Wednesday, April 28, 2010


For the first time, a new study examines how cell phone usage distracts preadolescent children while crossing the street.
In “Effects of Cell Phone Distraction on Pediatric Pedestrian Injury Risk,” researchers from the University of Alabama at Birmingham used data from children aged 10 to 11 years in simulated road crossings in an interactive, virtual pedestrian environment.
Distraction was only by cell phone conversation with a research assistant, not by other commonly used devices such as portable audio players or text messaging. Results indicate that when distracted, children were less attentive to traffic, left less time between themselves and the next oncoming vehicle, and were involved in more collisions and near misses.
While cell phones offer convenience and safety to families, the study authors indicate that pedestrians - especially children - are likely to be more distracted than adults, and should limit cell phone use while crossing the street.

news releases and briefs on statements appearing in the February ssue of Pediatrics, the peer-reviewed, scientific journal of the American Academy of Pediatrics (AAP).
January 26, 2009, 12:01 am (ET)

Saturday, April 24, 2010

Achieving Your Goals - Staying Positive

By: Will Edwards

Having unclear objectives or unrealistic expectations are sure-fire ways of sabotaging your goal-achieving, but so too are lack of self-belief, fear of failure and lack of motivation. If you have defined your goals properly using the SMART procedure, they should indeed be clear and realistic. In this article, we are going to consider the importance of staying positive in relation to goal-achieving.

Sometimes, in my workshops, I ask people if they are optimists or pessimists. Generally, what happens is that the optimists will happily reveal themselves, but the pessimists are usually a little more reticent; indeed, often preferring to use the term ‘realist’ rather than ‘pessimist’. I think this is completely understandable: no one, to my knowledge, has ever written a book on the subject of the power of negative thinking; but, by contrast, there are very many books on the market that deal with the power of positive thinking.

Every attitude of mind we take – and optimism and pessimism are exactly that – is a choice that we make; even if it does not feel like we are making a choice. But, after years of habitually adopting a pessimistic mindset, it can be hard to dump this habit in favour of adopting the new, empowering habit of optimism. Why? Because, pessimists have good reason – or perhaps we should say justification - for being pessimistic. Pessimists simply believe they are generally right – things don’t usually go their way.

Of course, optimists believe exactly the same thing – things do generally go right for optimists. Both optimists and pessimists and making use of exactly the same principle to attract outcomes into their lives. It cuts both ways: you can indeed attract both good and bad outcomes through your attitude; and that’s why it is so important to try to foster a positive outlook on life.

There are many ways to do this, but one we will briefly consider here is the use of affirmation. An affirmation is a sentence that declares something to be true. Generally such sentences begin with the words ‘I am’ for example: I am calm; I am confident; I am in control. If you are a pessimist, try to open your mind to the possibility of change; and then try making use of positive affirmations like these.

All you need do is repeatedly say the sentence to yourself. Try this three times per day; and on each occasion, say each affirmation three times with purpose. It may sound silly or even ridiculous, but such words have the power to change our attitudes and the outcomes we attract into our lives are, to a very great extent, a product of attitude.

Finally, even if you are an optimistic person, you should still practice using affirmations. Even optimists don’t always manage to stay positive. We all lose sight of our self-belief and motivation from time to time and have to sometimes contend with the fear of failure too. So remember to make use of this very powerful technique to help you to stay positive – it is a vital ingredient for achieving those important goals.

Smart Articles @

Preteen Marijuana Use Linked to Comorbid Substance Abuse and Psychological Disorders

From Medscape Medical News
Barbara Boughton

April 22, 2010 (San Francisco, California) — One of the largest studies to date of preteen marijuana users has found that those who start smoking the drug before age 13 years have an increased risk for comorbid substance abuse and psychosocial and legal problems, according to research presented here at the American Society of Addiction Medicine 41st Annual Medical-Scientific Conference.

In the study of 136 substance-dependent girls and boys, those who started using marijuana as a preteen were more likely to have a history of posttraumatic stress disorder (PTSD), suicide attempts, and traffic violations and to be dependent on other drugs.

"Our study supports a significant relationship between preteen marijuana use and poor outcomes. Its strengths include the fact that it is the largest clinical sample to date balanced by gender," lead researcher Youssef Mahfoud, MD, from the Department of Psychiatry at Case Western Reserve and University Hospitals Case Medical Center, Cleveland, Ohio, told Medscape Psychiatry.

First Drug of Abuse

In the study of substance-dependent youths in treatment (age range, 14 - 18 years), characteristics of those who started using marijuana before age 13 years were compared with those who started using the drug after that age.

In comparison with those who started as teenagers, children who started using marijuana as preteens were more likely to be dependent on hallucinogens (44% vs 27%; P < .05) and to have comorbid substance abuse disorders (M = 3.42 vs 2.59; P < .05).

Those who began using marijuana before age 13 years also had higher rates of PTSD (16% vs 6%; P < .05), a history of attempting suicide (32% vs 19%; P < .05), and a history of traffic violations (7% vs. 1%; P < .05). In addition, preteen marijuana users were also more likely to have used marijuana as their first drug of abuse (55%), rather than alcohol.

To determine whether there were any factors that predicted preteen marijuana use, the authors also looked at ethnicity, race, parental education, parental substance abuse history, and characteristics of preteen marijuana users on admission to substance abuse programs.

Those who started using marijuana as preteens were more likely to be younger when entering treatment and to be marijuana dependent on admission. There was also a trend toward a greater risk for nicotine addiction, Dr. Mahfoud said.

Preteen marijuana abusers were more likely to be Hispanic (14% vs 3%). Those who used marijuana as a preteen also tended to have parents with less education. Sixty percent of those who started using marijuana as a preteen had parents with just a junior high education compared with 47% of those who started as teenager.

Important Implications

The study has important implications for societal interventions, Dr. Mahfoud said. Preteens with parents who have less education, who are vulnerable because of PTSD or suicide attempts, or who are identified as heavy nicotine users might be targeted for interventions aimed at preventing marijuana use, he added.

The researchers plan to follow the sample in the study to see whether they find an improvement in outcomes for preteen marijuana users after substance abuse treatment and to gauge whether preteen marijuana use is associated with less successful response to substance abuse treatment therapies.

"Addiction is a disease of adolescent onset when children's brains are growing rapidly," said Gavin Bart, MD, director of the Division of Addiction Medicine at the Hennepin County Medical Center and assistant professor of medicine at the University of Minnesota Medical School, Minneapolis, Minnesota. Dr. Bart chaired the American Society of Addiction Medicine meeting and moderated the session at which the Case Western Reserve study was presented.

"So it's extremely helpful for those who treat substance abuse to know what the risk factors are for early marijuana use, and to use that information to identify patients at risk," he added.

"This is one of the first studies to look at preteens in clinical treatment, and to show that those who start using marijuana as a preteen have more problems controlling marijuana use and other drugs later in life. It reinforces the concept that prevention does not need to start in junior or senior high, but in grade school," commented Timothy Fong, MD, assistant professor of psychiatry and codirector of the addiction medicine clinic at the University of California–Los Angeles. "However, this is not evidence that marijuana is a gateway drug," he cautioned. "It does not show causality."

The study was supported by grants from the National Institute on Alcohol Abuse and Alcoholism and the John Templeton Foundation. Dr. Fong has disclosed being on speakers' bureaus for Reckitt-Benckiser, Pfizer Pharmaceuticals, and Lilly Pharmaceuticals. Dr. Mahfoud and Dr. Bart have disclosed no relevant financial relationships.

American Society of Addiction Medicine 41st Annual Medical-Scientific Conference: Abstract 2. Presented April 16, 2010.

Friday, April 16, 2010

Standardized Screening May Help Identify Suicidal Adolescents

From Medscape Medical News
Laurie Barclay, MD

April 15, 2010 — Standardized screening for suicide risk in primary care can detect adolescents with suicidal ideation, allowing referral to a behavioral healthcare center before a fatal or serious suicide attempt is made, according to the results of a study reported online April 12 and published in the May print issue of Pediatrics.

"Several associations and federal agencies have called for depression screening in pediatric primary care," writes Matthew B. Wintersteen, PhD, from Thomas Jefferson University in Philadelphia, Pennsylvania. "Screening for suicide risk is a natural adjunct to this call....To our knowledge, this is the first study to prospectively examine the impact of standardized screening for suicide risk on detection and referral rates in pediatric primary care."

The goals of the study were to evaluate whether brief standardized screening for suicide risk in pediatric primary care practices could improve detection of youth with suicidal ideation, maintain improved rates of detection and referral, and be duplicated in other practices.

Two primary care clinics (clinic A and clinic B) were selected as intervention clinics, and a third clinic (clinic C) asked about participating in the study and was offered the intervention. At these 3 clinics, physicians underwent brief training in detecting suicide risk, and 2 standardized questions for adolescents aged 12.0 to 17.9 years were added to their existing electronic medical chart psychosocial interview. Data without identifiers were extracted during intervention trials and for the same dates of the preceding year, and referral rates were determined from social work records.

The intervention was associated with doubling of the rates of inquiry about suicide risk, which resulted in a 219% increase overall (clinic A odds ratio [OR], 2.04; 95% confidence interval [CI], 1.56 - 2.51; clinic B OR, 3.20; 95% CI, 2.69 - 3.71; and clinic C OR, 1.85; 95% CI, 1.38 - 2.31).

In clinic A, the rate of case detection increased nearly 5-fold (OR, 4.99; 95% CI, 4.20 - 5.79), was maintained for a 6-month period after the intervention was implemented (OR, 4.38; 95% CI, 3.74 - 5.02), and was replicated in both clinic B (OR, 5.46; 95% CI, 3.36 - 7.56) and clinic C (OR, 3.42; 95% CI, 2.33 - 4.52).

Across all 3 clinics, case detection rate increased by 392%. The rate of increase of referral rates of suicidal youth to outpatient behavioral healthcare centers was commensurate to that of the detection rates.

"Standardized screening for suicide risk in primary care can detect youth with suicidal ideation and prompt a referral to a behavioral health care center before a fatal or serious suicide attempt is made," Dr. Wintersteen writes.

Limitations of this study include suicidal ideation based on history, not necessarily on present thoughts; and inability to determine the impact of the brief training in suicide risk.

"The findings from this study are particularly timely after the recent recommendation of the US Preventive Services Task Force to routinely screen youth for a major depressive disorder," Dr. Wintersteen concludes.

"In addition, the American Academy of Child and Adolescent Psychiatry along with the American Academy of Pediatrics Task Force on Mental Health also released a joint article in which routine behavioral health screening in primary care was recommended....Both reports cautioned against screening when psychotherapy followup was not readily available."

The American Foundation for Suicide Prevention supported this study. Dr. Wintersteen has disclosed no relevant financial relationships.

Pediatrics. Published online April 12, 2010. Abstract

Monday, April 12, 2010

Congenital Heart-Defect Risk Goes up With Severity of Maternal Obesity: Population Study

From Heartwire
Steve Stiles

April 12, 2010 (Bethesda, Maryland) — The risk of obese women bearing children with congenital heart defects climbs with increasing maternal body-mass index (BMI); this applies to such defects in general but also for many in particular, suggests a population-based case-control study from New York.

The jump in risk was 15% for all obese women, those with a BMI >30, and double that for those with a BMI >40, compared with women of normal weight. Women who were simply "overweight" or "underweight" showed no significant change in overall risk. The analysis was published online April 7, 2010 in the American Journal of Clinical Nutrition.

Maternal obesity is a well-established risk factor for some congenital malformations, including, a lot of evidence suggests, heart defects, lead author Dr James L Mills (National Institute of Child Health and Human Development, Bethesda, MD) observed for heartwire . "Our study goes beyond that to show significantly increased risks for a number of individual [heart] defects."

But its most important finding, according to Mills, is that the greater the obesity, the higher the risk. It potentially means that obese women who lose weight also diminish their risk of bearing children with heart defects, something that should be explored further in trials, he said.

The analysis comprised 7392 children born with heart defects and their mothers along with 56 304 control cases without such defects, who were among a million and a half children born in upstate New York from 1993 to 2003.

The risk of any defect was significantly increased among women in both categories of obesity severity by BMI. The trend of risk worsening with obesity was significant at p<0.0001.

Odds Ratio (OR)* for Birth of Child With Heart Defect by Maternal BMI Weight Category, vs Reference BMI 19–24 Maternal weight group OR (95% CI) p
Underweight, BMI <19 1.00 (0.91–1.10) 0.97
Overweight, BMI 25–29 1.00 (0.94–1.06) 0.96
Obese, BMI 30–39 1.11 (1.04–1.20) 0.004
Morbidly obese, BMI >40 1.33 (1.15–1.54) 0.0001
All obese, BMI >30 1.15 (1.07–1.23) <0.0001
*Adjusted for maternal age, education, race, smoking status, and type of healthcare coverage

BMI=body mass index (kg/m2)

Women with a BMI of 30 to 39, those with a BMI >40, and both groups combined, compared with those with a BMI of 19 to 24, showed significantly increased individual risks of a wide range of congenital defects, including all septal and conotruncal defects, all left and right ventricular outflow-tract obstructions, and cases of hypoplastic left-heart syndrome, aortic-valve stenosis, pulmonic-valve stenosis, tetralogy of Fallot, and double-outlet right ventricle.

Underweight or simply overweight women weren't at increased overall risk of defects compared with those of normal weight. However, those with a BMI <19 had an increased risk of bearing children with aortic-valve stenosis (odds ratio 1.75; 95% CI 1.09–2.81; p=0.02).

Overweight women also had an exception, a significantly higher risk of offspring with tetralogy of Fallot (OR 1.28; 95% CI 1.01–1.62; p=0.045). But their risk of having children with total anomalous pulmonary venous return (p=0.02) or double-outlet right ventricle (p=0.046) was significantly reduced.

The databases used for the analysis didn't include data on any potentially teratogenic drugs the mothers were taking; the authors acknowledge that as a weakness of the study.

According to the authors, women with diabetes, a well-recognized teratogen, had been excluded from the study. The relationship between BMI and defects strengthened somewhat in a separate analysis that included diabetic women, but the study's overall findings were "not materially changed," they write.

Mills said the observed effect of increased BMI on congenital heart defects resembles the corresponding effects of maternal diabetes in at least one distinctive way: both conditions are associated with a range of metabolic abnormalities, and both appear to affect a variety of embryonically separate heart structures.

"I suspect that we're seeing the effects of not one, but probably more than one aberration in the metabolic milieu. It may be hyperglycemia, it may be lipid abnormalities, it may be insulin resistance, it may be inflammation, but I think it’s an intriguing area for further investigation."

Thursday, April 8, 2010

Current Philosophy About Hitting Children

From Medscape Nurses > Viewpoints
Marilyn W. Edmunds, PhD, CRNP

J Pediatr Health Care. 2010;24:103-107

Article Summary
Over a century ago, it was common practice for men to hit their wives as a way of teaching them, gaining compliance, or chastising them. Today, this practice is clearly identified as abuse and is illegal. This cultural change in what was acceptable behavior came about slowly, as part of the concept of protection of human rights and acceptance that women were not the chattel of their husbands. Although both cultural mores and legal behavior in dealing with women have changed, the author of the present article states, "[I]ronically, the only humans it is still legal to hit are the most vulnerable members of our society -- those we are charged to protect -- children."This article discusses the position of the US government on corporal punishment (CP) of children.

"Spanking," "paddling," and "whupping," terms commonly used to describe punishment of children are, by definition, forms of hitting, either with a hand or with an instrument. Hitting children is at least as cruel and harmful an act as hitting adult women. It is an act of violence and a clear violation of the child's human rights.''

In the United States, it is against the law to hit older adults, prisoners, and criminals, and it is illegal for adults to hit children in school in more than half of US states, However, it is not illegal for parents to hit their children at home, largely "because of strongly held beliefs about parents' rights to discipline as well as a society view of parents as 'owners' of children."

The article by Knox summarizes numerous research studies that demonstrate strong associations between CP of children and later development of maladaptive behavior patterns, such as aggression and delinquency, and concludes that CP is probably more harmful than helpful. A meta-analysis of 80 studies shows that spanking and other forms of CP are associated with increased aggressive and delinquent behavior in children, poorer parent/child relationships, worse mental health in children, increased physical abuse of children, increased adult aggression and criminal behavior, poorer adult mental health, and increased later risk for abusing one's spouse or child. CP is often part of a larger pattern of abuse; it is also often the first behavior in a cycle of abuse of children, and the youngest children tend to suffer the most abuse.

Parents who practice CP are not aware of or fail to use alternatives that are more effective. Research documents that spanking does not have long-term positive effects on a child's adaptive behavior. When children are hurt physically, their brains and bodies become physiologically aroused, causing them to focus almost entirely on themselves and not on what they are supposed to be learning. Thus, researchers argue that children who are hit are, paradoxically, less likely to learn the lessons parents are trying to teach.

Many organizations, including the National Association of Pediatric Nurse Practitioners and the United Methodist Church, have taken a stand against CP. The article describes professional and international progress on ending CP, citing 24 countries that have enacted legislation to abolish all CP of children. In many countries, the ban on CP in the home is primarily educational and does not include a provision for criminal penalties. What has developed in these countries is a change in the cultural expectations about behavior toward children.

In 2006, the United Nations (UN) adopted a policy banning CP of children, maintaining that "No violence against children is justifiable; all violence against children is preventable."Leading reformers in the UN are outraged that only the United States and Somalia failed to ratify UN documents against CP in children, even though the death rate from maltreatment for US children younger than 15 years is 10 to 15 times higher than the average death rate in other wealthy nations.[1]

The author makes an appeal for efforts that hold promise for preventing child maltreatment, such as parent education and removal of social sanctions for hitting children. A key step in treating violent individuals is to confront, dispute, and develop alternatives to beliefs that support violence. The author suggests development of programs and campaigns to educate people about how to avoid hitting children. Many parents and caregivers are need help with discipline, and healthcare providers, such as pediatric nurse practitioners, can be highly effective educators for parents. These clinicians should provide anticipatory guidance as a preventive method of securing nonviolent parenting skills. Nurse practitioners are encouraged to teach parents about the potential adverse outcomes of CP and have parents commit to never hitting, shaking, or spanking their children.

This article emphasizes a problem that may not be a dominant clinical concern. I like the emphasis on anticipatory guidance for parents, assuming that most parents will experience times when they are frustrated and angry at their children and need to learn another way to respond. Helping parents think in advance about what they must not do and make decisions about alternatives addresses the problem before it happens. Early teaching of parents also has a chance of reaching parents with the message before they have adopted abusive patterns about which to feel guilty.

Changing the cultural behaviors about what was acceptable for men in their relationships with women took a long time. Although we might also accept that it will take a similar length of time to change societal behavior towards children, the first step is to discuss the problem more broadly. I think that awareness of failure of the United States to support the efforts of the UN and other countries in limiting abuse of children should generate some discussion and perhaps create additional positive action.



Wednesday, April 7, 2010

Maternal Smoking in Pregnancy Linked to Increased Risk for Psychotic Symptoms in Adolescents

Pregnant? Please do not smoke! Your Baby's brain's at stake.

From Medscape Medical News
Deborah Brauser

October 12, 2009 — The maternal use of tobacco while pregnant is associated with an increased risk for psychotic symptoms such as hallucinations and delusions in their children, with evidence of a dose-response effect, according to results from a large cohort study published in the October issue of the British Journal of Psychiatry.

"These findings indicate that the risk factors for development of non-clinical psychotic experiences may operate during early development," write Stanley Zammit, PhD, clinical senior lecturer in psychiatric epidemiology in the Department of Psychological Medicine at Cardiff University in Wales and the University of Bristol in the United Kingdom, and colleagues.

"This is the only study to really try and tease out to what extent this association is causal rather than being confounded or explained by other factors," Dr. Zammit told Medscape Psychiatry.

"There could still be confounding, of course, but this makes us a bit more confident that the association may be due to the effects of nicotine on the developing brain in the uterus," he added.

Smoking While Pregnant Common in the United Kingdom

"In the [United Kingdom], 15-20% of women continue to smoke throughout their pregnancy, and although cannabis use is less common, some alcohol intake during pregnancy is reported by most women," write the study authors.

They note that past studies have shown an association between maternal smoking and, to a lesser extent, maternal cannabis and alcohol use and adverse long-term effects on their offspring, including reduced cognitive ability and increased incidence of both attention-deficit/hyperactivity disorder and conduct disorder during childhood and adolescence.

However, the authors report that there have been very few epidemiological studies showing causal inference between maternal substance abuse and childhood psychopathology.

"Our aim [in this study] was to investigate, in a longitudinal design, whether maternal tobacco, cannabis, or alcohol use during pregnancy were independently associated with risk of the offspring developing psychotic symptoms during early adolescence," write the study authors.

"I'm interested in the effects of substance use on mental health outcomes," explained Dr. Zammit. "In animals, there is good evidence that nicotine in utero can disrupt the normal development/function of the fetal brain, so it seems very plausible that this could happen in humans and have subtle effects that are not noticeable early on in life but are only expressed later during development."

The investigators examined data from the Avon Longitudinal Study of Parents and Children, including 14,062 adolescents born between April 1991 and December 1992.

Dr. Zammit and his team focused their evaluation on a cohort of 6356 adolescents, all 12 years of age, who participated in a semistructured interview for psychosis-like symptoms (PLIKS). This interview included 12 core questions, which covered hallucinations, delusions, and experiences of thought interference during the past 6 months.

Data on parental substance use were obtained from self-report postal questionnaires completed by the mother at 8, 18, and 32 weeks of pregnancy and at 2, 21, 33, and 47 months after giving birth, and from the father at 18 weeks of pregnancy and at 2, 8, and 21 months after birth.

Of these mothers, 1219 (19.3%) smoked tobacco, 4372 (70.0%) drank alcohol, and 157 (2.5%) used cannabis at least once during pregnancy.

Maternal Tobacco Use Increased Risk for PLIKS

At the end of this cohort study, a total of 734 of the children (11.6%) were rated as having suspected or definite PLIKS, and 300 of these children (4.7%) had definite symptoms.

The investigators found that maternal tobacco use during pregnancy was strongly associated with an increased risk for suspected or definite PLIKS in their offspring (adjusted odds ratio [OR], 1.20; 95% confidence interval [CI], 1.05 – 1.37; P = .007). This risk further increased based on frequency of tobacco use.

In addition, "the offspring of mothers who used tobacco only in their third trimester had a greater risk of developing any suspected or definite PLIKS than offspring whose mothers smoked only in the first trimester (OR, 2.1; 95% CI, 0.96-4.59; P = 0.063)," report the authors.

After adjusting for confounders and maternal smoking during pregnancy, paternal smoking during pregnancy, maternal smoking postpregnancy, or maternal cannabis use were not associated with any suspected or definite PLIKS.

Although maternal alcohol use did show a nonlinear association with psychotic symptoms, this effect was found almost exclusively in the offspring of the 25 women who drank more than 21 units weekly.

Future Studies Needed

"Maternal smoking during pregnancy was associated with an increased risk of psychotic symptoms in the children, with evidence of a dose-response effect whereby risk of PLIKS was highest in the offspring of mothers who smoked most heavily," write the study authors.

"If our results are non-biased and truly reflect a causal relationship, we can estimate that about 20% of adolescents in this cohort would not have developed psychotic symptoms if their mothers had not smoked," they add.

Study limitations included missing data resulting from attrition and wave nonresponse, as well as possible underreporting of substance use (including cannabis, which is illegal in the United Kingdom).

"Hopefully this will encourage more research into the effects of tobacco on brain development in utero, and increase understanding of how any disruptions of brain development can impact risk of psychosis," Dr. Zammit concluded.

This study was supported by the Wellcome Trust Grant, with additional funding to Dr. Zammit through a Clinician Scientist Award from the National Assembly for Wales. The other study authors have disclosed no relevant financial relationships.

Br J Psychiatry. 2009;195:294–300. Abstract

Friday, April 2, 2010

Parental Stroke Associated With 3-Fold Increased Risk for Stroke in Offspring

Emma Hitt, PhD

Are your patients with moderate to severe chronic pain taking other medications? These patients may be at risk for drug-drug interactions.
Learn more March 31, 2010 — Parental stroke before the age of 65 years is associated with a 3-fold increased risk for stroke in offspring, according to new data from the Framingham Heart Study.

These findings suggest that "a reliable family history can serve as a 'poor man's genetic risk score' providing a simple, aggregate estimate of an individual's genetic risk," lead author Seshadri Sudha Seshadri, MD, with Boston University in Massachusetts, told Medscape Neurology.

The results are published in the March 23 issue of Circulation.

Inconsistent Results

According to the researchers, previous study results suggest that stroke risk ranges from a "doubling of risk in the offspring to no observed impact of parental history of stroke."

To further investigate the issue, Dr. Seshadri and colleagues used data from the Framingham study offspring cohort. The analysis included 3443 offspring of the original Framingham cohort who had not had a stroke at baseline and who had parental stroke status verified by the age of 65 years. All offspring attended required examinations and were followed up for up to 8 years.

A total of 106 parental strokes were documented by the age of 65 years, and 128 strokes were documented in the offspring. Of the strokes, 74 and 106 among the parents and offspring, respectively, were ischemic.

On multivariate analysis and after adjusting for conventional stroke risk factors, parental stroke was associated with an increased risk for incident stroke of the same type (hazard ratio [HR], 2.79; 95% confidence interval [CI], 1.68 – 4.66; P < .001) and for ischemic stroke (HR, 3.15; 95% CI, 1.69 – 5.88; P < .001).

Similar findings were observed in the offspring regardless of parental sex.

According to Dr. Seshadri, physicians should recognize that if one or both of a person's parents had a stroke before they turned 65 years old, their stroke risk is 3 times that of others.
"She or he should make it a point to check for and address modifiable risk factors, such as a higher blood pressure, smoking, and low levels of physical activity," she said.

Dr. Seshadri noted that more studies are required to understand which specific genes underlie stroke risk. "Framingham and collaborating studies identified 1 gene called NINJ2, and the findings were published in April 2009 in an article in the New England Journal of Medicine, but there is a lot more that needs to be done," she said (N Engl J Med. 2009;360:1718-1728).

Environment vs Genes

Ralph L. Sacco, MD, with the University of Miami, Miller School of Medicine, in Florida and president-elect of the American Heart Association, noted that prior studies have been inconsistent in documenting the importance of family history of stroke as a risk factor for stroke.

“Although there are many environmental determinants of stroke, such as smoking, physical inactivity, and diet, we also know that various factors are under genetic as well as environmental control, such as hypertension, diabetes, high cholesterol, and obesity,” he said. “The beauty of the Framingham Study is the long term in-person observation across multiple generations of family members,” he added.

According to Dr. Sacco, researchers continue to identify new genetic markers that may provide better clues to the specific genetic factors that increase risk. “This may also help in the discovery of new mechanisms that cause stroke and provide insights into new treatments,” he said.

The study was not commercially funded. Dr. Seshadri and Dr. Sacco have disclosed no relevant financial relationships.

Circulation. 2010;121:1304-1312.

Sharp Rise in HPV-Related Oropharyngeal Carcinoma -- A Legacy of the "Sexual Revolution"?

From Medscape Medical News
Zosia Chustecka

March 30, 2010 — The incidence of oropharyngeal carcinoma related to human papillomavirus (HPV) has been increasing in recent years, and there is speculation that this is the result of the "sexual revolution" of the 1960s.

This increase in the incidence of HPV-related oropharyngeal cancer has important public health implications, British experts warn in an editorial published online March 25 in the British Medical Journal.

HPV-related oropharyngeal carcinoma appears to be a new and distinct disease entity, with better survival than the classic non-HPV-related disease, they point out.

"These patients are typically younger and employed, and — because outcomes seem to be more favorable than for patients with non-HPV-related carcinoma — they will live longer with the functional and psychological sequelae of their treatment. Consequently, they need prolonged support from health, social, and other services, and may require help returning to work," write the authors, headed by Hisham Mehanna, BMedSc, MB ChB, FRCS, director of the Institute of Head and Neck Studies and Education at University Hospital in Coventry, United Kingdom.

However, currently, there is no good evidence to support managing patients with HPV-related head and neck cancer differently from those whose tumors are not HPV-related, the researchers write.

Clinicians should not change their current treatment policies.
Several studies are being planned to evaluate different treatment options, and Dr. Mehanna and colleagues urge clinicians to offer all patients with oropharyngeal cancer the opportunity to enroll in a clinical trial. However, until data from those trials are available, "we suggest that clinicians should not change their current treatment policies."

Maura Gillison, MD, PhD, professor of medicine, epidemiology, and otolaryngology at Ohio State University in Columbus, who was approached for independent comment, told Medscape Oncology that she agrees.

Currently, patients should be treated the same, whether they are HPV positive or negative, she said, but they should be "strongly encouraged" to participate in trials.

Increase Linked to Sexual Behavior?

As evidence for the increasing incidence of HPV-related oropharyngeal carcinoma, the researchers cite several studies. One of these, conducted in Stockholm, Sweden, found a progressive proportional increase in HPV detected in biopsies taken to diagnose oropharyngeal cancer, from 23.3% in the 1970s, to 29% in the 1980s, 57% in the 1990s, 68% in 2000 to 2002, 77% in 2003 to 2205, and 93% in 2006 and 2007 (Int J Cancer. 2009:125:362-366).

One reason for this increase could be the sexual transmission of HPV, primarily through orogenital intercourse, Dr. Mehanna and colleagues write.

They also cite a recently published pooled analysis of 8 multinational studies conducted by the International Head and Neck Cancer Epidemiology (INHANCE) consortium (Int J Epidemiol. 2010;39:166-181). Using pooled data, this group compared 5642 patients with head and neck cancer and 6069 control subjects, and found that the risk of developing oropharyngeal carcinoma was associated with a history of 6 or more lifetime sexual partners, 4 or more lifetime oral sex partners, and — for men — an earlier age at first sexual intercourse.

The association between HPV-related oropharyngeal cancers and sexual behavior — having several sexual partners, and with oral sex and "French kissing" — has been reported in previous studies. Last year, American experts highlighting the increase in HPV-related oropharyngeal cancer suggested an association with an increase in the practice of oral sex among white, younger Americans, as reported previously by Medscape Oncology.

Dr. Gillison told Medscape Oncology that "it is clear that the strongest behavioral risk for [HPV-related oropharyngeal cancer] is the lifetime number of oral sex partners."

"However, there are no data to specifically link the increase in disease incidence to changes in oral sexual behaviors over time," she added, pointing out that sexual-behavior surveys in the United States did not collect this type of information before the 1990s.

"This is something that I have looked at carefully," Dr. Gillison said, and she believes that the available data suggest that the sharp increase in HPV-related oropharyngeal cancer is a result of the sexual revolution of the 1960s.

Legacy of the Sexual Revolution

"Our own work, using the [Surveillance, Epidemiology, and End Results] database, shows a strong cohort effect, which means the greatest determinant of risk in any age group is the year that you were born," Dr. Gillison reported.

"These cohort effects are largely driven by societal changes, and they tend to affect people first who are younger, because they are the people leading the behavioral changes," she explained.

During the 1960s, teenagers and young adults were more active sexually than previous generations, and having multiple sexual partners became more acceptable. "The more sexual partners you have, the greater the risk of contracting any sexually transmitted disease, including HPV," Dr. Gillison pointed out.

The time lag between an oral HPV infection and the development of HPV-related oropharyngeal cancer is between 15 and 30 years, and the age at which this cancer is usually diagnosed is 50 years or more.

So the increase in this cancer that was seen in the 1990s and the 2000s is likely to be the result of young people participating in increased sexual activity in the 1960s and 1970s, Dr. Gillison suggested.

"We saw a really sharp climb in the incidence in 2000," Dr. Gillison noted. "So you have to think: What were these people [now 50 or more years old] doing 20 to 30 years ago?"

Dr. Mehanna told Medscape Oncology that he "totally agrees."

The time frame fits.
The time line of the sudden increase in these cancers seen in the past decade and the 20 to 30 years that it takes for HPV-related cancer to develop points to changes in sexual behaviors that began in the 1960s and 1970s, he said. "The time frame fits," he said, although he added that "this is conjecture."

However, there are many points that are backed up with data. "What we know for sure is that HPV causes oropharyngeal cancer, and we understand the molecular mechanisms involved, so we know how it causes it," Dr. Mehanna explained. "We also know that patients who have HPV-related oropharyngeal cancers are more likely to have had 6 or more sexual partners or 4 or more oral sex partners," he said, and men are more likely to have started having sex at an earlier age. This [fits] with data for cervical cancer, also caused by HPV, which is more likely in women who become sexually active at an earlier age, he noted.

Rethink on HPV Vaccination?

Because a vaccine against HPV is already marketed for use in girls and young women to prevent cervical cancer, and was recently approved for use in boys to prevent genital warts, there has been speculation about whether this vaccine will also protect against HPV-related oropharyngeal cancer.

Dr. Gillison points out that there is no scientific evidence, as yet, to show that HPV vaccination does protect against HPV-related orophageal cancer. "It ought to," she explained, because this cancer is mainly associated with HPV type 16, and this is one of the virus types that the vaccines contain. "But science can be surprising, and things don't always work out as we expect," she warned. She pointed out that the oral cavity is very different from the genital area, and the differences in mucosal surfaces and in the antibodies in saliva and genital secretions might alter the response to vaccination.

"Whether the currently available HPV vaccines have the potential to prevent oral HPV infections that lead to cancer, and thereby reverse the current upward incidence trends documented now in the United States, the United Kingdom, and Sweden, is an important and unanswered question," Dr. Gillison commented.

"Unfortunately, the studies designed to evaluate this question that were slated to start next month in young men have recently been cancelled by the pharmaceutical sponsors," she added.

In their editorial, Dr. Mehanna and colleagues suggest that the recent rapid rise in HPV-related oropharyngeal carcinoma might alter some of the cost-effectiveness considerations about this vaccine and, in particular, its use in boys before they become sexually active.

The HPV vaccination of boys was judged to be not cost-effective in a recent analysis (BMJ 2009;339:b3884), but this decision was made on the basis of old data, Dr. Mehanna explained to Medscape Oncology. The data in that cost-effectiveness study only go up to 2003, but there has been a considerable increase — a doubling, in fact — since then, he said. There are data from 2009 that suggest that about 70% of oropharyngeal cancer is HPV-positive, compared with about 35% in 2003, he noted.

Hence, that study underestimated the incidence of HPV-related oropharyngeal cancer, Dr. Mehanna said, and a new cost-effectiveness analysis needs to be carried out to take these new incidence data into account. "It may well turn out to be cost-effective," he added.

Dr. Mehanna is director of the Institute of Head and Neck Studies and Education, which does contract work for GlaxoSmithKline. One of his coauthors, Terence Jones, from the Liverpool CR-UK Cancer Centre, School of Cancer Studies, Division of Surgery and Oncology, in the United Kingdom, is involved in a clinical trial in patients with HPV-related oropharyngeal carcinoma with a therapeutic vaccine that the manufacturer (Advaxis) is providing free of charge.

BMJ. 2010;340:c1439. Abstract