sleep."

Diabetes Patients Press FDA To Move On Artificial Pancreas.

CQ Weekly  (11/28, Zeller, Subscription Publication) reports that diabetics believe that "makers of medical devices are on the verge of a major breakthrough," an artificial pancreas, but the Juvenile Diabetes Research Foundation International says that the Food and Drug Administration "has thus far been slow in approving protocols to guide researchers developing the device. At a Senate Homeland Security and Governmental Affairs Committee hearing in June, Charles Zimliki, who oversees artificial-pancreas research for the FDA," said that the agency would submit guidance for researchers by December 1. The New York-based group has also "presented the FDA with a petition, signed by more than 100,000 people, urging quick action. It persuaded two senators, Republican Susan Collins of Maine and Democrat Jeanne Shaheen of New Hampshire, to publicly call for speeding approval of the device."

Aspirin May Offer Little Benefit To Healthy Women.

Reuters  (11/24, Joelving) reported that, according to a study  published online Nov. 16 in the European Heart Journal, aspirin may offer little heart health benefits for healthy women. Investigators looked at data on approximately 28,000 healthy females at least 45 years of age who had been given aspirin or a placebo in a previous study. Altogether, aspirin reduced heart risks by just 2.2 to 2.4 %.

Four Medications Linked To Most Emergency Hospitalizations For Older Americans.

The New York Times  (11/24, O'Connor) "Well" blog reported, "Blood thinners and diabetes drugs cause most emergency hospital visits for drug reactions among people over 65 in the United States," according to a study  published in The New England Journal of Medicine. Researchers found that "just four medications or medication groups -- used alone or together -- were responsible for two-thirds of emergency hospitalizations among older Americans." The investigators looked at data from 58 "hospitals...participating in a surveillance project run by the CDC that looks at adverse drug events."

        The National Journal  (11/24, Quinton, Subscription Publication) reported that the researchers found that "forty-six percent of hospitalizations involved medicines used to prevent blood clots; a single anticoagulant, warfarin, was responsible for one-third of hospitalizations, the report found. Another 25 percent involved diabetes medications, either insulin injections or medicines taken by mouth."

        WebMD  (11/24, Doheny) reported, "The researchers estimated that 265,802 visits to emergency departments for adverse drug events occurred from 2007 to 2009 for adults 65 or older." More than "a third of these visits, or nearly 100,000, required hospitalization." The investigators found that "unintentional overdose of medication was the most common reason, accounting for nearly two-thirds of hospitalizations."

        Also covering the story were the Wall Street Journal  (11/24, Martin, Subscription Publication) "Health Blog," Modern Healthcare  (11/24, McKinney, Subscription Publication), HealthDay  (11/24, Goodwin), and MedPage Today  (11/24, Smith).

ICDs May Not Help Reduce Mortality For Patients With More Advanced CKD.

MedPage Today  (11/28, Phend) reports, "Implantable cardioverter-defibrillators (ICDs) did not help in reducing mortality for patients with more advanced chronic kidney disease, according to a single-center study" published in Europace. Investigators found that "poorer kidney function among ICD recipients with chronic kidney disease (CKD) boosted mortality risk 48% for each 10 mL/min/1.73 m2 reduction in estimated glomerular filtration rate (eGFR, P<0.001)." The researchers reported that, "in this group, appropriate ICD therapy had no significant effect on mortality."

Three Questions That Can Predict a Type 2 Diagnosis

http://www.diabeteshealth.com/read/2011/11/13/7345/three-questions-that-can-predict-a-type-2-diagnosis/

Want a simple way to find out if you or someone you know is likely to develop type 2 diabetes? Just answer these three simple questions!

-- Are you 55 years old or older?

-- Are you obese? That is, do you have a body mass index of 30 or over? (If you're 5'8", you have a BMI of 30 once you hit 197 pounds.)

-- Does your family have a history of diabetes?

That's it! According to new research, people who answer yes to those questions have a 19.9 percent chance of developing type 2 diabetes within five years. By contrast, someone who answers no to all those questions (and has a BMI under 25 -- that's 164 pounds or less for our 5'8" patient) has a 0.3 percent chance.

The research was performed by Dr. Harold Bays of the Louisville Metabolic and Atherosclerosis Research Center in Kentucky. He emphasized that this simple screening could be used to give patients a quick understanding of their risk factors without diving into a haze of other numbers and variables.

What's more, he said, it emphasizes one crucial fact: Weight control can reduce patients' risk of developing the disease. It's truly as simple as that. "I think that's a crucial message to be sent to patients," Bays said. "It's something that they can proactively address in order to reduce their risk of a serious disease."

Bays said that if healthcare providers are currently using more sophisticated screening measures regularly, there's not necessarily any reason for them to start using this one. For example, the American Diabetes Association has a seven-variable test for type 2 diabetes, which looks at age, race, family history, obesity, physical activity, hypertension, and gestational diabetes. But for clinicians who don't screen patients, this three-point checklist is an easy way to begin.

Bays' research was presented at the 2011 meeting of the Obesity Society.

Source:

http://www.diabetesincontrol.com/index.php?option=com_content&view=article&id=11608&catid=1&Itemid=17

Staggered Overdose Of Acetaminophen May Be Fatal.

MSNBC  (11/23, Rettner) reports, "Taking even slightly too much Acetaminophen [Tylenol] over a period of several days can lead to an overdose with deadly consequences," according to a new study  published online Nov. 22 in British Journal of Clinical Pharmacology. The study found "staggered overdoses of Tylenol (acetaminophen) were more deadly than single overdoses, even though people who experienced staggered overdoses typically took smaller total amounts of Tylenol than those who experienced a single overdose." Notably, "the researchers found that 37.3 percent of patients with staggered overdoses died, while 27.8 percent of single overdose patients died."

        HealthDay  (11/23, Preidt) reports that, after analyzing "data from 663 patients with acetaminophen-induced liver injury," researchers found that 161 of those patients "had suffered a staggered overdose while taking acetaminophen to relieve a variety of ailments, such as headache, toothache and abdominal and muscular pain." And, "compared with people who'd taken a single overdose of acetaminophen, those with a staggered overdose were more likely to have liver and brain problems, require kidney dialysis or help with breathing, and were at greater risk of dying." Also covering the story are BBC News  (11/23, Roberts) and the UK's Telegraph  (11/23, Collins).

Both Low, High Salt Intake May Be Linked To Increased Risk Of Cardiovascular Events.

Life is never simple...

The Los Angeles Times  (11/23, Roan) "Booster Shots" blog reports, both low and high salt intake may be linked to an increased risk of cardiovascular events, according to research  published in the Journal of the American Medical Association.

        Reuters  (11/23, Steenhuysen) reports that investigators looked at data on sodium and potassium levels in urine samples from approximately 30,000 individuals participating in two trials. Approximately four years later, about 16% of these individuals experienced some type of cardiovascular event.

        HealthDay  (11/23, Gardner) reports that "people who excreted higher levels of sodium than those with mid-range values had a greater risk of dying from heart disease, heart attack, stroke and hospitalization for heart failure, the report found." The researchers also found, however, that "people who excreted lower levels than mid-range were at a raised risk of dying from heart disease or being hospitalized for heart failure."

        MedPage Today  (11/23, Neale) reports, "Potassium intake, a proposed modifier of the relationship between sodium intake and cardiovascular disease, was associated with stroke risk only. Compared with an intake of less than 1,500 mg/day, higher consumption was associated with reduced risks of stroke (HRs 0.68 to 0.77)." HeartWire  (11/23, Wood) also covers the story.