Indian Medicine

A study presented at a nephrologists' conference last month has provided scientific evidence to support what many physicians have long suspected. Patients who develop kidney stones are more likely to develop chronic kidney disease and end-stage renal disease.

"Kidney stones are not a traditionally recognized risk factor ... but clinicians know it," said Dr. Rajiv Saran, associate professor and director of the Kidney Epidemiology and Cost Center at the University of Michigan, Ann Arbor.

The paper presented at Renal Week 2008, the American Society of Nephrology's 41st Annual Meeting and Scientific Exposition in Philadelphia suggested that those with a history of kidney stones had a 60% increased risk of developing CKD when compared with a healthy control group. The additional chance of ESRD was 40%. Those with stones also had a 40% increased risk of having an elevated serum creatinine or a reduced estimated glomerular filtration rate.

The authors say this finding adds importance to strategies to avert kidney stones in those who tend to form them, such as prescribing certain medications or recommending dietary changes.

"This should tell us to be a little more vigilant and think about treating patients to prevent kidney stones," said John Lieske, MD, lead author and professor of medicine at the Mayo Clinic in Rochester, Minn.

Kidney stones increase the risk of developing chronic kidney disease by 60%.

But those researching this area also expressed caution in interpreting these findings. This epidemiological study showed an association, but not cause and effect. It's unclear why these two conditions would be linked.

"The issue is, 'is this real and why?' It's an intriguing observation that needs to be followed up," said Anton C. Schoolwerth, MD, a nephrologist and professor of medicine at Dartmouth-Hitchcock Medical Center in Lebanon, N.H.

Some experts theorize that the stones themselves, or treatment to destroy them, may cause damage that later progresses to CKD and ESRD. Or it may start earlier. The process of stone formation may begin the cascade, but this association also may be because the same medical conditions that increase the chance of stones also increase the possibility of these other problems.

"It could be that there are common risk factors," said Gary Curhan, MD, ScD, a nephrologist and physician investigator at Brigham and Women's Hospital in Boston. "[Kidney stones] may not be causal."

But while the link between kidney stones and kidney disease is an open question, the fact that problems with this organ are becoming more common is not. The number of people affected has grown by 30% over the past decade. Most will die of cardiovascular disease before the kidney fails, although ESRD also increased by 3.4% from 2005 to 2006. In response, the U.S. Renal Data System last month issued its first report on the subject, in conjunction with its annual paper rounding up ESRD statistics. About 27 million people have CKD. The condition accounts for 24% of Medicare costs. The ESRD population makes up about 1% of the Medicare population and 7% of the program's costs.

"The major focus on chronic kidney disease in this year's report acknowledges that this disorder is a growing public health issue deserving of wider public awareness and intensified scientific investigation," said Elias A. Zerhouni, MD. He was director of the National Institutes of Health at the time the report was issued.

CKD also is a subject of growing public health surveillance efforts and medical society attention. In June, the American Medical Association passed policy at its Annual Meeting in Chicago that called for the U.S. Preventive Services Task Force to consider developing guidelines on the screening, diagnosis and staging of the condition.

NEW YORK (Reuters Health) - Regular exercise and a calcium-rich diet could be two ways to help lower the risk of metabolic syndrome, according to a new study.

Metabolic syndrome refers to a cluster of risk factors for diabetes and heart disease -- including abdominal obesity, high blood pressure, high blood sugar, low levels of "good" HDL cholesterol and high triglycerides (another type of blood fat). The syndrome is typically diagnosed when a person has three or more of these conditions.

In the new study, of more than 5,000 Illinois adults, researchers found that metabolic syndrome was less common among those who got the recommended amounts of exercise and dietary calcium.

Overall, the study found, people who failed to get adequate exercise -- at least 30 minutes of moderate activity, such as walking, on most days of the week -- were 85 percent more likely to have metabolic syndrome than their active counterparts.

Similarly, men and women who said they did not regularly eat calcium-rich foods had a 61 percent higher risk of the syndrome than those who frequently consumed calcium-packed foods.

"As with many health conditions, when the good behaviors are absent, the condition is more prevalent," lead researcher Adam Reppert, a dietitian at Swedish Covenant Hospital in Chicago, said in a written statement.

He and his colleagues report the findings in the American Journal of Health Promotion.

Beyond lifestyle factors, the researchers also found that African Americans and lower-income study participants had higher risks of metabolic syndrome.

About one-quarter of black adults had the condition, versus 16 percent of whites and 17 percent of Hispanics. When it came to income, more than one-third of people who earned less than $15,000 per year had metabolic syndrome, compared with only 10 percent of those earning more than $50,000.

The implication, the researchers say, is that it will be particularly important to encourage lower-income African Americans to take up exercise and healthier eating.

Lifestyle is also vitally important for anyone who already has metabolic syndrome, Reppert pointed out, as a healthy diet and exercise are ways to "intervene to prevent heart disease or diabetes."

SOURCE: American Journal of Health Promotion, November/December 2008.

Copyright © 2008 Reuters Limited.

NEW YORK (Reuters Health) - Women have easier and quicker access to the morning after pill since the Food and Drug Administration ruled that the medication could be sold to adults without a prescription, a survey of pharmacies in three large US cities shows.

In 2006, the FDA approved "behind the counter" status for Plan B -- meaning that people aged 18 and older can buy the emergency contraceptive over the counter, while younger people need a prescription from a doctor. The medication consists of a high dose of progesterone, and works by preventing the ovaries from releasing an egg, or delaying this release. Unlike the "abortion pill," RU-146, it will not affect an existing pregnancy.

"The sooner you take it the more effective it is, which is why availability is so important," Dr. Rebekah E. Gee of the University of Pennsylvania School of Medicine in Philadelphia, the lead researcher on the study, told Reuters Health. Plan B works best if it is taken within 24 hours of unprotected sex, she added.

To investigate whether the rule change had any effect on the drug's availability, Gee and her colleagues surveyed pharmacies in Atlanta, Boston, and Philadelphia in 2005 and 2007. The first round of the survey included 1,087 pharmacies, while the second included 795.

In 2005, Gee and her team found, 23 percent of pharmacies reported being unable to dispense Plan B within 24 hours. Two years later, just 8 percent did. And 2 percent of the pharmacists surveyed in 2007 said they would refuse to dispense the drug, compared to 4 percent in 2005.

In Atlanta, where state law permits pharmacists to refuse to dispense emergency contraception if it conflicts with their moral or religious beliefs, the rate of refusal was 9 percent in 2005 and fell to 2 percent in 2007. The percentage of pharmacies that were unable to dispense the drug within 24 hours fell from 35 percent to 14 percent.

Philadelphia has no laws on the books regarding whether a pharmacist can refuse to dispense emergency contraception or requiring pharmacies to stock commonly used medications. In that city, the percentage of pharmacies reporting being unable to dispense the drug fell from 23 percent in 2005 to 10 percent in 2007, while refusal rates were 3 percent in 2005 and 4 percent in 2007.

In Boston, which has laws requiring pharmacies to stock all commonly available medications, rates of being unable to dispense Plan B or refusing to do so were low at both time points.

Plan B is extremely safe, Gee noted, with nausea being the most common side effect. She said she believes it should be available without a prescription to younger people as well. "There's no evidence that use of Plan B leads to more intercourse or riskier behavior, even though some of its opponents have claimed that," she added. "The data definitely show that that's not true."

The US has the highest rate of unplanned pregnancies in the industrial world, Gee pointed out, while 1 in 3 US women will have an abortion. Plan B does not reduce rates of unplanned pregnancy in the population at large, she added; she and her colleagues say that this is because it isn't a replacement for routine contraception. "Only through increased access to more effective methods of contraception and by empowering women to be educated about their reproductive health will we likely see a change in unintended pregnancy rates," they wrote.

SOURCE: American Journal of Obstetrics & Gynecology, November 2008.

Copyright © 2008 Reuters Limited.

NEW YORK (Reuters Health) - Researchers from Harvard School of Public Health in Boston estimate that between 2000 and 2005 more than 330,000 lives were lost because a "feasible and timely" AIDS drug treatment program was not implemented in South Africa.

By not implementing a mother-to-child transmission HIV prevention program during the same 5-year period, an estimated 35,000 infants were born with HIV.

Dr. Pride Chigwedere and colleagues describe their analyses that generated these estimates in a Perspectives article published online in the Journal of Acquired Immune Deficiency Syndromes.

By way of background, at the peak of the South Africa AIDS epidemic, they explain, "the government, going against consensus scientific opinion, argued that HIV was not the cause of AIDS and that antiretroviral drugs were not useful for patients and declined to accept freely donated nevirapine (an AIDS drug) and grants from the Global Fund."

To estimate lost benefits due to these decisions, the investigators compared the actual number of South Africans who received drugs for treatment of HIV infection or for prevention of mother-to-child HIV transmission between 2000 and 2005 with what was reasonably feasible in the country during that period. They then multiplied the differences by the average "life-years" conferred by antiretroviral therapy for African patients with AIDS or the efficacy of antiretroviral treatment in preventing mother-to-child transmission.

For comparison, the researchers used data from Botswana and Namibia, neighboring countries facing a similar burden of HIV/AIDS and with similar resources per capita. In contrast to South Africa, Botswana and Namibia began a program for the prevention of mother-to-child transmission in 1999 and a national AIDS treatment program in 2001.

The investigators estimate that the total lost benefits of not using antiretroviral drugs between 2000 and 2005 amount to at least 3.8 million "person-years."

"Access to appropriate public health practice is often determined by a small number of political leaders," they note in their report.

"In the case of South Africa, many lives were lost because of a failure to accept the use of available antiretrovirals to prevent and treat HIV/AIDS in a timely manner," they conclude.

SOURCE: Journal of Acquired Immune Deficiency Syndromes, 2008.

Copyright © 2008 Reuters Limited.

NEW YORK (Reuters Health) - Results of a new study suggest that the use of oral moist snuff, a type of smokeless tobacco widely used in Sweden that is also known as "snus," may increase the risk of fatal stroke.

Dr. Maria-Pia Hergens, of the Karolinska Institute in Stockholm, and colleagues examined data on Swedish construction workers attending health check-ups between 1978 and 1993 who completed questionnaires that included information on tobacco use.

A total of 118,465 men who had never smoked and had no history of stroke were followed through 2003. The Inpatient Register and Causes of Death Register were used to identify subsequent illness and death from stroke.

During an average of 18 years of follow-up, 3,248 men suffered a stroke. Most of these (70 percent) were "ischemic" strokes due to restricted blood flow ischemic, whereas 17 percent were "hemorrhagic" or bleeding strokes. Thirteen percent of strokes were "unspecified."

Overall, 29 percent of the subjects had ever used snuff. The overall relative risk of stroke was not increased in these ever users of snuff.

However, for fatal stroke, the relative risk was 27 percent higher among ever-users of snuff compared with never users. This was mainly driven by an excess 38 percent risk of fatal stroke among current users of snuff.

When the team analyzed subtypes of stroke, they found a 71 percent increased risk of fatal ischemic stroke associated with current snuff use. No increased risk was observed for hemorrhagic stroke.

This study, the researchers conclude, suggest that "snuff use may elevate the risk of fatal stroke, and particularly of fatal ischemic stroke."

SOURCE: Epidemiology, November 2008.

Copyright © 2008 Reuters Limited.