Cigarette smoking and Parkinson's disease: a case-control study in a population characterized by a high prevalence of pesticide exposure.

Epidemiological studies have been consistent in showing that cigarette smoking is inversely associated with Parkinson's disease (PD), whereas pesticide use is positively associated with PD. However, the relationship between PD and cigarette smoking remains poorly understood. Our objective was to study the relationship between cigarette smoking and PD in a population characterized by a high prevalence of pesticide exposure. This case-control study was carried out among subjects enrolled in the Mutualite Sociale Agricole, the French health insurance organization for workers connected to the agricultural world. We included 247 cases and 676 controls matched on age, sex, and region of residency. Information on smoking was obtained through in-person interviews. Pesticide exposure was assessed using a case-by-case expert evaluation procedure. We found an inverse relationship between ever cigarette smoking and PD (odds ratio [OR] = 0.6; 95% confidence interval [CI] = 0.4-0.9). The strength of this association increased with the number of pack-years. This relationship was present even when smoking was considered as long as 40 years before PD onset. An inverse association was also present among subjects professionally exposed to pesticides (OR = 0.5; 95% CI = 0.3-0.8) and was independent of the duration of exposure among men. We confirm the inverse association between cigarette smoking and PD in a population characterized by a high prevalence of professional pesticide exposure. The relationship between PD and cigarette smoking was not significantly modified or confounded by exposure to pesticides.     

Treatment of chronic duodenal ulceration. Effectiveness of colloidal bismuth subcitrate tablets compared with cimetidine

Fifty-eight patients with chronic duodenal ulceration proven at endoscopy consented to enter a trial comparing the effect of colloidal bismuth subcitrate (CBS)tablets with that of cimetidine. Fifty-four patients completed the six-week trial. An endoscopic assessment of healing was made at four weeks. If healing had not occurred, the trial was continued for another two weeks and the endoscopy was repeated. At four weeks, healing at endoscopy was demonstrated in 82% of patients receiving CBS and in 58% of those receiving cimetidine. At six weeks, the healing rates were 93% and 81%, respectively. No side effects were noted in either group. Continued smoking was not found to have an adverse effect on the healing rate of ulcers in either treatment group.     

Oncologic and functional results of supracricoid partial laryngectomy with cricohyoidopexy.

OBJECTIVE: Supracricoid partial laryngectomy with cricohyoidopexy (SPL-CHP) is an alternative technique described for extensive tumors of the larynx that are beyond the limits of classical conservation partial laryngectomy and otherwise would be treated by total laryngectomy. STUDY DESIGN AND SETTING: Forty-six patients with carcinoma of the larynx underwent SPL-CHP between 1991 and 2003. The median age was 54 (range, 37 to 72). In 28 cases both arytenoids were spared; in 17 cases, 1 arytenoid was spared; and in 1 case, 2 arytenoids were resected. Bilateral elective neck dissections were performed in supraglottic carcinomas. In glottic carcinomas, neck dissection was performed in the presence of clinically positive lymph nodes. None of the patients were treated with postoperative radiation therapy. RESULTS: Forty-five patients were successfully decannulated; 1 patient with 2 arytenoids resected could not tolerate decannulation. The mean time for decannulation was 20 days (range, 9 to 60 days) when both arytenoids were spared with SPL-CHP, and 41 days (range, 13 to 150 days) for SPL-CHP when 1 arytenoid was spared. The average time for removal of the feeding tube was 21 days (range, 9 to 60 days) when both arytenoids were spared, and 40 days (range, 16 to 127 days) when 1 arytenoid was spared. The removal time of the feeding tube of the patient with 2 arytenoids resected was postoperative day 63. In 2 patients, aspiration pneumonia occurred as a result of swallowing impairment. In none of the patients temporary or permanent gastrostomy was needed. Two patients had local recurrence and were treated with a total laryngectomy; they are still alive. In 2 patients, secondary primary tumors were detected. The 3-year overall and cause-specific actuarial survival rates were 95.7 % and 87.5 % , respectively. CONCLUSIONS: Although prolonged hospitalization and delaying physiological functions can be termed as disadvantages of SPL-CHP, the operation is a reliable and oncologically valid procedure in selected cases of cancer of the larynx who would otherwise be operated by total laryngectomy.     

Insulin Resistance and Protein Energy Metabolism in Patients with Advanced Chronic Kidney Disease

Insulin resistance (IR), the reciprocal of insulin sensitivity is a known complication of advanced chronic kidney disease (CKD) and is associated with a number of metabolic derangements. The complex metabolic abnormalities observed in CKD such as vitamin D deficiency, obesity, metabolic acidosis, inflammation, and accumulation of “uremic toxins” are believed to contribute to the etiology of IR and acquired defects in the insulin‐receptor signaling pathway in this patient population. Only a few investigations have explored the validity of commonly used assessment methods in comparison to gold standard hyperinsulinemic hyperglycemic clamp technique in CKD patients. An important consequence of insulin resistance is its role in the pathogenesis of protein energy wasting, a state of metabolic derangement characterized by loss of somatic and visceral protein stores not entirely accounted for by inadequate nutrient intake. In the general population, insulin resistance has been associated with accelerated protein catabolism. Among end‐stage renal disease (ESRD) patients, enhanced muscle protein breakdown has been observed in patients with Type II diabetes compared to ESRD patients without diabetes. In the absence of diabetes mellitus (DM) or severe obesity, insulin resistance is detectable in dialysis patients and strongly associated with increased muscle protein breakdown, primarily mediated by the ubiquitin‐proteasome pathway. Recent epidemiological data indicate a survival advantage and better nutritional status in insulin‐free Type II DM patients treated with insulin sensitizer thiazolidinediones. Given the high prevalence of protein energy wasting in ESRD and its unequivocal association with adverse clinical outcomes, insulin resistance may represent an important modifiable target for intervention in the ESRD population.     

Low Health Literacy Associates with Increased Mortality in ESRD

Limited health literacy is common in the United States and associates with poor clinical outcomes. Little is known about the effect of health literacy in patients with advanced kidney disease. In this prospective cohort study we describe the prevalence of limited health literacy and examine its association with the risk for mortality in hemodialysis patients. We enrolled 480 incident chronic hemodialysis patients from 77 dialysis clinics between 2005 and 2007 and followed them until April 2008. Measured using the Rapid Estimate of Adult Literacy in Medicine, 32% of patients had limited (<9th grade reading level) and 68% had adequate health literacy (≥9th grade reading level). Limited health literacy was more likely in patients who were male and non-white and who had fewer years of education. Compared with adequate literacy, limited health literacy associated with a higher risk for death (HR 1.54; 95% CI 1.01 to 2.36) even after adjustment for age, sex, race, and diabetes. In summary, limited health literacy is common and associates with higher mortality in chronic hemodialysis patients. Addressing health literacy may improve survival for these patients.The worldwide epidemic of kidney disease continues to grow in parallel to chronic conditions such as diabetes, hypertension, and obesity.¹ In the United States it is estimated by 2020 there will be more than 750,000 people with ESRD, and on the basis of current practice 68% will be treated with hemodialysis therapy.² Kidney disease is the ninth leading cause of death in the United States, and despite advances in dialysis technology and treatment of associated conditions such as anemia, mineral metabolism, and malnutrition, mortality risk, both cardiovascular and noncardiovascular, of chronic hemodialysis patients remains high—8 times greater than people in the general population.^2–4 Early identification of hemodialysis patients with a higher risk for death is critical to customize therapies needed to reduce this risk, and identification of novel risk factors may guide new approaches to care delivery.In the United States, 90 million people are estimated to have basic or below basic literacy skills.⁵ Health literacy, or the “ability to obtain, process, and understand basic health information to make appropriate health decisions about one''s health and medical care,”⁶ has been associated with many health outcomes and characterized as contributing to disparities in health care. Limited health literacy has been associated with lower patients'' knowledge of complex diseases, less self-care behaviors such as medication adherence, and also poorer clinical outcomes such as glycemic control in patients with diabetes.^7–9Recently, it was suggested that health literacy may be an important factor in the care of patients with kidney disease.¹⁰ There is little research characterizing health literacy, and examining the relationship between literacy and health outcomes, in patients with kidney disease. With an estimated 26 million people in the United States with chronic kidney disease,¹¹ it is important to identify and establish all possible factors related to kidney disease progression, and to premature death in patients with advanced kidney disease. The objectives of this study were to characterize the prevalence and associated patient characteristics of limited health literacy, and to examine the risk of all-cause mortality by health literacy level in patients initiating chronic hemodialysis (HD) therapy.     

<Emphasis Type="Italic">CRP</Emphasis> polymorphisms and chronic kidney disease in the third national health and nutrition examination survey

Background

CRP gene polymorphisms are associated with serum C-reactive protein concentrations and may play a role in chronic kidney disease (CKD) progression. We recently reported an association between the gene variant rs2808630 and CKD progression in African Americans with hypertensive kidney disease. This association has not been studied in other ethnic groups.

Methods

We used data from 5955 participants from Phase 2 of The Third National Health and Nutrition Examination Survey (1991-1994) to study the association between CRP polymorphisms and CKD prevalence in a population-based sample. The primary outcome was CKD defined as estimated glomerular filtration rate (eGFR) <60 ml/min or the presence of albuminuria. Secondary outcomes were the presence of albuminuria (any degree) and continuous eGFR. Six single nucleotide polymorphisms (SNPs) from the CRP gene, rs2808630, rs1205, rs3093066, rs1417938, rs3093058, and rs1800947, were evaluated.

Results

CRP rs2808630 AG compared to the referent AA genotype was associated with CKD in non-Hispanic blacks (n = 1649, 293 of whom had CKD) with an adjusted odds ratio (OR) of 3.09 (95% CI 1.65-5.8; p = 0.001). For the secondary outcomes, rs2808630 AG compared to the referent AA genotype was associated with albuminuria with an adjusted OR of 3.07 (95% CI 1.59-5.94; p = 0.002), however not with eGFR. There was no association between the SNPs and CKD, albuminuria or eGFR in non-Hispanic whites or Mexicans Americans.

Conclusions

In this cross-sectional study, the 3' flanking CRP gene variant rs2808630 was associated with CKD, mainly through its association with albuminuria in the non-Hispanic blacks. Despite not finding an association with eGFR, our results support our previous study demonstrating an association between CRP gene variant rs2808630 and CKD progression in a longitudinal cohort of African American with hypertensive kidney disease.

     

Metabolic effects of paliperidone extended release versus oral olanzapine in patients with schizophrenia: a prospective, randomized, controlled trial

Metabolic effects are generally more pronounced with second-generation than first-generation antipsychotics. This study was designed to compare long-term metabolic effects and efficacy of paliperidone extended release (ER) with those of oral olanzapine in patients with schizophrenia. In this 6-month, multicenter, prospective, randomized, controlled, open-label, parallel-group study, adults with schizophrenia were treated with paliperidone ER (6-9 mg/d; n = 239) or oral olanzapine (10-15 mg/d; n = 220). The primary outcome was mean change in the ratio of serum triglyceride level to high-density lipoprotein level (TG/HDL), a marker of insulin resistance. Other outcome measures included the Positive and Negative Syndrome Scale scores, measures of lipid and glucose metabolism, and body weight. Significant improvements in psychotic symptoms were observed with both treatments (P < 0.0001). The TG/HDL ratio was significantly higher at end point versus baseline with olanzapine compared with that of paliperidone ER. Mean end point change in TG/HDL ratio was 0.097 ± 2.72 for olanzapine (P < 0.0001, reflecting worsening), with no significant change for paliperidone ER (-0.17 ± 2.51). Newly diagnosed impairment in TG and metabolic syndrome was more common with olanzapine (P < 0.05). Insulin resistance, as measured by the homeostasis model assessment of insulin resistance, worsened significantly with olanzapine (P = 0.0003), but not with paliperidone ER. Glucose sensitivity for insulin worsened significantly with olanzapine (P < 0.03), with no significant changes for paliperidone ER. End point increase in body weight was significantly higher with olanzapine than paliperidone ER (3.8 vs 1.2 kg; P = 0.0013). In summary, both paliperidone ER and olanzapine effectively treated schizophrenia; however, undesirable metabolic effects were significantly greater with olanzapine.     

Myogenic and melanotic differentiated medulloblastoma: case report

Medulloblastoma is the most common malignant tumor of childhood and usually arises from the cerebellar vermis. Several histological types of medulloblastoma have been described. Myogenic and melanotic differentiated medulloblastoma are seldom seen. We present a case diagnosed as myogenic medulloblastoma with focal areas of melanotic differentiation. A 4-year-old boy was admitted due to headache, nausea and vomiting for a month. MRI revealed a heterogeneous enhanced posterior fossa tumor rising from the fourth ventricle. He was operated and pathological examination of the specimen revealed myogenic medulloblastoma with myogenic and melanotic differentiation. According to our knowledge there are six cases reported in the literature so far. Oncogenic factors in medulloblastoma development are controversial. Presence of multiple differentiation patterns supports a pluripotent origin for these tumors.