Clinical Briefs by Louis Kuritzky, MD
By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville. Dr. Kuritzky is a consultant for Sucampo Pharmaceuticals, Takeda, Boehringer Ingelheim; and is a consultant and on the speaker's bureau for Novo Nordisk, Lilly, Daiichi Sankyo, Forest Pharmaceuticals, Cephalon, Novartis, and Sanofi Aventis.
Aspirin after colon cancer diagnosis
Source: Chan AT, et al. JAMA 2009; 302:649-658.
Most colorectal cancers overexpress cyclo-oxygenase 2 (COX-2). Primary prevention with aspirin (ASA) is associated with reduced risk for colon cancer and colonic adenoma. Secondary prevention with ASA (and celecoxib) is effective in reducing risk of new adenomas in persons who have been previously diagnosed with colonic neoplasia. Because ASA has recognized toxicities, including cerebral hemorrhage and GI bleeding, it is important to determine whether use of ASA in high-risk subjects (persons previously diagnosed with colon cancer) provides net benefit for overall and/or colon cancer-specific mortality.
The Physicians' Health Study and the Nurses' Health Study are observational studies, providing a window of observation for the role of ASA in both primary and secondary prevention. A cohort within both populations took maintenance ASA prior to any diagnosis of colon cancer, and further information about effects of ASA in persons who developed colon cancer and continued with ASA subsequent to the cancer diagnosis (vs subjects who did not take ASA after a diagnosis of colon cancer) is presented here.
Of subjects who developed colon cancer (n = 1279) in these two study populations (combined), there were statistically significant differences in total mortality (35% vs 39%) and colon cancer-related mortality (15% vs 19%) favoring use of ASA. Concordant with current thinking on the putative mechanism of ASA benefit, the risk reduction was greatest in persons whose colon cancer overexpressed COX-2. Despite these favorable results, the authors caution that routine utilization of ASA post colon cancer might be considered premature since these data are observational; placebo-controlled randomized trials are needed for confirmation.
The short-term risks of bariatric surgery
Source: The Longitudinal Assessment of Bariatric Surgery (LABS) Consortium; et al. N Engl J Med 2009;361: 445-454.
Long-term benefits from bariatric surgery have been definitely established. Nonetheless, perioperative risks associated with bariatric surgery are not insignificant, especially since persons undergoing bariatric surgery often suffer comorbidities of diabetes, hypertension, and dyslipidemia.
The LABS Consortium performed an observational study of short-term outcomes subsequent to bariatric surgery in the United States. From 2005 to 2007, data supplied by 10 different clinical sites (combined total n = 4776 first-time bariatric surgical procedures) provided information on the composite endpoint of 30-day major adverse outcomes (death, DVT, postoperative intervention, and extended hospital stay). Roux-en-Y bypass was performed on approximately 70% of subjects; the majority of the other patients underwent gastric banding.
Death occurred in 0.3% of subjects within 30 days; an additional 4% of subjects experienced at least one adverse event included in the composite primary endpoint. A previous history of DVT was associated with greater likelihood of a postoperative adverse event; additionally, the higher the BMI (mean BMI in this report = 46.5 kg/m2), the greater the frequency of adverse events.
Bariatric surgery has significant associated risks. For most appropriately selected patients, the long-term benefits far outweigh these risks, but patients need to be informed of the potential for serious adverse outcomes.
Testosterone, depression, and hypogonadal men
Source: Shores MM, et al. J Clin Psychiatry 2009;70:1009-1016.
Subthreshold depression (sDEP), also known as minor depression, occurs in as many as 1 of 4 elderly patients. Although by definition the symptom burden of sDEP is less than major depressive disorder (MDD), it is more common than MDD and is still associated with diverse negative outcomes including decreased quality of life and function, and increased morbidity, mortality, and health care utilization.
Symptoms of hypogonadism include fatigue, decreased libido, and dysphoria, any of which may also be manifestations of depression. Shores et al studied the impact of testosterone replacement in hypogonadal men (total testosterone < 280 ng/dL) meeting DSM-IV criteria for sDEP.
This double-blind trial randomized adult men (n = 33) to testosterone gel 7.5 g/d or placebo for 12 weeks. The primary outcome was change in HAM-D depression score.
At the end of the trial, testosterone-treated men had a significantly improved HAM-D score compared to placebo, and the percent with remitted sDEP was dramatically different (52.9% vs 18%) favoring testosterone.
No serious testosterone-attributable adverse effects were seen. Testosterone replacement shows benefit for improving sDEP in hypogonadal men.Most colorectal cancers overexpress cyclo-oxygenase 2 (COX-2). Primary prevention with aspirin (ASA) is associated with reduced risk for colon cancer and colonic adenoma.
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