Objective: To examine the association of low-carbohydrate diets with mortality during 26 years of follow-up in women and 20 years in men.

Design: Prospective cohort study of women and men who were followed from 1980 (women) or 1986 (men) until 2006. Low-carbohydrate diets, either animal-based (emphasizing animal sources of fat and protein) or vegetable-based (emphasizing vegetable sources of fat and protein), were computed from several validated food-frequency questionnaires assessed during follow-up.

Setting: Nurses’ Health Study and Health Professionals’ Follow-up Study.

Participants: 85 168 women (aged 34 to 59 years at baseline) and 44 548 men (aged 40 to 75 years at baseline) without heart disease, cancer, or diabetes.

Measurements: Investigators documented 12 555 deaths (2458 cardiovascular-related and 5780 cancer-related) in women and 8678 deaths (2746 cardiovascular-related and 2960 cancer-related) in men.

Results: The overall low-carbohydrate score was associated with a modest increase in overall mortality in a pooled analysis (hazard ratio [HR] comparing extreme deciles, 1.12 [95% CI, 1.01 to 1.24]; P for trend = 0.136). The animal low-carbohydrate score was associated with higher all-cause mortality (pooled HR comparing extreme deciles, 1.23 [CI, 1.11 to 1.37]; P for trend = 0.051), cardiovascular mortality (corresponding HR, 1.14 [CI, 1.01 to 1.29]; P for trend = 0.029), and cancer mortality (corresponding HR, 1.28 [CI, 1.02 to 1.60]; P for trend = 0.089). In contrast, a higher vegetable low-carbohydrate score was associated with lower all-cause mortality (HR, 0.80 [CI, 0.75 to 0.85]; P for trend ≤ 0.001) and cardiovascular mortality (HR, 0.77 [CI, 0.68 to 0.87]; P for trend < 0.001).

Limitations: Diet and lifestyle characteristics were assessed with some degree of error. Sensitivity analyses indicated that results were probably not substantively affected by residual confounding or an unmeasured confounder. Participants were not a representative sample of the U.S. population.

Conclusion: A low-carbohydrate diet based on animal sources was associated with higher all-cause mortality in both men and women, whereas a vegetable-based low-carbohydrate diet was associated with lower all-cause and cardiovascular disease mortality rates.

Primary Funding Source: National Institutes of Health.

Article and Author Information
Acknowledgment: The authors thank Dr. Tricia Y. Li for statistical and programming support.
Grant Support: By the National Institutes of Health (grants CA87969, HL60712, and CA95589).
Potential Conflicts of Interest: None disclosed. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-0297.

Cellulitis is a diffuse infection that causes redness, heat, and swelling of the skin and underlying soft tissue, particularly on the legs. It should be distinguished from cutaneous inflammation associated with a suppurative focus, such as an abscess, furuncle, or underlying osteomyelitis. The microbial cause of cellulitis has been difficult to define, because cultures of blood, skin aspirates, or cutaneous biopsies are generally positive in less than 20% of patients. Findings from previous studies that made use of cultures, serology, immunofluorescent staining of skin biopsies for streptococcal antigens, and experimental models in animals have suggested that the vast majority of cases are caused by beta-hemolytic streptococci, not only Group A (Streptococcus pyogenes), but other groups as well. Some cases may be caused by Staphylococcus aureus, but the role of methicillin-resistant S. aureus (MRSA) strains has been unclear.

Investigators evaluated 179 patients with cellulitis, excluding those with animal or human bites, foreign bodies, or neutropenia. The patients were tested for acute and convalescent titers of anti-streptolysin O and anti-DNaseB; the former helps to detect infection with streptococcal Groups A, C, and G; the latter detects Group A infections alone. Along with results from blood cultures, these tests implicated beta-hemolytic streptococci in 73% of cases. In a medical center where MRSA was common in cutaneous abscesses and other skin and soft-tissue infections, 96% of patients receiving beta-lactam antibiotics ineffective against MRSA had a successful outcome.

Comment: This study may underestimate the frequency of a streptococcal etiology for cellulitis, because the serologic tests employed may miss some infections caused by Groups A, C, and G, and because they do not detect infections with other beta-hemolytic streptococci, such as Groups B and F, that can also cause cellulitis. In any event, the excellent response to beta-lactam antibiotics indicates that MRSA is a very uncommon cause of cellulitis and that the increasing use of antimicrobial therapy directed against that organism, such as trimethoprim-sulfamethoxazole or doxycycline, is rarely necessary in cellulitis. Instead, to treat patients with typical nonculturable cellulitis, clinicians can prescribe beta-lactam penicillins, such as parenteral oxacillin or oral dicloxacillin, or first-generation cephalosporins, such as parenteral cefazolin or oral cephalexin.

— Jan V. Hirschmann, MD

Investigators randomized some 500 patients from 24 general practices to self-titration and telemonitoring or to usual care for 1 year. Patients had blood pressures above 140/90 mm Hg despite taking one or two antihypertensive drugs. Intervention patients took pressure readings each morning during the first week of the month. If readings were above the target of 130 systolic for 2 consecutive months, drug dosages were adjusted according to a pre-agreed titration schedule without seeing the family doctor.

By 12 months, mean systolic pressure had dropped 17.6 mm Hg in the intervention group versus 12.2 among controls. Intervention patients were prescribed more drugs over the course of the year than controls — especially calcium antagonists and thiazides. Side effects were largely similar between groups.

An editorialist concludes that wide use of this strategy “is not far off on the horizon.”

Posted on 29 June 2010.

Alzheimer’s disease is not just memory loss. It impacts the brain in many ways, causing changes in cognitive abilities, judgment, executive function, language abilities and behavior. Following is a list of warning signs that include the common symptoms of Alzheimer’s disease. Some symptoms are also indicative of other dementias, such as Lewy body disease, Parkinson’s dementia, Pick’s disease and fronto-temporal lobe dementia. Please click our pictures for videos and more information.

1. Difficulty With Familiar Tasks
Tasks once easily accomplished might begin to be too daunting for someone in early stages of Alzheimer’s disease. Good cooks often begin saying that they no longer feel like cooking. Mail begins to pile up because the prospect of sorting it, paying bills and throwing away the junk mail becomes too confusing. Has your loved one suddenly or gradually stopped doing familiar activities?

2. Slipping Job Performance
Going into a room and forgetting why you went, or losing a colleague’s phone number only to remember it later can be a normal part of a business day. People with Alzheimer’s begin to forget items or events much more often, and may not remember them at a later point. Memory lapses, and missed appointments and deadlines negatively impact job performance.

3. Language Difficulties
The ability to find the appropriate word becomes more difficult with the onset of Alzheimer’s. Temporary lapses (such as momentarily forgetting a friend’s name) are a normal part of the aging process. People affected by Alzheimer’s disease might experience language difficulties much more often, forgetting words and then substituting inappropriate words in such a way that their speech becomes incomprehensible.

4. Confusion of Place and Time
People with Alzheimer’s disease can lose their sense of place and time. They might begin to speak of long-ago memories in the present tense or refer to their deceased parents as still living. The affected person might become lost in his or her own home and not recognize a loved one whom the person has known for decades.

5. Lack of Judgement
Alzheimer’s patients can exhibit increasingly poor judgment about activities of daily living.The affected person might observe a loved-one preparing a salad and then attempt to help by shredding newspaper and placing it into a bowl. He or she might put a dress on backwards, walk in the middle of a busy street or go outside dressed for summer on a cold winter day.

6. Problem in Abstract Thinking
An individual with Alzheimer’s may have problems with abstract reasoning, such as doing simple mathematics. While balancing a checkbook or manipulating fractions in a recipe can be a daunting task for any of us, a person with Alzheimer’s disease might also forget how to add and subtract, or even what numbers are used for. Additionally, the affected person might lose so-called executive functions, such as the ability to plan or strategize.

7. Misplacing and Hiding Objects
Who among us hasn’t temporarily misplaced our car keys or checkbook? A person with Alzheimer’s disease might begin losing items more frequently and will have greater difficulty remembering where items are stored. Because of these frequent losses, he or she might also begin hiding objects so that they won’t be “stolen.” A person with Alzheimer’s may put a wallet in the freezer or look for eye glasses in the family aquarium, and appear to think this is perfectly normal behavior.

8. Mood Fluctuations
It is a familiar part of human condition to feel melancholy or moody from time to time. An individual with Alzheimer’s can exhibit extremely rapid emotional outbursts, however. These might start with sudden laughter followed by extreme anger and shouting and end with wracking sobs-all experienced with no apparent rhyme or reason.

9. Changes in Personality
People with Alzheimer’s disease can undergo dramatic changes in personality and disposition. Someone who has been traditionally cheerful and outspoken may turn confused, timid and frightened. As coping skills diminish, the affected person may become suspicious of strangers and family members alike.

10. Lack of Initiative
Alzheimer’s patients can exhibit passivity and lack of energy, even about important things. We all temporarily tire of the daily stresses of work and home. But people with Alzheimer’s may require constant prompting and encouragement to get involved in even the simplest task of daily living. They may need encouragement and guidance to comb their hair in the morning. They may even chew their food but forget to swallow

Excessive sunlamp and tanning bed use is linked to increased risk for both melanoma and nonmelanoma skin cancers. Repeat tanners may exhibit addictive behaviors similar to those exhibited by people addicted to substances such as alcohol. To determine whether tanning is a substance-related disorder (SRD), investigators modified two measures widely used to identify SRDs: the CAGE (Cut down, Annoyed, Guilty, Eye-opener) questionnaire and the diagnostic criteria for SRDs in the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision; DSM-IV-TR). Overall, 237 of the 421 study participants (56.3%) visited tanning salons during the previous year (mean number of sessions, 23). Of 229 patients eligible for analysis, 70 (30.6%) met modified CAGE (mCAGE) criteria, and 90 (39.3%) met the modified DSM-IV-TR criteria for addiction to indoor tanning. The mCAGE and mDSM-IV-TR results were significantly correlated but not associated with gender or skin type. Study participants who met the criteria for addiction to indoor tanning reported greater symptoms of anxiety, although only the frequency of indoor tanning significantly predicted tanning addiction status (P<0.001). Subjects who met addiction criteria also reported greater alcohol and marijuana use but not more tobacco or stimulant use; 21 of the 50 participants (42.0%) who met addiction criteria used two or more substances during the previous month. Comment: This study nicely demonstrates the psychological underpinnings of repetitive tanning use, shifting away from the behavior’s purely physical effects and substantially supporting the notion that indoor tanning addiction involves the same drives as other forms of SRD. Strengths of this study are its large numbers and its rigorous application of psychological metrics. It is important to distinguish addicted from nonaddicted users. The real challenge is to translate these findings into concrete interventions to reduce the risky behavior. Perhaps lessons gained from the study of other SRDs can be used as a template. — Hensin Tsao, MD, PhD

The statement, published in Circulation, is based on meta-analysis of nine trials examining the effects of aspirin to prevent cardiovascular disease events in patients with diabetes. It also recommends the following:

• Adults with diabetes who are at increased risk for cardiovascular disease (e.g., men over 50 or women over 60 with an additional CVD risk factor) should receive aspirin for primary prevention.
• Patients at intermediate risk for cardiovascular disease (e.g., younger patients with at least one risk factor, older patients with no risk factors, or patients with a 10-year risk of 5% to 10%) may consider taking daily aspirin.

FDA Approves New Injectable Osteoporosis Treatment for Postmenopausal Women

The U.S. Food and Drug Administration today approved Prolia, an injectable treatment for postmenopausal women with osteoporosis who are at high risk for fractures.

Osteoporosis is a disease in which the bones become weak and are more likely to break. According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases, 80 percent of the people in the United States with osteoporosis are women. One out of every two women over age 50 will break a bone in their lifetime due to osteoporosis.

People with osteoporosis at high risk for fracture include those that have had an osteoporotic fracture, or have multiple risk factors for fracture; or those who have failed or are intolerant to other available osteoporosis therapy. Prolia works to decrease the destruction of bone and increase bone mass and strength. An injection of Prolia is recommended once every six months.

“Due to its prevalence, osteoporosis is a serious concern to public health,” said Julie Beitz, M.D., director of the FDA’s Office of Drug Evaluation III. “The approval of Prolia provides another treatment option for postmenopausal women with osteoporosis who are susceptible to fractures.”

The safety and efficacy of Prolia in the treatment of postmenopausal osteoporosis was demonstrated in a three-year, randomized, double-blind, placebo-controlled trial of 7,808 postmenopausal women ages 60 to 91 years. In the study, Prolia reduced the incidence of vertebral, non-vertebral, and hip fractures in postmenopausal women with osteoporosis.

The most common side effects reported with Prolia include back pain, pain in the extremities, musculoskeletal pain, high cholesterol levels, and urinary bladder infections. Serious adverse reactions include hypocalcaemia (low calcium levels in the blood), serious infections, including infections of the skin, and dermatologic reactions such as dermatitis, rashes, and eczema.

Prolia causes significant suppression of bone turnover and this suppression may contribute to the occurrence of osteonecrosis of the jaw, a severe bone disease that affects the jaw, atypical fractures, and delayed fracture healing.

Prolia was approved with a risk evaluation and mitigation strategy (REMS) that includes a Medication Guide for patients and communications to health care providers that explains the risks and benefits of the drug.

Prolia is manufactured by Amgen Manufacturing Limited, a subsidiary of Thousand Oaks, Calif.-based Amgen Inc.

For more information

Fast Facts on Osteoporosis – National Institute of Arthritis and Musculoskeletal and Skin Diseases