Lithotripsy

Definition
Lithotripsy is the use of high-energy shock waves to fragment and disintegrate kidney stones. The shock wave, created by using a high-voltage spark or an electromagnetic impulse, is focused on the stone. This shock wave shatters the stone and this allows the fragments to pass through the urinary system. Since the shock wave is generated outside the body, the procedure is termed extracorporeal shock wave lithotripsy, or ESWL.

Purpose
ESWL is used when a kidney stone is too large to pass on its own, or when a stone becomes stuck in a ureter (a tube which carries urine from the kidney to the bladder) and will not pass. Kidney stones are extremely painful and can cause serious medical complications if not removed.

Precautions
ESWL should not be considered for patients with severe skeletal deformities, patients weighing over 300 lbs (136 kg), patients with abdominal aortic aneurysms, or patients with uncontrollable bleeding disorders. Patients who are pregnant should not be treated with ESWL. Patients with cardiac pacemakers should be evaluated by a cardiologist familiar with ESWL. The cardiologist should be present during the ESWL procedure in the event the pacemaker needs to be overridden.

Description
Lithotripsy uses the technique of focused shock waves to fragment a stone in the kidney or the ureter. The patient is placed in a tub of water or in contact with a water-filled cushion, and a shock wave is created which is focused on the stone. The wave shatters and fragments the stone. The resulting debris, called gravel, then passes through the remainder of the ureter, through the bladder, and through the urethra during urination. There is minimal chance of damage to skin or internal organs because biologic tissues are resilient, not brittle, and because the the shock waves are not focused on them.

Preparation
Prior to the lithotripsy procedure, a complete physical examination is done, followed by tests to determine the number, location, and size of the stone or stones. A test called an intravenous pyelogram, or IVP, is used to locate the stones. An IVP involves injecting a dye into a vein in the arm. This dye, which shows up on x ray, travels through the bloodstream and is excreted by the kidneys. The dye then flows down the ureters and into the bladder. The dye surrounds the stones, and x rays are then used to evaluate the stones and the anatomy of the urinary system. (Some people are allergic to the dye material, so it cannot be used. For these people, focused sound waves, called ultrasound, can be used to see where the stones are located.) Blood tests are done to determine if any potential bleeding problems exist. For women of childbearing age, a pregnancy test is done to make sure the patient isn’t pregnant; and elderly patients have an EKG done to make sure no potential heart problems exist. Some patients may have a stent placed prior to the lithotripsy procedure. A stent is a plastic tube placed in the ureter which allows the passage of gravel and urine after the ESWL procedure is completed.

Key terms
Aneurysm — A dilation of the wall of an artery which causes a weak area prone to rupturing.
Bladder — Organ in which urine is stored prior to urination.
Bleeding disorder — Problems in the clotting mechanism of the blood.
Cardiologist — A physician who specializes in problems of the heart.
EKG — A tracing of the electrical activity of the heart.
ESWL (Extracorporeal shock wave lithotripsy) — The use of focused shock waves, generated outside the body, to fragment kidney stones.
Gravel — The debris which is formed from a fragmented kidney stone.
IVP (Intravenous pyelogram) — The use of a dye, injected into the veins, used to locate kidney stones. Also used to determine the anatomy of the urinary system.
Kidney stone — A hard mass that forms in the urinary tract and which can cause pain, bleeding, obstruction, or infection. Stones are primarily made up of calcium.
Stent — A plastic tube placed in the ureter prior to the ESWL procedure which facilitates the passage of gravel and urine
Ultrasound — Sound waves used to determine the internal structures of the body
Ureter — A tube which carries urine from the kidney to the bladder.
Urethra — A tube through which urine passes during urination.
Urologist — A physician who specializes in problems of the urinary system.

Aftercare
Most patients have a lot of blood in their urine after the ESWL procedure. This is normal and should clear after several days to a week or so. Lots of fluids should be taken to encourage the flushing of any gravel remaining in the urinary system. The patient should follow up with the urologist in about two weeks to make sure that everything is going as planned. If a stent has been inserted, it is normally removed at this time. Patients may return to work whenever they feel able.

Risks
Abdominal pain is not uncommon after ESWL, but it is usually not cause to worry. However, persistent or severe abdominal pain may imply unexpected internal injury. Colicky renal pain is very common as gravel is still passing. Other problems may include perirenal hematomas (blood clots near the kidneys) in 66% of the cases; nerve palsies; pancreatitis (inflammation of the pancreas); and obstruction by stone fragments. Occasionally, stones may not be completely fragmented during the first ESWL treatment and further ESWL procedures may be required.

Resources
Organizations
American Urological Association. 1120 North Charles St., Baltimore, MD 21201-5559. (410) 727-1100. 〈http://www.auanet.org/index_hi.cfm〉.
Gale Encyclopedia of Medicine. Copyright 2008 The Gale Group, Inc. All rights reserved.
lithotripsy /litho·trip·sy/ (lith´o-trip″se) the crushing of a calculus within the urinary system or gallbladder, followed at once by the washing out of the fragments; it may be performed surgically or by noninvasive methods, such as by laser or by shock waves.
extracorporeal shock wave lithotripsy a procedure for treating upper urinary tract stones: the patient is immersed in a large tub of water and a high-energy shock wave generated by a high-voltage spark is focused on the stone by an ellipsoid reflector. The stone disintegrates into particles, which are passed in the urine.
pneumatic lithotripsy lithotripsy in which a rigid probe is inserted through the ureter and pneumatic pressure is applied directly to the calculus.

Dorland’s Medical Dictionary for Health Consumers. © 2007 by Saunders, an imprint of Elsevier, Inc. All rights reserved.
lith·o·trip·sy (lth-trps) n.

The procedure of crushing a stone in the urinary bladder or urethra. Also called lithotrity.
The American Heritage® Medical Dictionary Copyright © 2007, 2004 by Houghton Mifflin Company. Published by Houghton Mifflin Company. All rights reserved.

Cognitive Behavioral Therapy Aids Long-Term Pain Management
Kate Johnson
Authors and Disclosures
February 12, 2012 (Miami Beach, Florida) — The benefits of adding cognitive behavioral therapy (CBT) to a chronic pain management protocol are evident in patients up to 3 years after the end of treatment, according to research.

“In our program, we don’t use analgesic drugs, strong opioids, or anything,” Magnus Olason, MD, from the Chronic Pain Division at Reykjalundur Rehabilitation Center in Iceland, told Medscape Medical News. Instead, he said, “we wean patients off them, and we try to teach patients relapse control: how to deal with the pain, if it gets worse, without taking drugs again.”

The findings were presented here at the 6th World Congress of the World Institute of Pain.

Chronic Pain

The new study followed-up 113 patients (64% women), mean age 38 years, who had been through a 6-week pain management program to deal with noncancerous, musculoskeletal pain.

“These were chronic pain patients, almost half have had pain for more than 5 years, over 40% had low back pain, and they were on pain relievers, nonsteroidal anti-inflammatory drugs, antidepressants, relaxants,” Dr. Olason said.

All patients were screened to assess whether they needed CBT, based on their scores on the Beck Anxiety Inventory, the Beck Depression Inventory (BDI-II), the Fear and Avoidance Beliefs Questionnaire, and the Pain Catastrophizing Scale. Quality of life (QOL) was also measured with the short-form 36 health survey questionnaire.

Patients were divided into groups based on these scores: those who did not need CBT (n = 34), and who therefore were put into the non-CBT pain management program; , and those who were eligible for CBT (n = 79) who were subsequently randomly assigned to either the non-CBT program or a CBT program that consisted of 12 individual manual-based sessions delivered by trained therapists.

The non-CBT program focused primarily on physical rehabilitation and exercise.

Baseline scores were measured 6 weeks before entry into the program, and again at the start of the program, and these scores were compared with scores at the end of the 6-week program, as well as 1 and 3 years after treatment.

The study showed that compared with their baseline scores, all patients showed similar statistically significant reductions in pain, catastrophizing, anxiety, and depression (P < .001), both at the end of treatment as well as at the 1-year follow-up.

Similarly, both non-CBT groups and the CBT group showed significant improvements in QOL, social functioning, and return to work.

However, at the 3-year follow-up, a statistically significant difference emerged between the groups, with the CBT group having maintained a meaningful and clinical improvement in BDI scores, and both non-CBT groups having reverted to baseline levels.

Pain and catastrophizing improvements were maintained in the CBT group, but had reverted to baseline in the non-CBT groups.

Mounting Evidence

Asked to comment, Magdalena Naylor, MD, PhD, professor of psychiatry and director of the Clinical Neuroscience Research Unit at the University of Vermont’s MindBody Medicine Clinic in Burlington, said there is mounting evidence that CBT can partially reverse abnormal brain anatomy associated with chronic pain, which would explain the persistence of improvements in the CBT group alone.

She said her group’s work with functional magnetic resonance imaging shows that CBT can alter dysfunctional neural circuitry associated with chronic pain, improving both coping and perception of pain, regardless of baseline depressive or anxiety symptoms.

“Our neuroimaging study documented that the gray matter atrophy associated with chronic pain can be reversed by an 11-week group CBT,” she told Medscape Medical News. “We propose that increased gray matter volume in the prefrontal cortex reflects greater top-down control over pain, while changes in pregenual cingulate and somatosensory cortices reflect changes in the perception of noxious signals.”

The study was supported by the Icelandic Center for Research. Dr. Olason and Dr. Naylor have disclosed no relevant financial relationships.

6th World Congress of the World Institute of Pain: Abstract 260. Presented February 5, 2012.

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Send comments and news tips to news@medscape.net.

Because the relationship between low vitamin D levels and depression was stronger in those with a prior history of depression, “it may be more of a marker for relapse than for new-onset,” senior investigator E. Sherwood Brown, MD, PhD, head of the psychoneuroendocrine research program at the University of Texas Southwestern Medical Center, Dallas, told Medscape Medical News.

Dr. E. Sherwood Brown
“Our findings suggest that screening for vitamin D levels in depressed patients — and perhaps screening for depression in people with low vitamin D levels — might be useful,” Dr. Brown added in a university-issued statement.

The study was published in the November 2011 issue of Mayo Clinic Proceedings. It involved 12,594 participants (4005 women and 8595 men) from the prospective Cooper Center Longitudinal Study (CCLS). Participants’ mean age was 51.7 years. A total of 1563 participants had a history of depression; 11,031 did not.

All participants completed baseline examinations that included measurement of serum 25-hydroxyvitamin D [25(OH)D] levels and an assessment using the Center for Epidemiologic Studies Depression Scale (CES-D). A CES-D score of 10 or higher was defined as evidence of depression.

According to the investigators, low vitamin D levels were common in the sample as a whole, with 50.7% of participants having levels in either the deficient range [25(OH]D < 20 ng/mL], according to Institute of Medicine recommendations, or the insufficient range [25(OH)D < 30 ng/mL]. Mean vitamin D levels did not differ significantly between those with and without a history of depression.

Biologically Plausible

In the overall sample, higher vitamin D levels were associated with a decreased risk for current depression, based on CES-D scores. The odds ratio [OR] was 0.92 (95% confidence interval [CI], 0.87 – 0.97; P < .002) for each 10 ng/mL increase in 25(OH)D.

When study participants with and without a history of depression were analyzed separately, the link was stronger in those with a prior history of depression (OR, 0.90; 95% CI, 0.82 – 0.98; P = .02) and was not significant in those without such a history (OR, 0.95; 95% CI, 0.89 – 1.02; P = .17).

It is biologically plausible that vitamin D could have a role in depression, Dr. Brown and colleagues note in their article. Vitamin D “appears to be important for brain health and may be involved in the pathogenesis of depression.” Yet, studies to date have yielded conflicting results.

Three small clinical studies found an association between low 25(OH)D levels and depression, whereas the 5 population-based studies that have explored the association yielded more mixed results.

Positive studies include 1 involving 1282 older adults from Amsterdam that found 14% lower 25(OH)D levels in those with major and minor depression relative to control participants (Hoogendijk et al, Arch Gen Psych, 2008;65:508-512).

A British national survey of older adults showed clinical vitamin D deficiency [25(OH)D level < 10 ng/mL] was significantly associated with depressive symptoms, independent of age, sex, social class, physical health status, and season. Milder states of vitamin D deficiency were not strongly associated with depression in older adults (Psychosom Med , 2010;72:608-612.)

Largest Data Set to Date

Negative studies include 1 from China involving 3262 adults aged 50 to 70 years. In this study, depressive symptoms were less prevalent in those in the top tertile of 25(OH)D concentrations compared with those in the lowest tertile. The association disappeared, however, after controlling for geographic location (Pan et al, J Affect Disord, 2009;118:608-612).

Additionally, a study in 527 Japanese adults aged 21 to 67 years found no significant association between CES-D scores and 25(OH)D levels (Nanri et al, Eur J Clin Nutr, 2009;63:1444-1447).

A study of 3916 adults in the United States showed that 25(OH)D levels and parathyroid hormone levels were not significantly associated with depressive symptoms after adjusting for several potential confounding factors (Zhao et al, Br J Nutr, 20120;104:1696-1702).

The current study, Dr. Brown told Medscape Medical News, represents the largest data set to investigate this issue and, importantly, unlike prior studies, it included a subanalysis by history of depression.

“This subset analysis may shed light on why there were conflicting results in earlier studies because the populations were not assessed on the basis of prior history of depression,” he and his colleagues write.

Nonetheless, he points out that “it’s a cross-sectional study, and the old saying is true that correlation does not mean causation.” Additional research is needed to determine the nature and direction of the association. “Right now, we don’t really know whether low vitamin D makes you depressed or whether being depressed makes you have low vitamin D,” Dr. Brown said.

“Studies looking at vitamin D supplementation in depressed people with low vitamin D to see if that in itself would help with depressive symptoms would help answer some of those questions,” Dr. Brown commented.

Slow Acting

Vijay K. Ganji, PhD, RD, of the College of Health and Human Sciences, Georgia State University in Atlanta, who was not involved in the study, agrees. “We need more randomized trials to see if taking vitamin D really helps lowering the episodes of depression,” he told Medscape Medical News.

To date, there have been only a few small trials of vitamin D supplementation in various depressed populations, with mixed results. In 2008, a placebo-controlled study from Norway found that supplementation with high doses of vitamin D (20,000 or 40,000 IU vitamin D per week) for 1 year seemed to ameliorate depressive symptoms in adults (Jorde et al, J Intern Med, 2008;264:599-609).

In 2009, in a study of 9 women with depressive symptoms and serum vitamin D levels < 40 ng/mL, vitamin D3 supplementation was associated with an increase in serum vitamin D levels (by 27 ng/mL on average) and a decline in depressive symptoms, as measured using the Beck Depression Inventory–II, of an average of 10 points (Shipowick et al, Appl Nurs Res, 2009).

Last year, however, as reported by Medscape Medical News, in a large study of women aged 70 years and older, those who received a high dose of vitamin D3 (500,000 IU) once a year for up to 5 years did not show any improvement in symptoms of depression (Sanders et al, Br J Psychiatry, 2011;198:357-364).

“One thing that complicates trials is that if you give someone vitamin D, it takes a long time for it to have much effect, as vitamin D levels go up and down very slowly; it probably wouldn’t be a fast antidepressant,” said Dr. Brown.

Dr. Brown reports that he has received research support from the National Heart, Lung, and Blood Institute, the National Institute of Mental Health, the National Institute on Alcohol Abuse and Alcoholism, the National Institute on Drug Abuse, the Stanley Medical Research Institute, and AstraZeneca. Dr. Ganji has disclosed no relevant financial relationships.

Mayo Clin Proc. 2011;86:1050-1055. Abstract

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Send comments and news tips to news@medscape.net.

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What are you afraid of?
How long have you been afraid of it?
When is the first memory you have of this fear?
Does anyone in your family has the same fear?
What methods have you tried to overcome your fear?
Did it work?
For how long?

Did you ever think of going to a hypnotherapist to rid yourself of this daily torment?
Hypnosis/Hypnotherapy does work.
Investigate someone qualified in your area and stop the suffering.
Performed correctly by a trained/certified hypnoist, you need not suffer any longer
no matter what your phoia may be.

Mursu J, Robien K, Harnack LJ, Park K, Jacobs Jr DR. Dietary supplements and mortality rate in older women. Arch Intern Med. 2011;171:1625-1633.

Dietary supplements are widely used by older adults, even though the effectiveness of these supplements in preventing illness is questionable. But can dietary supplements actually promote a higher risk for death? A new study suggests that the answer is yes for some of the most common supplements. This Best Evidence Review describes the findings of this study and puts these results in context.

Background

Vitamins and dietary supplements play an important role in the health and healthcare of many adults, and the business of supplements constitutes a multibillion-dollar industry worldwide. Based on the Third National Health and Nutrition Examination Survey, 40% of men and 50% of women older than 60 years of age consume at least 1 vitamin or mineral supplement.[1] A national survey by the US Food and Drug Administration found that 73% of US adults were found to use dietary supplements in 2002, providing annual sale costs in 2005 of over $20 billion.[2,3]

The widespread use of dietary supplements is not supported by practice guidelines. The US Preventive Services Task Force (USPSTF) states that there is insufficient evidence to recommend for or against the use of vitamins A, C, E, or multivitamins with folic acid or antioxidants.[4] Specifically, the USPSTF cites concerns regarding the balance of benefits vs harms of these supplements. The American Medical Association recommends supplements specifically for seniors who have generalized decreased food intake, while the American Dietetic Association advises low-dose multivitamin and mineral supplements depending on individualized dietary assessment.[5] The American Heart Association emphasizes healthy eating patterns rather than supplementation with specific nutrients.[6]

These recommendations against the routine use of supplements are grounded in good evidence. A Cochrane intervention review of 77 randomized controlled trials with 232,550 participants found no evidence to recommend antioxidant supplementation for primary or secondary prevention of mortality.[7] Moreover, there is the possibility of harm related to the use of some supplements. For example, the Alpha-Tocopherol Beta-Carotene Cancer Prevention Trial demonstrated that beta-carotene supplements increased the risk for lung cancer among male smokers.[8]

The Study

The study under discussion by Mursu and colleagues raises even more concerns regarding the safety of dietary supplements. The study enrolled 41,836 women between the ages of 55 and 69 years in 1986. Women completed validated food frequency questionnaires at baseline and in 2004, and the use of any of 15 different dietary supplements was queried in 1986, 1997, and 2004.

The main study outcome was the relationship between supplement use and all-cause mortality, which was assessed from state and national registries. Researchers adjusted this result to account for the following factors: age, energy intake, educational level, place of residence, smoking status, body mass index (BMI), waist-to-hip ratio, physical activity, diet composition, alcohol consumption, the use of estrogen therapy, and the presence of diabetes mellitus and hypertension. Serum lipids or blood pressure were not measured as part of the study.

A total of 38,772 women provided study data. The mean age of participants at enrollment was 61.6 years, and over 99% of women were white. The average BMI was 27 kg/m2 at baseline and follow-up in 2004, and the majority of women were physically active. The average consumption of fruits and vegetables exceeded 6 servings per day during the study period. Out of this population, 36.8% of women reported hypertension, and 6.8% had diabetes.

The use of dietary supplements increased with time; 62.7% of women reported use of at least 1 supplement in 1986, and this figure rose to 85.1% by 2004. The most commonly used supplements were calcium, multivitamins, vitamin C, and vitamin E.

Women who used supplements generally had better health characteristics compared with nonusers. They had higher educational status, lower BMI and waist-to-hip ratio, and lower rates of diabetes and hypertension compared with nonusers, and they were also less likely to smoke and had a healthier dietary profile. Supplement users were also more likely to use estrogen therapy compared with nonusers.

There were 15,594 deaths (40.2% of the study cohort) during a mean follow-up period of 19 years. In fully adjusted models, the use of multiple supplements was associated with a higher risk for mortality, including multivitamins (hazard ratio [HR], 1.06; 95% confidence interval [CI], 1.02-1.10), vitamin B6 (1.10; 1.01-1.21), folic acid (1.15; 1.00-1.32), iron (1.10; 1.03-1.17), magnesium (1.08; 1.01-1.15), zinc (1.08; 1.01-1.15), and copper (1.45; 1.20-1.75). The use of vitamin A, beta-carotene, and selenium were associated with nonsignificant trends toward a higher risk for mortality, and the use of vitamins C, D, and E had nearly no effect on mortality. In contrast, taking calcium supplements significantly reduced the risk for mortality (HR, 0.91, 95% CI, 0.88-0.94).

Researchers performed a number of additional analyses of the data to evaluate the validity of their outcomes. The main study results were not significantly changed after excluding women with a known history of cardiovascular disease or diabetes at baseline. An analysis using shorter follow-up intervals also confirmed the findings of higher risks for mortality with the use of iron. Moreover, there was evidence of a positive dose-response relationship between iron supplements and the risk for mortality. However, no dose-response effect was found for vitamins A, C, D, and E as well as the minerals selenium and zinc.

Commentary

The principal limitation of the current study was its observational nature, which leaves open the possibility of confounding by indication. Specifically, there is the possibility that women with higher risks for mortality or who developed serious chronic illnesses as they grew older had a wider use of supplements.

Nonetheless, it is worth remembering that women who used supplements had superior health characteristics compared with nonusers. Therefore, supplement users should have experienced a lower risk for death overall. While it is plausible that some women started taking multiple supplements when confronted with news of a severe illness, such as cancer, it is hard to imagine that this practice alone was common enough to tip the scales toward a higher overall risk for mortality associated with the use of supplements.

One of the more fascinating findings in this very interesting study is the higher risk for mortality associated with the use of iron supplements. Higher levels of serum iron and transferrin saturation have been associated with a lower risk for mortality.[9,10] However, another study found that men with a serum ferritin level of 200 mcg/L or more experienced more than a twofold increased risk for myocardial infarction.[11] Finally, both increased serum iron levels and higher transferrin saturation have been associated with an increased risk for death due to cancer.[12] Of course, in this study, women with existing anemia due to any number of chronic serious medical conditions, such as cancer or chronic kidney disease, could have been told to take iron supplements by their physician, and these illnesses might account for their higher mortality. In any case, it appears that the role of iron among adults without iron deficiency is controversial, and there is little data from clinical trials to suggest a benefit to the routine use of iron supplementation among adults.

An additional interesting finding in the current study is the effect of calcium, but not vitamin D, supplements in reducing the risk for mortality. This is another controversial area because calcium supplements have been implicated in promoting a higher risk for myocardial infarction among women.[13] However, in the Women’s Health Initiative trial, the use of calcium plus vitamin D reduced the risk for some types of cancer without an overall effect on the risk for mortality.[14]

The findings from the current study offer several lessons to physicians. First, physicians need to pay close attention to nonprescription therapies used by patients. These treatments are routinely omitted from the history of many patients, but the current study suggests that physicians make such errors at the peril of their patients.

Physicians should be a trusted resource for patients interested in dietary supplements. We can help balance self-treatment practices that might be effective against those that appear harmful or excessive. The findings of the current study should be sobering for the most ardent supporters of supplements, and patients need to understand the potential risks inherent in the treatment choices they make.

So… You decide and talk to your doctor….

Nearly half of older adults routinely use dietary supplements, with higher rates of use among women compared with men.
The routine use of many dietary supplements is discouraged in practice guidelines.
The use of multivitamins, vitamin B6, folic acid, iron, magnesium, zinc, and copper was associated with a higher risk for mortality among older women in the current study.
Conversely, calcium supplements were associated with a lower risk for mortality.
Physicians need to analyze nonprescription therapies used by patients and warn them of potential harms associated with the use of supplements.

References

Glade MJ. National Institutes of Health Conference: dietary supplement use in the elderly. Nutrition. 2003;19:981-987. Abstract
Sadovsky R, Collins N, Tighe AP, et al. Patient use of dietary supplements: a clinician’s perspective. Curr Med Res Opin. 2008;24:1209-1216. Abstract
Dwyer JT, Picciano MF, Betz JM, et al. Progress in developing analytical and label-based dietary supplement databases at the NIH Office of Dietary Supplements. J Food Composition Analysis. 2008;21:S83-S93.
US Preventive Services Task Force. Routine vitamin supplementation to prevent cancer and cardiovascular disease: recommendations and rationale. Ann Intern Med. 2003;139:51-55. Abstract
Tripp F. The use of dietary supplements in the elderly: current issues and recommendations. J Am Diet Assoc. 1997;97:S181-S183. Abstract
Eilat-Adar S, Goldbourt U. Nutritional recommendations for preventing coronary heart disease in women: evidence concerning whole foods and supplements. Nutr Metab Cardiovasc Dis. 2010;20:459-466. Abstract
Bjelakovic G, Nikolova D, Gluud LL, et al. Antioxidant supplements for prevention of mortality in healthy participants and patients with various diseases. Cochrane Database Syst Rev. 2008;16:CD007176.
Albanes D, Heinonen OP, Huttunen JK, et al. Effects of alpha-tocopherol and beta-carotene supplements on cancer incidence in the Alpha-Tocopherol Beta-Carotene Cancer Prevention Study. Am J Clin Nutr. 1995;62:1427S-1430S. Abstract
Sempos CT, Looker AC, Gillum RF, et al. Body iron stores and the risk of coronary heart disease. N Engl J Med. 1994;330:119-124.
Corti MC, Guralnik JM, Salive ME, et al. Serum iron level, coronary artery disease, and all-cause mortality in older men and women. Am J Cardiol. 1997;79:120-127. Abstract
Salonen JT, Nyyssönen K, Korpela H, et al. High stored iron levels are associated with excess risk of myocardial infarction in eastern Finnish men. Circulation. 1992;86:803-811. Abstract
Wu T, Sempos CT, Freudenheim JL, Muti P, Smit E. Serum iron, copper and zinc concentrations and risk of cancer mortality in US adults. Ann Epidemiol. 2004;14:195-201. Abstract
Bolland MJ, Grey A, Avenell A, Gamble GD, Reid IR. Calcium supplements with or without vitamin D and risk of cardiovascular events: reanalysis of the Women’s Health Initiative limited access dataset and meta-analysis. BMJ. 2011;342:d2040.
Bolland MJ, Grey A, Gamble GD, Reid IR. Calcium and vitamin D supplements and health outcomes: a reanalysis of the Women’s Health Initiative (WHI) limited-access data set. Am J Clin Nutr. 2011;94:1144-1149. Abstract

A report conducted by the Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Survey on Drug Use and Health shows the rate of mental illness among those aged 18 to 25 years was 29.9% vs 14.3% among Americans aged 50 years and older.

In addition, adult women were more likely than their male counterparts to have experience mental illness in the past year — 23% vs 16.8%.

For the purposes of the survey, mental illness was defined as having had a diagnosable mental, behavioral, or emotional disorder (excluding developmental and substance use disorders) in the past year on the basis of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria.

The survey also showed that 11.4 million adults (5% of the US adult population) suffered from a serious mental illness, which was defined as a mental illness that resulted in serious functional impairment that substantially interfered with or limited 1 or more major life activities.

“Mental illnesses can be managed successfully, and people do recover. Mental illness is not an isolated public health problem. Cardiovascular disease, diabetes, and obesity often co-exist with mental illness and treatment of the mental illness can reduce the effects of these disorders. The Obama Administration is working to promote the use of mental health services through health reform. People, families and communities will benefit from increased access to mental health services,” SAMHSA Administrator Pamela S. Hyde said in a statement.

According to SAMHSA, the economic impact of mental illness in the United States was approximately $300 billion in 2002. The World Health Organization reports that mental illness accounts for more disability in developed countries than any other group of illnesses, including cancer and heart disease.

Further, according to the report, approximately 8.7 million Americans considered suicide during the past year. Of these, 2.5 million made suicide plans, and 1.1 million attempted suicide.

The report also showed that rates of substance abuse among adults who had experienced mental illness within the past year were 3 times higher compared with those who had no mental illness in the past year — 20% vs 6.1%.

The rate of substance abuse or dependence was 25.2% among those with serious mental illness.

The survey also revealed that 1.9 million youth aged 12 to 17 years (8% of this population) had experienced a major depressive episode in the past year.

It also showed people in this age group who had experienced major depression in the past year had more than double the rate of illicit drug use compared with their counterparts who were without depression — 37.2% vs 17.8%.

“These data underscore the importance of substance abuse treatment as well,” said Hyde.

The complete survey findings from this report are available on the SAMHSA Web site.

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Send comments and news tips to news@medscape.net.

“The current paradigm when we’re thinking of prevention is to assess risk over the next 10 years using something like the Framingham risk score . . . and that’s supposed to guide decision making,” senior author Dr Donald Lloyd-Jones (Northwestern University, Chicago, IL) told heartwire . “That’s a perfectly valid approach, but that’s an incomplete way to represent risk to our patients.”

The new results from the Cardiovascular Lifetime Risk Pooling Project, published in the January 26, 2012 issue of the New England Journal of Medicine, show that risk in people in their 40s or 50s with one or two risk factors such as hypertension or high cholesterol ramps up sharply over their lifetime. “So there’s a disconnect between the short-term risk information that we routinely calculate and what we know, especially with this paper, are long-term risks that are dramatically higher.

“This isn’t necessarily news, but this is a new way to look at it that I hope will grab people’s attention more,” he said. “If I can tell you that, sure your 10-year risk may be low, but based on your profile right now, your lifetime risk might be 50% or more of having a major heart attack or stroke before you die. . . . I hope that’s a little more of a motivating message.”

The study analyzed 18 cohort studies with 257 384 patients, including black and white men and women across a 50-year range of birth cohorts. The studies measured important cardiovascular risk factors at ages 45, 55, 65, and 75. The risk factors measured include smoking, cholesterol levels, diabetes, and blood pressure.

Calculation of lifetime risks of cardiovascular events shows that the presence of even one risk factor in middle age can dramatically increase one’s lifetime risk of cardiovascular disease compared with no risk factors, and the risk goes up with each additional risk factor.

Across the whole meta-analysis, participants with no risk factors at age 55 (total cholesterol level: <180 mg/dL; blood pressure: <120 mm Hg systolic and 80 mm Hg diastolic; nonsmoking; nondiabetic) had drastically better odds of avoiding death from cardiovascular disease through the age of 80 than participants with two or more major risk factors (4.7% vs 29.6% among men and 6.4% vs 20.5% among women).

People with an optimal risk-factor profile also had lower lifetime risks of fatal coronary heart disease or nonfatal MI (3.6% vs 37.5% among men, <1% vs 18.3% among women) and fatal or nonfatal stroke (2.3% vs 8.3% among men, 5.3% vs 10.7% among women), compared with those with two or more risk factors.

Similar Risks Across Race

The lifetime risk of death from cardiovascular disease and coronary heart disease or of nonfatal MI were generally about twice as high among men than among women, but the lifetime risks of fatal and nonfatal stroke were similar for men and women.

Also, the trends shown in the study were similar for both white and black people and did not change across the diverse birth-year cohorts. “[We saw] remarkably similar results for whites and blacks in the same risk-factor categories, but there’s a back story there that is a bit nuanced and is, unfortunately, bad news,” he said. Black people have, on average, a greater burden of cardiovascular risk factors than white people, but black people, especially men, are at higher risk to die at younger ages from other causes and less likely to live out their “cardiovascular destiny.” “So, at the end of the day, we found that the lifetime risks for whites and blacks are remarkably similar, but they arrive at those rates for somewhat different reasons. And it’s important to say that it’s not ‘African Americaness’ that’s creating that situation. It’s largely socioeconomic factors.”

Lloyd-Jones added that the large studies of Hispanic patients do not have enough follow-up yet to provide robust lifetime-risk data, but he hopes that data will be available eventually. He expects long-term cardiovascular risk data on Asian Americans will be available soon.

Now Is the Time to Address Risk Factors

“If we can get our young adults living healthier lifestyles and more of them into middle age with optimum [risk-factor] levels, that would be fabulous news,” Lloyd-Jones said. “But if you are middle-aged and you do have a risk factor or two or more, it’s really time to address those. You must get [in touch] with your doctor, understand your numbers, and understand where your risk is coming from. It’s almost certainly going to require help to control those [risk factors], but just as important is partnering lifestyle changes to get control of those things too. . . . It’s a critically important partnership. . . . You can’t put the horse completely back in the barn, but you can do a lot to mitigate those risks if you get serious about it.”

Commenting on the study, epidemiologist Dr Aaron Folsum (University of Minnesota, Minneapolis) told heartwire ,”The data suggest that the US could largely eliminate coronary heart disease if, through lifestyle, we can enable adults to avoid risk factors in the first place. Coronary heart disease is a preventable disease. We need to be more aggressive at fostering healthy lifestyles in young people. This paper indicates targeting young people should pay off in the long run, not just in less CHD, but, by extrapolation, also in reduced health costs.”

This study was supported by grants from the National Heart, Lung, and Blood Institute. None of the authors have any

References
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