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The way to reduce the chances of developing dementia such as Alzheimer’s disease after a stroke is to prevent a second stroke by concentrating on all the known stroke risk factors, a new British study suggests.

Two major findings emerged from an analysis of 30 previous studies that involved more than 7,500 people who had suffered a stroke, said Dr. Sarah Pendlebury, a senior clinical fellow at the Stroke Prevention Research Unit of John Radcliffe Hospital in Oxford and lead author of a report published online Sept. 23 in The Lancet Neurology.

“First, there is a clear relationship between having multiple strokes and the risk of dementia,” Pendlebury said. “If someone has multiple strokes at the same time, that person has a strong risk of becoming demented in the first month.”

“Second, the data suggest that the presence of complications after stroke — such as hypertension [high blood pressure], low oxygen saturation, cardiac events and seizures — also increases the risk of developing dementia.”

Because of this, Pendlebury said, the focus of stroke treatment units should be on all the risk factors for stroke. “So, to prevent worsening of damage to the brain, the patient must be maintained in as stable a condition as is possible,” she said. “We must prevent either high or low blood pressure and maximize all other secondary prevention measures.”

The study found that dementia rates in the first year after a stroke vary widely, ranging from 7.4 percent in population-based studies of stroke victims who did not previously have dementia to 41.3 percent in hospital-based studies that included people who had signs of dementia before a stroke.

But the study’s conclusion that the risk of dementia was associated with the risk and number of strokes, rather than underlying risk factors for cardiovascular diseases, was contested in an accompanying editorial by Dr. Michael G. Hennerici, chairman of neurology at the University of Heidelberg in Germany.

“This study lumps together several studies that have been performed in the last 30 years,” Hennerici said. “These studies are of very different quality. From these data, they draw the conclusion that stroke per se has a risk of post-stroke dementia. I question this finding because, according to the data, it is not stroke itself but rather an additional neurodegeneration that is ongoing, or additional changes in the brain in combination with stroke, that produces post-stroke dementia.”

Hennerici’s interpretation is that treatment of one major risk factor, hypertension, is essential to prevent both stroke and the underlying deterioration of brain function that leads to dementia.

“Hypertension is the best treatable risk factor for dementia and stroke,” he said. “It should be addressed even in those patients who are not hypertensive but who have other risk factors, such as diabetes and advanced age. The aging population should be carefully treated with hypertensive agents and also should be advised about methods of dealing with other hypertension risk factors, such as reduced salt intake, exercise and lifestyle changes.”

That recommendation drew no argument from Pendlebury. “Yet more aggressive treatment of high blood pressure can help prevent dementia, and also stroke,” she said.

Ductal carcinoma in situ (DCIS), the most common non-invasive lesion of the breast, presents unique challenges for patients and providers largely because the natural course of the untreated disease is not well understood. Because most women diagnosed with DCIS are treated, it is difficult to determine the comparative benefits of different treatment strategies versus active surveillance, meaning systematic follow-up. An independent panel convened by the NIH urged the scientific community to identify appropriate biomarkers and other prognostic factors to better predict the risk of developing breast cancer.

“Instead of treating all women diagnosed with DCIS, we need to determine which individuals are likely to develop invasive breast cancer and which will not,” said Dr. Carmen Allegra, panel chair and Chief of Hematology and Oncology at the University of Florida. “If we could accurately predict this, we might save some women from undergoing unnecessary invasive treatments while achieving the same positive outcomes.”

DCIS is a condition in which a spectrum of abnormal cells are found in the breast duct and have not spread outside the duct to other tissues in the breast. Since the advent of widespread screening mammography in the early to mid 1980’s, rates of DCIS have increased sharply. It is estimated that more than one million U.S. women will be living with a prior diagnosis of DCIS by 2020.

Despite the connotations associated with the term carcinoma, DCIS is associated with ten-year survival rates close to 100% when treated with currently available therapies. These include breast-conserving surgery (local excision, with or without radiation), removal of the breast (mastectomy), and/or tamoxifen. It is important to stress that each of these treatment options has physical and emotional impacts to patients and should be weighed accordingly. The panel recognized that there are relatively few reliable data on the comparative effectiveness of both diagnostic and therapeutic options in DCIS.

To improve our understanding of this complex disease, the panel recommended efforts to ensure detailed collection of clinical, pathological, imaging, and molecular data about DCIS using standardized reporting measures, annotated specimen repositories, and multicenter databases.

The panel emphasized the importance of patient preferences and recommended improved communication between patients and providers, and serious consideration of new nomenclature that more closely reflects the excellent survival rates for this condition.

Efforts to improve communication would also include further development of formal decision aids. Such tools would reduce misinformation and improve understanding of a DCIS diagnosis and the risks and benefits of various treatment options. Individuals who have DCIS should have access to the best possible information and guidance to aid them in making care decisions that reflect their unique circumstances, perspectives, and preferences.

The panel’s updated draft state-of-the-science statement will be available later today at http://consensus.nih.gov. The conference was sponsored by the NIH Office of Medical Applications of Research and the National Cancer Institute along with other NIH and Department of Health and Human Services components. This conference was conducted under the NIH Consensus Development Program, which convenes conferences to assess the available scientific evidence and develop objective statements on controversial medical is sues.

The 14-member conference panel included experts in the fields of oncology, radiology, surgery (general and reconstructive), pathology, radiation oncology, internal medicine, epidemiology, biostatistics, nursing, obstetrics and gynecology, preventative medicine and population health, and social work. A complete listing of the panel members and their institutional affiliations is included in the draft conference statement. Additional materials, including panel bios, photos, and other related resources, are available at http://consensus.nih.gov/2009/dcismedia.htm.

In addition to the material presented at the conference by speakers and the comments of conference participants presented during discussion periods, the panel considered pertinent research from the published literature and the results of a systematic review of the literature. The systematic review was prepared through the Agency for Healthcare Research and Quality Evidence-based Practice Centers (EPC) program, by the Minnesota Evidence-based Practice Center. The EPCs develop evidence reports and technology assessments based on rigorous, comprehensive syntheses and analyses of the scientific literature, emphasizing explicit and detailed documentation of methods, rationale, and assumptions. The evidence report on diagnosis and management of DCIS is available at http://www.ahrq.gov/clinic/tp/dcistp.htm.

The panel’s statement is an independent report and is not a policy statement of the NIH or the federal government. The NIH Consensus Development Program was established in 1977 as a mechanism to judge controversial topics in medicine and public health in an unbiased, impartial manner. NIH has conducted 119 consensus development conferences, and 32 state-of-the-science (formerly “technology assessment”) conferences, addressing a wide range of issues. A backgrounder on the NIH Consensus Development Program process is available at http://consensus.nih.gov/backgrounder.htm.

A study in mice suggests lack of sleep may play a role in the development of Alzheimer’s disease, U.S. researchers said on Thursday.

The findings, reported in the journal Science, are some of the first to link sleep with the development of Alzheimer’s, the most common form of dementia.

Researchers at Barnes-Jewish Hospital in St. Louis studied levels of amyloid beta — a protein that accumulates in the brain of people with Alzheimer’s — in mice genetically engineered to have a version of Alzheimer’s disease.

Amyloid levels rose in the brain when the mice were awake, and fell when they slept.

When the researchers prevented the mice from sleeping, it made matters worse, said Dr. David Holtzman of Barnes-Jewish Hospital, who worked on the study.

“Sleep deprivation markedly accelerated amyloid-beta plaque formation,” he said in an e-mail.

When the team injected orexin — a compound that regulates sleep — into the brains of the mice, the mice stayed awake longer, and amyloid beta levels rose. And when they blocked orexin, these levels decreased.

In people, orexin plays a role in the sleep disorder narcolepsy, which causes excessive sleepiness.

Holtzman said the findings suggest drugs that target orexin may be useful to try as Alzheimer’s treatments.

They also reinforce the need to treat sleep disorders, not only because they cause immediate problems, but because they may have a long-term impact on brain health, he said.

Despite decades of research, doctors still have few effective weapons against Alzheimer’s, a mind-robbing form of dementia for which there are few effective treatments and no cure. Many treatments that have shown promise in mice have had little effect on humans with Alzheimer’s disease.

More than 35 million people globally will suffer from Alzheimer’s disease or other forms of dementia in 2010, according to the Alzheimer’s Association.

Women with atrial fibrillation are significantly more likely to have a stroke or die than are men with the heart condition, a new study has found.

Despite this, the study suggests, women with the condition receive less medical attention than men.

Atrial fibrillation occurs when the two small upper chambers of the heart, the atria, quiver rather than beat effectively. This can lead to pooling and clotting of blood. If a clot travels from the atria to an artery in the brain, it can cause a stroke.

Rush University Medical Center researchers reviewed past studies and medical literature and found that women with atrial fibrillation are more likely than men to experience symptomatic attacks and have recurrences, and that women have significantly higher heart rates during atrial fibrillation, which increases the risk for stroke.

“Stroke is one of the most devastating results of cardiovascular disease, and atrial fibrillation increases the risk of stroke,” the lead investigator, Dr. Annabelle Volgman, medical director of the Heart Center for Women at Rush University Medical Center, said in a news release from the hospital. “Women are at higher risk of atrial fibrillation-related stroke than men and are more likely to live with stroke-related disability, which can significantly lower quality of life.”

Volgman and her fellow researchers reviewed 20 years of studies that examined gender differences in atrial fibrillation and “were able to determine the most rational, safe and effective gender-specific approach to therapy for women.”

For starters, prevention therapies should be emphasized, the researchers said, as should treatments to ensure safe management once the condition is diagnosed.

Their findings and recommendations related to gender differences included:
Women are not prescribed blood thinners as often as men, resulting in a higher incidence of the formation of clots that break loose and block other vessels. The risk/benefit ratio should be assessed individually for each woman.
Women have a greater risk of bleeding from anticoagulation therapy, so this treatment must be monitored carefully.
Closely monitor women being treated with antiarrhythmic drugs because they have a higher risk for life-threatening arrhythmias and slow heart rates requiring permanent pacing.
Women’s hormonal fluctuations can cause more life-threatening arrhythmias.
Monitor women’s potassium levels in the blood because they have a higher risk of low levels, which boost the risk for drug-related arrhythmias.
Because women have a higher sensitivity to such therapies as statins and vasodilators, liver and kidney function should be closely watched.
Women are referred less often or later for non-drug treatments such as pacemaker implantation or ablation. Ablative therapy should remain an option for symptomatic women because they have success rates similar to those of men.

The study also found that, in general, women with atrial fibrillation have a lower quality of life than men with the disease. But the researchers said that careful assessment and relief of symptoms, and adequate control of heart rate or rhythm can make things better.

“For women with atrial fibrillation, these gender differences should always be kept in mind to help prevent strokes and heart failure and improve their quality of life,” Volgman said.