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People with bipolar disorder who smoke appear to have a heightened risk of suicidal behavior — possibly because they are generally prone to impulsive acts, a new study suggests.

Bipolar disorder, also known as manic depression, is marked by dramatic swings in mood — ranging from episodes of debilitating depression to periods of euphoric recklessness. Previous studies have found that bipolar patients who smoke have a higher suicide risk than their non-smoking counterparts, but the reasons have not been clear.

The new findings suggest that high levels of impulsivity — one of the symptoms of bipolar disorder — may draw some patients to both smoking and suicidal behavior.

Dr. Michael J. Ostacher and colleagues at Massachusetts General Hospital in Boston found that among 116 bipolar patients they followed, current smokers generally scored higher on a standard measure of suicidal thoughts and behaviors.

Moreover, smokers were more likely to make a suicide attempt over the next nine months, the researchers report in the journal Bipolar Disorders.

Five of the 31 smokers in the study (16 percent) attempted suicide during the study period. By comparison, only 3 of 85 non-smokers (3.5 percent) attempted suicide during the study.

The researchers also used a standard questionnaire to gauge patients’ impulsiveness — such as how often they speak or act without thinking and how well they plan for the future.

When those scores were factored in, the link between smoking and suicidal behavior diminished. The implication, according to Ostacher’s team, is that high levels of impulsivity partly explain why smokers were at greater risk.

From a practical standpoint, the researchers write, the findings add more evidence that smoking can be considered a “clinical marker” of higher suicide risk in bipolar patients.

Smoking, in and of itself, may not be a strong predictor of patients’ suicide odds, but doctors can still consider it as part of a comprehensive patient assessment, the researchers suggest.

It is unknown, they note, whether helping bipolar patients quit smoking would have any effect on their risk of suicidal behavior.

Millions of adults die every year from bugs and toxins in what they eat, according to new World Health Organization data that shows food-borne diseases are far more deadly than the U.N. agency previously estimated.

The research faults unsafe food for 1.2 million deaths per year in people over the age of five in Southeast Asia and Africa — three times more adult deaths than the Geneva-based WHO had thought occurred in the whole world.

“It is a picture that we have never had before,” WHO Food Safety Director Jorgen Schlundt said in an interview. “We now have documentation of a significant burden outside the less than five group, that is major new information.”

Ailments linked to contaminated food and water have long been seen as a major threat to young children, who can dehydrate quickly. But the Danish veterinarian and microbiologist said the risks to older populations had been grossly underestimated.

Older children and the elderly are especially vulnerable to severe illness from major food- and water-borne diseases such as salmonella, listeria, E. coli, Hepatitis A and cholera.

Food safety experts are now seeking to measure the burden of such afflictions in people over the age of five in the Arab world, Latin America and elsewhere in Asia including China.

And already, Schlundt said, health officials are recognizing the need to confront the most dangerous types of contamination in their industrial regulations and trade standards.

“Literally millions are dying every year and we know that a lot of these could be prevented,” he told Reuters. “There is a realization that instead of doing what we did in the past, in the future we should really focus on where the problems are.”

MODERN FOOD PRODUCTION

Many of the contaminants that have made headlines in recent years in the United States, such as salmonella and E. coli, also exist in poorer countries but are not monitored as carefully there, according to Schlundt.

Health authorities in developed countries are now much more able to document food safety risks because of tests that can quickly connect disparate cases of illness to tainted foods such as lettuce, peppers, spinach and beef.

But the WHO expert said that some ailments have also become more prevalent in the food system alongside the globalization of the food supply and the rise of modern food production methods, which can propagate ailments quickly and on a large scale.

“There are certain pathogens that have increased over the last 20 or 30 years. Some problems clearly have moved and become bigger because of the ways that we produce,” he said.

Simple steps can cut the levels of chemicals and toxins in foods, such as avoiding conditions where mold can grow, Schlundt said. Farming techniques can also root out microorganisms from the food chain and parasites can be wiped out by targeting their hosts and transmission patterns, he said.

Because it is now clear that some foods are more vulnerable to certain food-borne ailments than others, health officials are well-placed to focus their energies on monitoring areas posing the highest potential disease risk, according to Schlundt.

Another vital part of the food-borne disease fight is having consumers take precautions in the way they prepare foods, and ensuring patients and health workers take symptoms such as diarrhea seriously as a risk across population groups.

“Many of the deaths that we see in developing countries, if they had been treated at the right time, they would not have died,” Schlundt said.

An unusual look at internal documents from a pharmaceutical company suggests that clinical data was manipulated to make a popular anti-seizure drug, gabapentin (Neurontin), look more effective than it actually was, thereby increasing possibilities for its off-label usage, according to a new report.

“This means we’re not seeing the full picture, and the picture we are seeing is suspect because perhaps there was selective reporting of outcomes so that only the positive outcomes were reported,” said Kay Dickersin, senior author of a paper reporting the alleged deception in the Nov. 12 issue of the New England Journal of Medicine.

But this revelation may just be the tip of the iceberg, especially given that internal company research protocols are rarely available to outsiders, stated another expert.

“The reality is that a deliberate fraud is extremely difficult to unearth. If scientists and companies agree to report results in a way that wasn’t initially intended, unless you have access to original documents, it is extremely difficult to actually figure out what happened and how it happened,” said Dr. Steven Nissen, chairman of cardiovascular medicine at the Cleveland Clinic Foundation in Ohio. “How many other examples like this are there out there that we simply don’t know about? That’s what’s frightening.”

Dickersin, a professor of epidemiology at the Johns Hopkins Bloomberg School of Public Health in Baltimore, gained access to internal company documents when she was asked to testify for the plaintiff in a lawsuit alleging that Pfizer and Parke-Davis (now a division of Pfizer as a result of its Warner-Lambert acquisition) illegally tried to market the drug for off-label uses.

Neurontin is approved by the U.S. Food and Drug Administration to treat seizures and shingles, but is also widely used off-label to fight migraines, bipolar disorder and pain.

Dickersin compared internal company documents to 20 trials funded by Pfizer and Parke-Davis, 12 of which were published.

Typically, clinical trials are set up to track both primary and secondary outcomes. These initial decisions then dictate other aspects of the trial, such as how many participants will be included. And that feeds back into how valid the final results are for that specific trial design and that specific primary outcome.

But here, Dickersin and her colleagues discovered that the primary outcomes specified in the early company protocols were not always the same as those appearing in later reports.

“What appears to be happening is that outcomes are changing between what was planned and what was published,” Dickersin said.

Sometimes researchers changed what the primary outcome was (if a different outcome cast the drug in a more positive light), neglected to report the primary outcome at all, turned a secondary outcome into the primary outcome or simply added new outcomes, the report said.

“This distorts the scientific evidence that’s available on the benefits and risks of therapies,” Nissen said.

On Tuesday, Pfizer issued a statement in response to the study, part of which read: “The suggestion that Pfizer attempted to mislead the medical community about the effectiveness of gabapentin [Neurontin] for certain off-label conditions is untrue. The review recently published in the New England Journal of Medicine, regarding the reporting of industry-sponsored trials for gabapentin for off-label use, was derived from a report created for litigation and coauthored by plaintiffs’ expert witness, who was hired to produce opinions to support plaintiffs’ arguments. We believe the review suffers from significant bias, insufficient data, poor methodology, and cannot pass the threshold of credible scientific research.”

“The safety and efficacy of gabapentin has been widely published, both by Warner-Lambert/Pfizer as well as independent researchers, and Pfizer has supported the dissemination of the results of these studies, regardless of outcome. At Pfizer, science and medical integrity come first and foremost,” the statement concluded.

Although regulations require that all clinical trials be registered at some point, the study authors feel that’s not enough.

“We need to actually have the protocol itself available for people to look at so there aren’t opportunities for people to fiddle around with what they submit,” Dickersin said.

One possibility would be to register the protocol itself. “This doesn’t necessarily fix it, but it does mean that it’s transparent, that the public has access to what people say they’re going to do before they do it,” she added.

“The peer-reviewed scientific literature is how we write our guidelines and how we make decisions about what therapies to give patients,” Nissen said. “If the material available to us is severely distorted by commercial influences, then the evidence we use to take care of patients is flawed. That is too high a price to pay.”

Adult Acne Occurs More Frequently in Women than in Men
Often mistakenly considered a condition that only affects teenagers, acne can occur at any age and is very common in adults in their 20s, 30s, and 40s. Acne that occurs during the teenage years generally affects more boys than girls, but adult acne occurs more frequently in women than men. Studies show that acne affects more than 50 percent of women between the ages of 20-29 and more than 25 percent of women between the ages of 40-49.

Dr. Jaliman explained that the two main causes of acne in women can be attributed to hormones (referred to as hormonal acne) and cosmetics (known as acne cosmetica). In hormonal acne, an increase in the production of androgens (the male hormones present in men and women) can over-stimulate the oil glands and hair follicles in the skin, leading to hormonally triggered acne flares, particularly in women.

To treat hormonal acne in women, Dr. Jaliman noted that there are several oral contraceptives available – three of which have been approved by the U.S. Food and Drug Administration (FDA) for the treatment of acne. These therapies can be beneficial, but Dr. Jaliman cautioned that a patient must be carefully screened and matched with the right therapy before starting treatment because some birth control pills can cause acne in certain patients.

In addition, time-released antibiotics that are now dosed by a person’s body weight can be very effective, and laser and light treatments also can help treat acne lesions and reduce future breakouts in many patients.

For women whose acne is attributed to cosmetics, Dr. Jaliman advises patients to stop using these products and switch to a different brand that has been tested as noncomedogenic (does not clog pores). “With acne cosmetica, stopping use of the cosmetics is an important first step, but a dermatologist should still extract all the clogged pores and prescribe a topical medication for long-term clearing,” she said.

In addition, a type of acne that frequently occurs in African-Americans and is caused by hair products is pomade acne. African-Americans tend to have dry hair and they often use conditioners and products that are very oily to help add moisture to the hair. However, these products tend to be comedogenic and can cause acne breakouts in areas where they come in contact with the skin, such as around the hairline, on the forehead, and at the nape of the neck. If this occurs, Dr. Jaliman said people should stop using these products and see a dermatologist to successfully clear the acne.

Rosacea Can Be Managed
Rosacea is a chronic skin condition characterized by redness, swelling, and vascular abnormalities, most commonly on the face, with varying degrees of severity. It can occur at any age, and Dr. Jaliman explained that rosacea commonly occurs in adults over age 50 and is three times more likely in women. There are many known triggers for rosacea, including alcohol, spicy foods, ultraviolet light, heat and citric acid, and behavioral changes can help alleviate some of the symptoms. However, Dr. Jaliman noted that in most cases medications are necessary to treat rosacea.

“In the past, topical medications for rosacea were greasy and irritating, but now a new wave of topicals has been introduced that are lightweight and easy on the skin,” said Dr. Jaliman. “These new topicals include metronidazole and azeleic acid, and both are very effective for rosacea patients.”

UV exposure is a common trigger for rosacea, and Dr. Jaliman stressed the importance of daily sunscreen use. With the introduction of new sheer sunscreens, Dr. Jaliman said that rosacea patients are more likely to use them because they are not greasy and are less likely to further irritate inflamed skin. “I find that the sunscreens that contain physical sunblocks, such as titanium dioxide and zinc oxide, work best for rosacea patients rather than chemically based sunscreens.”

Leg Veins Can Develop at Any Age
The appearance of two common types of leg veins – spider veins and varicose veins – can develop at almost any age. They often appear over time and typically affect those who are older. But Dr. Jaliman noted that even people in their 20s can get spider or varicose veins. Both types of leg veins are genetic, but there are differences in who is more prone to them and how they are treated.

Spider veins, also referred to as roadmap veins, are very tiny superficial blood vessels that increase in size over time. Those who are more susceptible to spider veins include women, women who are pregnant, and people who are on their feet regularly in their jobs.

“While spider veins can be unattractive and cause embarrassment for people, they are not painful and are very treatable,” said Dr. Jaliman. “Sclerotherapy, in which a sclerosing agent is injected into clusters of spider veins with very fine needles, is the gold standard for treating spider veins and dissolves the veins permanently in most cases in only two to three treatments. Lasers also are being used to treat spider veins, and your dermatologist will recommend the best treatment depending on the size of the vessels.”

Varicose veins are larger, dilated blood vessels that can be raised above the skin’s surface and occur from a malfunction of the valve. Those with a blood relative with varicose veins are more likely to develop them and being overweight can worsen the problem by putting more pressure on the veins. Unlike spider veins, varicose veins can cause the legs to feel sore or tired. Dr. Jaliman noted that new endovascular lasers are being used successfully to treat varicose veins. With this procedure, the small tip of the laser creates a small nick in the vein and is inserted to completely dissolve the vein.

“Endovascular lasers are highly safe and effective in treating varicose veins and only one procedure is needed to dissolve the veins,” said Dr. Jaliman. “In most cases, patients can go back to work the next day with minimal discomfort, which is quite different from invasive procedures in the past that were performed in hospitals.”

Hair loss, acne, rosacea and leg veins among the more common medical dermatologic concerns that come with ageEveryone expects their bodies to change as they get older. From wrinkles and sagging skin to brittle bones and aches and pains, the aging process is inevitable. In addition, there are a number of medical dermatologic conditions that surface with age that can cause people even more stress. Fortunately, dermatologists can help diagnose and treat these conditions no matter when they strike.

Speaking today at the American Academy of Dermatology’s SKIN academy (Academy), dermatologist Debra Jaliman, MD, FAAD, assistant clinical professor of dermatology at Mount Sinai School of Medicine in New York, N.Y., discussed why hair loss, acne, rosacea, and leg veins can occur as we age and she presented some of the latest ways to treat them.

“When we age, a number of changes take place on and beneath the surface of our skin that can affect how we look and feel,” said Dr. Jaliman. “But while we might expect to see fine lines and wrinkles as the years pass, many of us might be surprised to wake up one day with adult-onset acne, thinning hair or embarrassing spider veins. The reality is that many dermatologic conditions are more likely to affect us as we age, and the key is to address these problems early to rule out more serious medical conditions and start proper treatment.”

Hair Loss Can Be Treated Effectively
Many people are genetically predisposed to hair loss, but it becomes increasingly common with age. Dr. Jaliman noted that everyone over age 40 has less hair than they did when they were younger – even if the hair does not appear thinner on the surface.

The most common form of hair loss that affects both men and women is androgenetic alopecia (often referred to as male-pattern hair loss or female-pattern hair loss). In both genders, a miniaturization of the hair follicles occurs – meaning the hair stays on the head for a shorter period of time due to a short growth phase. As a result, a person will develop baby fine hairs that do not reach their full length or diameter. In men, this results in a receding hairline or baldness on top of the scalp. However, in women, the frontal hairline is not affected but there is visible thinning over the crown and at the part.

Before starting any treatment for hair loss, Dr. Jaliman stressed that it is important for men and women to see a dermatologist for proper diagnosis and to rule out a potentially serious medical condition, such as lupus, thyroid disease, or iron-deficiency anemia. Other causes of hair loss include drug reactions, birth control pills, menopause, or a diet lacking in protein.

To treat hair loss, several effective therapies are available for both men and women. For men with male-pattern hair loss, effective medical therapies that are FDA-approved include finasteride, a prescription oral medication, and minoxidil 2% and 5%, topical solutions that are available over the counter. For women with hair loss, minoxidil 2% is the only topical medication approved by the FDA for female-pattern hair loss.

For men and women who want a permanent solution for hair loss, Dr. Jaliman said that hair transplants are a good option because surgical hair restoration has evolved in recent years and the results are much more natural than in the past. Now, single follicular units (or one hair at a time) are implanted in thinning and bald areas rather than clusters of hair, often referred to as plugs. To prevent future hair loss, Dr. Jaliman suggested that hair transplant patients supplement their treatment with a medical therapy recommended by their dermatologists.