Clinical Briefs
By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville
Dr. Kuritzky is an advisor for Endo, Kowa, Pricara, and Takeda.
Could Thinner be Worse for Newly Diagnosed Diabetics?
Source: Carnethon MR, et al. JAMA 2012;308:581-590.
USUALLY, WE ANTICIPATE A DIRECT RElationship between overweight and cardiovascular adversity, attributed to increases in blood pressure, lipids, glucose, insulin resistance, and sympathetic tone that are associated with obesity. There appears to be some exception to this general rule in reference to diabetes. For instance, in the TRIAD study, diabetics who were normal weight at entry to the study had a higher mortality than overweight/obese study subjects; similarly, in the PROactive trial, normal weight subjects or those who lost weight had higher mortality than overweight subjects. Because these two studies included confounding issues such as diabetes of varying duration and pre-existing cardiovascular disease, a more clear-cut relationship between body mass index (BMI) and outcome in diabetes could be discerned by selecting newly diagnosed diabetics.
Carnethon et al performed a pooled analysis of five longitudinal cohort studies (n = 2625) to examine the relationship between mortality and BMI for persons with newly diagnosed diabetes. Overall, only 12% of study subjects had a BMI < 25 at the time of diagnosis, but the relative risk for total mortality during follow-up (up to 15 years) was essentially doubled in this population compared to overweight individuals.
The mechanism(s) by which lower BMI increases mortality risk are unknown. Clinicians must not be falsely reassured that this lower-BMI phenotype, which is commonly seen in Asian-Americans, portends a favorable future.
The Impact of Exercise on Depression in Heart Failure
Source: Blumenthal JA, et al. JAMA 2012;308:465-474.
IT IS ESTIMATED THAT 5 MILLION AMERIcans have chronic heart failure (CHF), and almost half of these patients fulfill diagnostic criteria for depression. Subsyndromal depression is present in as many as 75%. Notwithstanding the burden of depression on quality of life, a direct impact on mortality has been shown in post-myocardial infarction patients, and even in patients with hypertension in the Systolic Hypertension in the Elderly Program. Unfortunately, to date the information on the impact of treating depression is both limited and generally disappointing. For instance, a clinical trial of sertraline in depressed patients with CHF found no cardiovascular event outcomes benefit.
Exercise is a treatment for depression, and exercise has been shown to provide event reduction in CHF patients. Whether it might improve depression and cardiovascular events in CHF patients was the object of the HF-ACTION trial (Heart Failure-A Controlled Trial Investigating Outcomes of Exercise Training).
More than 2000 patients with stable CHF were randomized to an aerobic exercise program. The exercise subjects enjoyed a statistically significant 11% reduction in mortality over the next 30 months. Although the mean score on the Beck Depression Inventory was statistically significantly lower in the exercise group, the improvement was sufficiently modest to be of uncertain clinical impact. Exercise in CHF reduces mortality and may have a modest effect on depression.
Reversible Dementia from Corticosteroid Therapy
Source: Cipriani G, et al. Clin Geriatrics 2012;20:38-41.
ALTHOUGH THERE ARE MANY CLINICAL situations in which corticosteroids (CTS) are disease modifying and life saving, one aspect of CTS that has not received much attention is the potential for central nervous system (CNS) adverse effects. CTS may be largely subgrouped into mineralocorticoids exemplified by aldosterone, and glucocorticoids (GLC) like prednisone, the latter of which is the object of this case report.
There are at least two types of CTS receptors in the brain: type I (mineralocorticoid receptors) and type II (glucocorticoid receptors). Type II receptors are found in the hippocampus as well as other diffuse sites throughout the brain. The hippocampus is required for voluntary recollection of learned information, such as recalling what you had for dinner last night. Even low doses of GLC have been shown to impair hippocampal function, despite being used for short time periods, doses of prednisone of 80 mg/day have been shown to alter cognitive function within 4-5 days.
The authors include discussion of a report detailing six cases of dementia-like cognitive decline (distinct from steroid psychosis) in patients whose cognitive function was restored upon GLC discontinuation.
Clinicians should be vigilant for decline in cognitive function in persons receiving GLC treatment, even over the short-term.
Clinical Briefs: Could Thinner be Worse for Newly Diagnosed Diabetics?; The Impact of Exercise on Depression in Heart Failure; Reversible Dementia from Corticosteroid TherapyYou have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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