Cardiovascular risk and bone loss in men undergoing androgen deprivation therapy for non-metastatic prostate cancer: implementation of standardized management guidelines

Our objective was to evaluate the effectiveness of implementing standardized guidelines to mitigate metabolic and bone side effects of androgen deprivation therapy (ADT) in men with non-metastatic prostate cancer. We conducted a 2-year prospective cohort study at a tertiary referral teaching hospital. Overall, 236 men (mean age 69.8 ± 7.1) commencing ADT for non-metastatic prostate cancer attended a baseline clinic visit between 2007 and 2011, and 153 men were eligible for follow-up after 2 years of continuous ADT. Of these, 113 men had data available for analysis at 2 years. At baseline, 87% of the men were overweight or obese, 61% had hypertension, 56% had hypercholesterolaemia, 27% prior cardiovascular disease, 11% osteoporosis and 40% osteopaenia. After 2 years of ADT, there was an increase in waist circumference (+2.8 ± 6.3 cm, p = 0.002), and, in men without diabetes, in HbA1c (+0.13 ± 0.34%, p = 0.019). Despite this, due to treatment, there were significant reductions in total cholesterol (-0.35 ± 1.00 mmol/L, p < 0.001), and blood pressure (systolic -7.6 ± 19.3 mmHg; diastolic -4.7 ± 11.6 mmHg, p < 0.001). After 2 years, men not receiving anti-resorptive therapy experienced a significant decline in lumbar spine (-0.042 ± 0.134 g/cm(2) , p = 0.012) and total hip bone mineral density (BMD) (-0.026 ± 0.036 g/cm(2) , p < 0.001), whereas bisphosphonate treatment maintained stable BMD. Prevalence of anaemia increased from 13.8 to 32.5%. Older age independently predicted a greater drop in haemoglobin (p = 0.005). We conclude that a structured approach to assess and treat men undergoing ADT effectively improves cardiovascular risk factors and prevents bone decay. Larger studies are needed to determine effects on cardiovascular outcomes, fracture prevention and survival.

Does antiviral therapy reduce the risk of hepatocellular carcinoma in patients with chronic hepatitis C?

Infection with the Hepatitis C virus (HCV) affects nearly 200 million people in the world. It is a leading cause of chronic hepatitis, cirrhosis and hepatocellular carcinoma (HCC). It is estimated that 25% of HCC worldwide is related to HCV, being the main cause in Western Europe, North America and Japan. HCV can be implicated in the development of HCC in an indirect way through induction of chronic inflammation, or directly by means of viral proteins activating several signaling pathways. For patients with clinically significant hepatic fibrosis there is widespread agreement that antiviral therapy is indicated in order to eliminate the virus. It is generally accepted that sustained virologic response (SVR), i.e. undetectable HCV RNA at 24 weeks after treatment withdrawal, is associated with resolution of liver disease in patients without cirrhosis. In the last decades, results of treatment for chronic hepatitis C have improved substantially. The current standard of care is a combination of pegylated interferon and ribavirin for 24 to 48 weeks, depending on the genotype. In the near future, this standard of care will include addition of directly-acting antivirals. In 2011 two protease inhibitors (boceprevir and telaprevir) have been registered for use in adults with genotype 1 chronic hepatitis C, increasing the SVR rates from less than 50% to about 70% in patients treated with a triple combination. There is limited evidence for the role of interferon-based therapy in primary, secondary and tertiary prophylaxis of HCC in patients with chronic Hepatitis C, as most studies were primarily designed to assess the antiviral effect of treatment and not the long-term impact on the natural history of the disease. Further prospective studies using the more successful emerging treatments of chronic hepatitis C are to be conducted to evaluate the risk of HCC.

Viral hepatitis B and hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the sixth most common cancer in the world, some 630,000 new cases being diagnosed each year. 82% of cases are related to viral hepatitis, 55% to hepatitis B virus (HBV), 89% of those in regions where HBV is endemic. There is a striking parallel between the geographical distribution of the rates of chronic HBV infection and that of HCC. In the majority of HCC cases (70-90%) there is underlying liver cirrhosis. However, because HBV is an oncogenic virus, it can cause HCC in the absence of cirrhosis. The annual risk of HBV-induced HCC varies according to the presence or absence of concomitant cirrhosis. In HBV carriers without cirrhosis, the risk is 0.02-03% in Caucasians and 0.4-0.6% per year in Asians. In those with cirrhosis, the risk is 2.2% and 3.7% respectively in Caucasians and Asians. HBV likely causes HCC via both indirect (necro-inflammation and regeneration injury) and direct (by integration of its DNA in the host genome) pathways. During recent years it has become evident that HBV viral load >2000 IU/mL is associated with a high risk of malignant transformation. The most effective measure of prevention of HBV-related HCC is prevention of HBV infection by vaccination. A universal vaccination program in Taiwan was shown to be effective in reducing the rate of childhood and early adulthood HCC. In patients already infected with HBV, antiviral therapy remains the best strategy. Interferon-alfa therapy appears to be effective in preventing HCC in cirrhosis in Asia but not in Europe. Medium-term nucleos/tide-analogue therapy significantly reduces but does not eliminate the risk of HCC, especially in patients with pre-existing cirrhosis. Maintenance of virological remission is important for the reduction of HCC risk. With more potent antiviral drugs currently available (entecavir, tenofovir), long-term HBV DNA suppression is now possible with very low risk of drug resistance.

Assessing kidney function in Asia

An equation for accurate estimation of the glomerular filtration rate (GFR) is vital for staging and directing the treatment of chronic kidney disease (CKD), which is a source of considerable morbidity and mortality around the world. The Modification of Diet for Renal Disease (MDRD) equation, which includes a racial coefficient, is commonly used. The MDRD equation has been validated in Caucasian populations, but modifying the racial coefficient for Asian countries has resulted in substantially different values that may not be due to race alone. Moreover, it is sometimes difficult to define race, particularly in multi-ethnic populations and among offspring of inter-ethnic marriages. Furthermore, the precision of the MDRD equation is poorer at the early stages of CKD. New markers, such as cystatin C, and new equations may be needed to accurately assess wider ranges of GFR in multi-ethnic countries. We review the development of GFR-estimating equations from an Asian perspective.

Sonography for the investigation of a child with a limp

Hip pain is a common paediatric presentation and is potentially serious. While hip pain can be attributed to primary hip pathology, the hip area is also a common site for referred pain. This often poses a diagnostic challenge particularly in the young child who may not verbalise the point of pain and may not report an injury. Differential diagnoses for paediatric hip joint pain range from fracture, transient synovitis, septic arthritis with or without osteomyelitis, juvenile idiopathic arthritis (JIA, previously juvenile rheumatoid arthritis JRA), Legg-Calve-Perthes' disease (LCP), slipped capital femoral epiphysis (SCFE) to haemarthrosis in patient with a clotting disorder. Referred pain from abdominal pathology, for example; appendicitis, psoas abscess or haematoma should also be considered. The evaluation and management of hip pain requires a thorough history and physical examination. A radiograph is usually indicated to rule out any bony injury. Septic arthritis is a medical emergency requiring urgent surgical as well as medical treatment. Ultrasound of the hip joint plays a role in helping to differentiate which hips require early intervention and to guide a needle aspiration of joint fluid if indicated. In this article, we aim to review the anatomy of the hip, techniques in ultrasonographic examination and some common pathologies in the paediatric hip.

Is routine urine cytology useful in the haematuria clinic?

INTRODUCTION

The objective of this study was to determine the value of routine urine cytology in the initial evaluation of patients presenting to a one-stop haematuria clinic.

PATIENTS AND METHODS

A total of 1000 consecutive patients who attended the haematuria clinic between June 2003 and November 2004 were studied prospectively. A standard protocol was used to investigate these patients. This included urine cytology, upper tract imaging and flexible cystoscopy.

RESULTS

Overall, 986 samples of urine were sent for cytology. In 126 patients, the report was abnormal; of these, 71 patients were found to have bladder transitional cell carcinoma by flexible cystoscopy and a further 3 had upper tract transitional cell carcinoma diagnosed radiologically. The remaining 52 patients with abnormal cytology were not found to have cancer on further investigations. The total cost for urine cytology and additional investigations was pound50,535.

CONCLUSIONS

In this study of the initial evaluation of patients with haematuria, no case of urothelial malignancy was diagnosed on the basis of urine cytology alone. Therefore, urine cytology need not be used routinely in the initial diagnostic work-up for haematuria.

Impaired osteoinduction in a rat model for chronic alcohol abuse

Alcohol abuse is a risk factor for bone fractures. Following a fracture, alcoholics have a higher risk for impaired fracture healing. However, the specific alcohol-induced defect(s) in bone healing are not known. Alcohol is a potent inhibitor of bone formation during bone growth and turnover. Thus, the purpose of this study was to determine the effects of alcohol consumption on induction of new bone formation. Demineralized allogeneic bone matrix (DABM) cylinders were used to model osteoinduction in a rat model for chronic alcohol abuse. DABM cylinders, prepared from femurs and tibiae of rats fed a normal diet, were implanted into sexually mature male rats adapted to alcohol (ethanol contributed 35% of caloric intake) or control liquid diets. Food intake in the control rats was restricted to match food intake of alcohol-fed animals. The implants were recovered 6 weeks later and analyzed by histology, muCT and chemical analysis. Histological evaluation revealed a robust osteoinductive response, resulting in mature bone ossicle formation, in DABM implants in rats fed the control diet. Alcohol consumption affected bone mass and architecture of the DABM implants but not volumetric density or mineral composition. Specifically, alcohol consumption resulted in significant decreases in DABM-induced bone volume, bone volume/mg original cylinder weight, connectivity density, trabecular number and thickness, ash weight and % ash weight. There were no changes in mineral (ash) density nor in the relative amounts of calcium, magnesium, iron, selenium and zinc (microg/mg ash), indicating that alcohol consumption did not impair mineralization. Taken together, these results show that alcohol abuse resulted in decreased bone formation within the DABM implant. We conclude that reduced osteoinduction may contribute to impaired bone healing in alcoholics.

Is wheezing associated with decreased sleep quality in Sri Lankan children? A questionnaire study

AIM

To investigate the association between wheezing and impaired sleep in Sri Lankan children, aged 6-12 years; and, to report the prevalence of asthma-related symptoms in these subjects.

METHODS

The International Study of Asthma and Allergies in Childhood questionnaire and a separate sleep questionnaire were completed.

RESULTS

Of 800 originally distributed questionnaires, 652 were analyzed. Wheezing was present in 89 children (14%). Within this group, 66% reported wheezing in the last 12 months. Wheezing children had a significantly higher presence of snoring, restless sleep, nocturnal awakenings and daytime tiredness. Wheezing was found to be independently associated with restless sleep (odds ratio (OR) = 2.4). There was no association between wheezing and difficulties falling asleep, nocturnal awakenings, apneas, and daytime sleepiness and tiredness. After adjusting for possible confounders, the following significant associations were present: snoring and apneas (OR = 1.6), chronic rhinitis and apneas (OR = 1.6), snoring and restless sleep (OR = 3.2), chronic rhinitis and restless sleep (OR = 2.1), and hayfever and daytime tiredness (OR = 4.3). Wheezing was related to an increased risk of snoring (OR = 2.8) and subjects with chronic rhinitis had also an increased risk of snoring (OR = 1.7), adjusting for possible confounders.

CONCLUSION

The sleep of wheezing children was impaired compared with their non-wheezing peers, resulting in an increased prevalence of daytime tiredness. Upper airway symptoms, such as chronic rhinitis or hayfever, should be carefully considered in these children, as they might be responsible for these sleep problems.

Acupuncture for the alleviation of lateral epicondyle pain: a systematic review

OBJECTIVES

Lateral epicondyle pain is a common complaint in North America. In the past 10 yr acupuncture has become increasingly recognized as an alternative treatment for pain, including epicondyle pain. This review evaluates the effectiveness of acupuncture as a treatment for lateral epicondylitis using the appropriate analysis.

METHODS

Online bibliographic database searches in any language from Medline, PsychINFO, CINAHL, Healthstar, PMID, CAM, EMBASE, Cochrane Database of Systematic Review (3rd quarter 2003), articles listed in reference lists of key articles and the author's personal files were performed. Randomized and quasi-randomized controlled trials examining the effects of acupuncture on lateral epicondyle pain were selected. From the six studies that met inclusion criteria, the first author, year of publication, population studied, dropout rate, treatment plan, assessment scale and outcome measures were extracted. Study quality was determined by using the Jadad scale, in which all studies were rated as high quality. A best evidence synthesis approach was used to analyse the data presented in the six studies.

RESULTS

All the studies suggested that acupuncture was effective in the short-term relief of lateral epicondyle pain. Five of six studies indicated that acupuncture treatment was more effective compared to a control treatment.

CONCLUSIONS

There is strong evidence suggesting that acupuncture is effective in the short-term relief of lateral epicondyle pain.