Can vitamins stop photoaging of the skin?
Source: Zussman J, et al. Vitamins and photoaging: Do scientific data support their uses? J Am Acad Derm 2010;63:507-525.
UV light is responsible for some of the skin changes associated with aging, which is known as photoaging (PHA). Expenditures in the United States for so-called "cosmeceuticals" is anticipated to reach more than $6 billion this year, although only a few components of commonly applied topical agents have any clearly demonstrated benefit.
Vitamin A derivatives, particularly the prescription retinoids such as tretinoin cream and tazarotene, are FDA-approved for aging-related fine line wrinkles, skin roughness, and mottled hyperpigmentation. OTC vitamin A derivatives have less convincing evidence, but of these, retinol should be the preferred agent according to Zussman et al.
Amelioration of PHA has been seen in several topical vitamin C trials using L-ascorbic acid; chemically related compounds (e.g., ascorbyl palmitate, ascorbyl tetraiopalmitate) provide greater vitamin C stability, but do not have sufficient clinical trial outcomes data to advocate for them.
Topical formulations of vitamin E, although widely touted for antioxidant potential, do not have data to support their use in management of PHA. Limited data on topical niacin suggest promise.
The best method to address photoaging is overall good nutrition and an appropriate combination of sunscreen and sun avoidance.
Once weekly exenatide vs sitagliptin or pioglitazone for type 2 diabetes
Source: Bergenstal RM, et al. Efficacy and safety of exenatide once weekly versus sitagliptin or pioglitazone as an adjunct to metformin for treatment of type 2 diabetes (DURATION-2): A randomised trial. Lancet 2010;376:431-439.
The incretin class of medications (exenatide, liraglutide, sitagliptin, saxagliptin) all share the favorable quality of not being associated with weight gain. Recently published data support the efficacy, tolerability, and simplicity of once-weekly exenatide. Bergenstal et al compared exenatide once weekly (EXEN-W) with sitagliptin (STG) or pioglitazone (PIO) as add-on therapy for persons with type 2 diabetes (n = 491) who had not attained goal with metformin.
At the end of 26 weeks, several outcomes favored EXEN-W. A1c on EXEN-W was 0.6% lower than STG, and 0.3% lower than PIO. Weight loss was also greatest in the EXEN-W group. Adverse effect profiles with each treatment arm were consistent with prior trials, and the discontinuation rate was similar for each group.
EXEN-W reduced systolic BP more than sitagliptin, but similarly to pioglitazone. Favorable lipid effects were seen with each treatment arm: The greatest increase in HDL was seen with pioglitazone.
As clinicians make their therapeutic choices for diabetes management, the relevance of medication impact upon CV risk factors such as BP, weight, and lipids merits our consideration.
Tai chi for fibromyalgia
Source: Wang C, et al. A randomized trial of tai chi for fibromyalgia. N Engl J Med 2010;363:743-754.
FDA-approved pharmacologic treatments for fibromyalgia (FIB) include duloxetine, milnacipran, and pregabalin. Although each of these agents has shown both statistically significant and clinically relevant impact, few patients are relieved of all problematic symptoms. Hence, additional treatment paths for FIB are sought.
Exercise has long been recognized as having a favorable impact on FIB, although it has been uncertain which type of exercise should be preferred. For a variety of reasons, some patients will not readily embrace strenuous or aerobic exercise programs, leaving a therapeutic gap in activity programs that can be relied upon to improve FIB symptoms and functionality.
Wang et al enrolled FIB patients (n = 66) into a 12-week program comparing tai chi to a stretching + wellness education component. For the physical activities, both groups participated in two 60-minute sessions per week for 12 weeks. Fibromyalgia patients were diagnosed using the American College of Rheumatology criteria.
At the conclusion of the study, Fibromyalgia Impact Questionnaire and SF-36 physical component scores were superior in the tai chi group as compared to the stretching group. Discontinuation of medications used to treat FIB was seen in both active treatment groups, with a trend favoring tai chi.
Tai chi instruction was provided by a single tai chi master to all of the subjects in that group. Generalizability whether clinicians can anticipate similar efficacy when tai chi is taught by others remains to be confirmed.
Prevalence of hearing loss in U.S. adolescents
Source: Shargorodsky J, et al. Change in prevalence of hearing loss in U.S. adolescent. JAMA 2010;304:772-778.
My grandmother always claimed that listening to loud rock and roll music would be the demise of my hearing ... but I still don't know if she was right. In those days we used to listen to something called a record player (younger clinicians interested to see such an archaic device can readily locate one on Google), and I have always wondered whether those cars bouncing up and down at the traffic light next to me, loaded with rap music, would be determined to be similarly ototoxic, or worse. Well, if the NHANES data are correct, we still don't know.
According to this analysis of data from NHANES, the prevalence of hearing loss has increased when one compares the 1988-1994 interval with 2005-2006. Indeed, the relative risk of any hearing loss (induced by any factor) has increased by more than 30%.
Hearing loss was associated with poverty and a history of > 3 ear infections, but not exposure to persistent (> 5 hrs/week) loud noise or firearm use. In support of grandma's point of view, a recent study from Australia noted hearing loss 70% more often in teens who had used personal stereo devices.
Overall, the prevalence of any hearing loss increased from 11.1% to 14.0% over the decade studied; further elucidation of modifiable risk factors would be helpful.
When to initiate dialysis? Early vs late GFR threshold
Source: Cooper BA, et al. A randomized, controlled trial of early versus late initiation of dialysis. N Engl J Med 2010;363:609-619.
The number of individuals requiring renal replacement therapy (dialysis) continues to grow. Because dialysis is an expensive, time-intensive, and intrusive intervention, it is wise to try to refine an optimum threshold for initiation of dialysis. Intuition might suggest that earlier is better than later, but few data to support this notion are in evidence.
Cooper et al performed a study of adults (n = 828) who qualified for dialysis. Study subjects were randomized to either early (GFR = 10-15 mL/min/1.73 m2) or late (GFR = 5-7 mL/min/1.73 m2) dialysis. The primary outcome of the trial was all-cause mortality.
Over an 8-year interval, 828 diabetic subjects with Stage V CKD (GFR < 15 mL/min/1.73 m2) were randomized to initiate dialysis at either the early or late GFR threshold. The mean time to dialysis initiation in the early group was 1.8 months vs 7.4 months in the late group, but this difference might be expanded further, since more than 75% of the late start group actually initiated dialysis because of symptoms before reaching a GFR of 7.
Overall mortality during 3.6 years of follow-up was not significantly different between the two groups. There does not appear to be any mortality detriment associated with delaying dialysis until GFR is 7 mL/min/1.73 m2 or less, although many patients may require earlier dialysis due to symptoms.
Postoperative abdominal wall hernias: Best repair methodology
Source: Itani KM, et al. What to advise patients about hernias. Arch Surg 2010;145:322-328.
The literature indicates that almost one-fourth of persons who undergo abdominal surgery will subsequently incur an abdominal wall hernia. The optimum method for repairing such hernias has not been established. Itani et al performed a randomized trial of laparoscopic vs open repair of ventral incisional hernias at four Veterans Affairs hospitals (n = 162).
There was a substantial risk reduction for complications in the laparoscopic group vs the open repair group (absolute incidence = 31.5% vs 47.9%). In particular, surgical wound site infection was almost 4-fold less in the laparoscopic group. Pain scores at 1 year were less in the laparoscopic group, and return to work was quicker. The only major advantage of open surgical treatment was the incidence of major complications, primarily bowel injury (4.4% in the laparoscopic group vs 1.4% in the open surgery group). One additional advantage of open surgical repair was a trend toward lower recurrence in this group (8.2% vs 12.5%; P = NS).
In general, asymptomatic incisional ventral hernias do not require repair, but once they are symptomatic, laparoscopic surgery shows distinct advantages. The surgeons in this trial had not performed a high volume of laparoscopic procedures; hence, clinicians might anticipate even better outcomes as experience accrues.
Can vitamins stop photoaging of the skin?; Once weekly exenatide vs sitagliptin or pioglitazone for type 2 diabetes; Tai chi for fibromyalgia; Prevalence of hearing loss in U.S. adolescents; When to initiate dialysis? Early vs late GFR threshold; Postoperative abdominal wall hernias: Best repair methodologyYou have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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