Carotid Artery Stenting

According to the authors, treatment options for patients with significant carotid atherosclerosis include carotid endarterectomy (CEA), carotid artery stenting (CAS), and medical therapy. This is an analysis of results from the Stenting and Angioplasty with Protection in Patients at High-Risk for Endarterectomy (SAPPHIRE) randomized trial, which examined patients at higher surgical risk to determine factors predictive of death or stroke within 30 days of CAS. A new study gives guidance on patient features that identify patients at high and low risk for stroke or death after  carotid artery stenting - CAS. Using a population of patients at high surgical risk undergoing stenting (the SAPPHIRE worldwide study), researchers identified variables that were independently associated with higher risk, including demographic, clinical history, and lesion anatomy features, with the aim of developing a bedside tool for risk prediction. "We developed and validated a predictive model and integer-based tool to predict the occurrence of death or stroke within 30 days of CAS," Neil J. Wimmer, MD, from the Division of Cardiovascular Medicine, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts, and colleagues conclude. The tool was validated internally by statistical methods, but the investigators are also in the process of validating it externally in a new dataset, told senior author Laura Mauri, MD, also from the Division of Cardiovascular Medicine, Brigham and Women’s Hospital, and Harvard Medical School. "That being said, it's pretty robust," she said of the tool. "It's been constructed in over 10,000 patients and is already in a form that's easy to use, so we hope it will be able to be used right away by clinicians to estimate risk in individual patients." Their report was published online November 5 in Stroke to coincide with its presentation at the American Heart Association Scientific Sessions 2012 in Los Angeles, California.  The  SAPPHIRE  trial was a randomized comparison of CEA (carotid endarterectomy) vs carotid angioplasty and stenting in patients deemed at high surgical risk. However, with only 334 patients, it was not large enough to determine the features strongly associated with periprocedural risk, the authors write. For this analysis, they used data from SAPPHIRE, a single-group prospective study of higher-risk patients undergoing CAS using distal protection. The goal was to develop and internally validate a model and bedside tool to predict death or stroke within 30 days of stenting in patients at higher surgical risk by using variables that could be collected easily during clinical practice, the authors write. "The prediction model generated here can be used to support decision-making." Only patients with at least a single anatomic or comorbid factor associated with elevated surgical risk were included; in all, 10,186 patients were included in the analysis. The overall rate of stroke or death was 3.6% at 30 days after carotid stenting, which, Dr. Mauri said, is "interesting, because the patients who were included in the study were selected for having a high risk for undergoing carotid endarterectomy. And there are certain consensus opinion variables that surgeons feel increase the risk of carotid endarterectomy. Well, those variables are different from the ones that pertain to carotid artery stenting." They found that elevated age, history of stroke, history of transient ischemic attack (TIA), recent myocardial infarction (MI), the need for both cardiac surgery and carotid revascularization, dialysis treatment, the presence of a type 2 or 3 aortic arch, a right-sided carotid stenosis, a longer carotid plaque, and a severely tortuous carotid arterial system were all important risk factors for the development of stroke or death within 30 days of CAS.

·         Increased age

·         History of stroke

·         History of TIA presentation

·         Recent (<4 weeks) MI

·         Dialysis treatment

·         Need for cardiac surgery as well as carotid revascularization

·         Right-sided carotid stenosis

·         Longer carotid plaque

·         Type 2 or 3 aortic arch

·         Tortuous carotid arterial system

Using these factors, the researchers developed a model and integer-based risk score for predicting stroke or death within 30 days. The model was calibrated and internally validated, using bootstrap resampling. The risk score, included in the article, assigns points for each risk factor. The sum of the points relates to the level of risk, ranging from a less than 3% risk with 8 or fewer points to a greater than 10% risk with 16 or more points. "If you just look at the table for the risk score, the most powerful predictors obviously are the ones that give you the most points, and patients who needed to have carotid surgery together with coronary revascularization were at very high risk; patients with a recent MI, patients undergoing dialysis, those were really strong predictors, in addition to patients with advanced age, particularly those who were over 70 years of age," Dr. Mauri said.

Beautiful people

Despite the widely accepted ‘What is beautiful is good’ stereotype, our findings suggest that the beautiful strive for conformity rather than independence, and for self-promotion rather than tolerance,” writes a research team led by Lihi Segal-Caspi of the Open University of Israel.

In other words, the positive traits we attribute to good-looking people are simply a matter of stereotyping. But this study, published in the journal Psychological Science, suggests the unusually attractive have a distinct set of values—and they’re not, well, pretty.

The experiment featured 236 university students (mean age 29), all of whom completed detailed questionnaires designed to uncover their personality traits and deeply held values. Half the participants—118 women—were then videotaped for roughly one minute apiece as they walked around a table and read a weather forecast while looking into the camera.
The other 118 (a mixed group, 59 percent female and 41 percent male) subsequently watched the tapes. They rated each woman for attractiveness (passing judgment on her body, voice, degree of refinement and stylishness of dress), and offered their perception of her traits and values.
In line with prior research, “perceiving a target as physically attractive was associated with perceiving her as agreeable, open to experience, extroverted, conscientious and emotionally stable,” the researchers write. In contrast, on their self-assessment forms, attractive and less-attractive women did not significantly differ on these traits.
However, attractive and less-attractive women did differ on their self-reported values. “Attractiveness correlated with values that express the motivation to conform and submit to social expectations,” the researchers write, “and with values that express a focus on self-promotion rather than on concern for others.”
This is, of course, one small sample from one small country, but the results make intuitive sense. If beautiful people get doted on from a young age, they surely get the sense that society values them highly; it follows that they’d be more likely to be conformists than rebels.
Similarly, a focus on self-promotion as opposed to empathy may suggest narcissism—but isn’t being treated as special the perfect incubator for such an attitude?

Vision and Hearing Loss in Older Adults

Among 446 older adults (mean age, 79.9 years) screened, 3 measures of low-contrast visual acuity were significantly associated with moderate bilateral hearing loss in analyses controlling for age and comorbid conditions, report Marilyn E. Schneck, PhD, and colleagues at the Smith-Kettlewell Eye Research Institute in San Francisco, California. "It is suggested that audiologists consider including a brief test of low contrast vision, such as low contrast acuity. Likewise, eye care practitioners should consider performing a screening test of hearing on their patients. Depending on the severity of the dual sensory loss, referral for rehabilitation may be called for," they write. Although most people can adapt well to moderate loss of either vision or hearing, dual sensory impairment can lead to significant decline in quality of life, said Dr. Schneck, a scientist at Smith-Kettlewell and a research scientist at the University of California at Berkeley School of Optometry. "If someone has a vision impairment and is more likely to have a hearing impairment, it has implications for things like speech reading, which we all do to some extent, but people with hearing impairment come to rely on more and more. 

If they're compromised in their low-contrast visual acuity, that could pose a problem to them when they try to make up with vision the information lost to hearing. The investigators cite evidence that dual sensory loss can have greater effects on depression, cognitive function, and quality of life compared with sensory hearing or vision loss alone. Although the study has substantial design flaws, it draws attention to the fact that older adults frequently have sensory deficits that may get overlooked, commented William J. Hall, MD, Fine Professor of Medicine at the Center for Healthy Aging at the University of Rochester School of Medicine in New York. "All healthcare providers who deal with older people need to be aware of the potential for multiple morbidities at the same time. Frankly, what I find is that we commonly miss hearing loss in older people," said Dr. Hall . However, he questioned the investigators' choice to control for age by 5- to 8-year groups rather than as a continuum, and he noted that it would be a mistake to infer from the data that a single mechanism might be responsible for both hearing and vision loss. Johanna M. Seddo, MD, ScM, director of the Ophthalmic Epidemiology and Genetics Service at the New England Eye Center at Tufts Medical Center in Boston, Massachusetts, agrees with Dr. Hall that the authors should have looked at age as a continuous variable. She also noted that the study sample was small, with only 57 of the 446 participants having moderate hearing loss. "It might also have been helpful if the authors had looked at cardiovascular risk factors [other than stroke]. For example, smoking has been shown to be a risk factor for hearing loss in some studies, and we know that it's related to diseases that cause visual loss, both macular degeneration and cataract," she said. Dr. Schneck and colleagues looked at a cohort of older adults enrolled in a longitudinal study of vision and function in Marin County, California. The participants were screened for visual function with both high-contrast and low-contrast visual acuity tests. Moderate visual impairment was defined as binocular high-contrast visual acuity worse than 0.54 logarithm of the minimum angle of resolution, equivalent to 6/21 or 20/70 or worse on a Snellen chart. The authors defined moderate hearing impairment as the inability to hear pure tones presented twice to each ear by an audioscope set to deliver 500-, 2000-, and 4000-Hz frequencies at 40 decibels. As might be expected, the investigators found that prevalence of hearing loss, visual impairment, and dual sensory deficits increased with age. For example, only 1.6% of 67- to 74-year-olds had moderate hearing impairment, compared with 32.7% of those aged 85 years and older. Similarly, although no participants in the 67- to 74-year-old age range met the vision impairment criteria, 19.1% of those aged 85 and up had at least moderate vision loss. No participants younger than age 75 had dual hearing and vision loss, compared with less than 1% of those aged 75 to 79 and 11.8% of those aged 85 and older. In multivariate logistic regression analysis controlling for age, hearing impairment was significantly positively associated with a history of cataract surgery (odds ratio [OR], 1.97; 95% confidence interval [CI], 1.01 - 3.85; P < .05) and self-reported stroke (OR, 2.69; 95% CI, 1.18 - 6.15; P < .05) and was negatively associated with a history of glaucoma (OR, 0.37; 95% CI, 0.15 - 0.88; P < .05). The overall rate of moderate visual impairment was 5.4%, and the rate of moderate, bilateral hearing impairment was 12.8%, suggesting that the conditions are linked in at least some participants, the investigators say. "If vision and hearing impairments were independent, the probability of having both would be the product of the separate impairment probabilities. In this case, we would expect dual sensory loss in 0.7% of people. In fact, the prevalence of dual sensory loss was over four times higher (3.1%), indicating that the two kinds of impairment are associated," they write. The vision measures that were significantly associated with hearing loss were overall low contrast (10%) acuity (OR, 1.50; 95% CI, 1.02 - 2.22; P < .05), low contrast acuity at low luminance (OR, 1.46; 95% CI, 1.07 - 1.98; P < .05), and low contrast and acuity in glare (OR, 1.40; 95% CI, 1.02 - 1.91; P < .05). "For any of these three measures, those who perform poorly were 40-50% more likely to have moderate bilateral hearing loss than those who scored well on that measure," the investigators write. Normal or high-contrast acuity measures were not significantly associated with hearing loss, however.

alcohol

Does moderate, prudent drinking protect the heart and arteries? Two analyses say, actually that the answer is yes. But they raise a bigger issue: What should we do with this information? The answer to that question may come as a surprise. Let's look at the findings first. Researchers from the University of Calgary, University of Texas Health Science Center, and Harvard Medical School scoured the medical literature for long-term studies that compared drinking habits with the development of cardiovascular disease. Of the 4,235 studies they identified, 84 met the researchers' strict criteria. When combined, these studies included more than two million men and women who were followed for an average of 11 years. Using a technique called meta-analysis, the researchers pooled results from the 84 publications and analyzed the data as if they were from one gigantic study. Compared with no alcohol use, moderate alcohol use over the average study duration

• reduced the risk of a new diagnosis of coronary artery disease by 29%
• reduced the risk of dying from any cardiovascular disease by 25%
• reduced the risk of dying from a heart attack or coronary artery disease by 25%
• reduced the risk of dying from any cause by 13%
• reduced the risk of having an ischemic (clot-caused) stroke by 8%
• increased the risk of dying from a stroke by 6%
• increased the risk of having a hemorrhagic (bleeding) stroke by 14%.
The amount of alcohol consumed influenced the effect. For coronary artery disease and death from it, any amount of alcohol, from just under one-half drink per day on up , reduced heart disease risk by about 25%. But this was offset by stroke risk: at four drinks per day, the risk of having a stroke was 62% higher than it was with no alcohol use, and the risk of dying from a stroke was 44% higher. The lowest risk for any cause of death was at one drink per day (BMJ, Feb. 26, 2011). A companion article by the same authors summarized the strong evidence for how alcohol might influence cardiovascular disease, by boosting protective HDL and adiponectin (a hormone that has beneficial effects on blood sugar, the breakdown of fats in the bloodstream, and the inner lining of arteries), and reducing levels of fibrinogen (a protein that helps form blood clots). Wine, beer, and spirits appeared to have similar effects.
In the United States, a standard drink contains about 0.6 fluid ounces of alcohol. The drinks shown above contain roughly that amount of alcohol. Moderate drinking is generally defined as no more than two drinks a day for men and no more than one drink a day for women. The National Institute on Alcohol Abuse and Alcoholism defines drinking as low risk, increased risk, and highest risk.
You might expect the authors of this work to conclude that drinking alcohol is good for the heart and arteries and might be recommended to some people. Instead, they concluded that "our findings lend further support for limits on alcohol consumption." The researchers based this conclusion on the complexity of alcohol's effects on health. Moderate drinking offers some protection against coronary artery disease, but it does just the opposite for hemorrhagic stroke, while heavier drinking significantly increases the risk of having or dying from a stroke. And then there's the rest of the body to consider. Alcohol affects every system in the body, from the brain on down. For people who aren't addicted to alcohol, a little bit has no long-lasting ill effects and may, in some instances, be beneficial, as with the heart and arteries. For example, a small amount of alcohol taken with a meal improves tissues' sensitivity to insulin, which may decrease the chances of developing type 2 diabetes. Excessive consumption of alcohol is only harmful. It is a major cause of preventable deaths and contributes to liver disease, a variety of cancers, and other health problems. Too much alcohol can dissolve the best intentions and the closest relationships. "Few people know what so-called safe drinking is, and many have no idea of the harm alcohol can cause," says Dr. Kenneth J. Mukamal, an author of the two BMJ papers and an internist at Harvard-affiliated Beth Israel Deaconess Medical Center.
When it comes to health, alcohol is a sharp, double-edged sword. A little bit of alcohol, in the neighborhood of a drink a day, may be beneficial for the heart and arteries. With excessive drinking, which differs from person to person, the risks or hazards outweigh the benefits. The CDC estimates that excessive alcohol use contributes to almost 80,000 deaths a year in the United States. These come from motor vehicle accidents and violence, liver disease and hemorrhagic stroke, and 50 other causes.
Immediate health risks
• motor vehicle accidents, falls, drownings, burns
• violence, including intimate partner violence and child maltreatment
• risky sexual behaviors that can result in unintended pregnancy, sexually transmitted diseases, or intimate partner violence
• miscarriage, stillbirth, physical and mental birth defects
• alcohol poisoning
Long-term health risks
• dementia and stroke
• heart attack, cardiomyopathy, atrial fibrillation, hypertension
• depression, anxiety, suicide
• family problems, unemployment
• cancer of the mouth, throat, esophagus, liver, colon, breast
• cirrhosis of the liver, alcoholic hepatitis
• pancreatitis, gastritis
For some people, having a glass of wine, a beer, or a cocktail is a pleasurable social or relaxing activity. For others, drinking alcohol leads to nothing but problems. There are more people in the latter category than we'd like to think. A nationwide survey of 43,000 adults conducted by the National Institutes of Health tells a cautionary tale. Among those who said they drink alcohol, four in 10 were heavy drinkers or at risk for becoming one. To look at it another way, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) estimates that nearly 19 million Americans have a problem with alcohol. The terms "moderate" and "excessive" have long been used to describe drinking habits. The NIAAA now uses more descriptive terms — low risk, increased risk, and highest risk. In this case, risk refers to the chances of developing alcohol-related health problems, alcoholism, or both.
Low-risk drinking. For men, this is no more than four drinks in a single day and no more than 14 drinks in a week; for women, no more than three drinks in a single day and no more than seven drinks in a week. (About 57% of Americans who drink alcohol fall into this category.) Increased-risk drinking is drinking more than either the single-day limit or the weekly limit (29% of drinkers). Highest-risk drinking is drinking more than the single-day limit and the weekly limit (14% of drinkers).
No prescription for alcohol: Studies supporting the cardiovascular benefits of drinking alcohol have often raised the question of whether some older people should start drinking, or if doctors should sometimes recommend it. "From a health perspective, there are few, if any, situations in which it makes sense for someone to begin drinking alcohol," says Dr. Mukamal. The potential benefit is limited (more exercise would be a better choice). It would take more time than most doctors can give to have a nuanced conversation about the risks and benefits of alcohol. And encouraging nondrinkers to begin drinking "doesn't make good medical sense, since there's no proof they can do it safely," Dr. Mukamal cautions. If alcohol affected only the coronary arteries, drinking it might be good medicine. But it affects almost every other part of the body, and the amount consumed determines the ultimate outcome. That means a more careful approach to this two-faced beverage is in order.

Poor Glucose Control

Poor glycemic control , whether too high or too low, is associated with decreased survival in diabetic patients on hemodialysis, Kamyar Kalantar-Zadeh, MD, MPH, PhD, professor of medicine, pediatrics, and epidemiology at the University of California at Los Angeles David Geffen School of Medicine, reported here at Kidney Week 2011: American Society of Nephrology 44th Annual Meeting. Dr. Kalantar-Zadeh reported that in a 6-year study, moderate hyperglycemia raised the risk for all-cause or cardiovascular mortality of hemodialysis patients with diabetes, and levels of glycated hemoglobin (HbA1c) below 6% or blood glucose below 100 mg/dL were associated with an elevated risk for death. According to most studies, he said, if glucose is well controlled, there are improvements in mortality, microvascular complications, and cardiovascular disease. One study showed that for every 1% decrease in HbA1c, deaths related to diabetes decreased 21%, microvascular complications decreased 37%, and myocardial infarctions decreased 14%. "Diabetes mellitus is a potent cardiovascular risk factor in both the general population and dialysis patients, almost half of whom suffer from diabetes in the United States," Dr. Kalantar-Zadeh said during a news conference. "Some guidelines recommend that diabetic dialysis patients follow the same HbA1c target area as the American Diabetic Association." However, he said, although there are some data from studies with varying methodologies, there is no clear guidance on glucose targets for the dialysis patient population. He and his colleagues examined the predictive value of glycemic control on all-cause and cardiovascular mortality, using a large database (n = 54,757) of hemodialysis patients with HbA1c data from 2001 to 2006, and follow-up to 2007. Random (not necessarily fasting) serum glucose measurements correlated moderately well with HbA1c (correlation coefficient, r = 0.56). Examining a range of HbA1c values (from less than 5% to more than 10%), they found the lowest all-cause mortality between 6% and 8%. Above 8%, the higher the HbA1c, the greater the mortality; it is "up to 50% higher for HbA1c above 10%," Dr. Kalantar-Zadeh said. "At the same time,...a very low HbA1c level, below 5%...increased mortality." A similar relation was seen for cardiovascular mortality. A subgroup analysis showed that HbA1c above 7% had a detrimental effect on mortality for all parameters and groups of maintenance hemodialysis diabetic patients examined, including race, sex, age, and serum albumin, hemoglobin, and ferritin levels. The same sort of relation held when random glucose measurements were considered. All-cause mortality rose at glucose levels below 100 mg/dL, and rose dramatically above 200 mg/dL. The lowest death rates were seen at glucose levels between 100 mg/dL and 200 mg/dL. Cardiovascular mortality was lowest in this same range. Subgroup analyses in terms of glucose levels yielded results very similar to those of HbA1c. Potential limitations of the study are that it was observational, Dr. Kalantar-Zadeh noted. Patients were not randomized to receive treatments, treatments for diabetes were not considered, and medication data were lacking. In addition, HbA1c and glucose measurements were taken at random times. Dr. Kalantar-Zadeh concluded that poor glycemic control, with HbA1c above 8% or glucose above 200 mg/dL, "appears to be associated with decreased survival in prevalent diabetic dialysis patients, and moderate hyperglycemia increases the risk for all-cause or cardiovascular mortality of diabetic hemodialysis patients, especially in...Caucasians, men, and individuals with serum albumin less than 3.8 g/dL." Levels of HbA1c below 6% or glucose below 100 mg/dL "are bad, too," he said. He suggested performing controlled trials to target a certain range of HbA1c in diabetic dialysis patients to verify these observational findings. News conference moderator Katherine Tuttle, MD, executive director for research at Providence Sacred Heart Medical Center and professor of medicine at the University of Washington School of Medicine in Spokane, who was not involved in the study, said that clinical guidelines have been updated and will be issued soon. Although she could not elaborate before they are published, she said: "You will see a change in several things, including targets for glycemic control based on published data. I think the data presenting will only add to that." She said previous Kidney Disease Outcomes Quality Initiative guidelines were based on the primary prevention of kidney disease, and an HbA1c below 7% was shown to prevent new-onset kidney disease. But there were no data on the treatment of patients with kidney disease; those data are expected to figure in the new guidelines, with higher HbA1c targets for people with multiple comorbidities and limited life expectancies, which would include the dialysis population.

Child abuse

Women who suffer either physical or sexual abuse early in life have a significantly increased risk for subsequent cardiovascular events, including myocardial infarction and stroke, a new study suggests. The study, using data from the Nurses' Health Study II, shows that women who reported they had experienced forced sexual activity during childhood or adolescence had a greater than 50% increased risk for cardiovascular disease. The relationship with physical abuse was significant but less robust, the authors note, and will have to be confirmed in other data sets.

This is the third study to show that forced sex among girls is linked with at least a 50% increase in cardiovascular event risk, lead author Janet Rich-Edwards, ScD, MPH, associate professor in the Department of Medicine at Brigham and Women's Hospital in Boston, Massachusetts, said at a press conference here. The relationship was only partially explained by traditional cardiovascular risk factors. "The consistency of the sexual abuse studies suggests that we continue our abuse prevention efforts in childhood, and that we also develop specific cardiovascular disease prevention strategies tailored to the needs of women who've experienced abuse in childhood," Dr. Rich-Edwards concluded. The results were presented here at the American Heart Association (AHA) 2011 Scientific Sessions. A national survey of 8000 women conducted by the National Institute of Justice and the Centers for Disease Control and Prevention in 1995 to 1996 showed that 52% of women "were willing to report to a stranger on the telephone that they had been physically assaulted during their lives, and 18% reported completed or attempted rape," Dr. Rich-Edwards said. "I have to say that no matter how many times I see this, the data shock me every time." Most attacks took place in childhood, with 54% of those who reported a rape, or 9% of the overall group, reporting that the assault occurred before the age of 18 years, "so this is an exposure of girls and adolescent women." There are 2 other studies in the literature looking at cardiovascular outcomes after physical or sexual abuse, she noted. One, the Adverse Childhood Experience Study of 17,000 men and women, found an increased risk for coronary heart disease of 50% for physical abuse and 40% for sexual abuse. The other, the National Comorbidity Survey of 4251 women, showed divergent findings for physical and sexual abuse, with no increased risk for coronary heart disease for those reporting physical abuse, but a 5-fold increased risk for those with a history of sexual abuse. "Both of these studies are considerably smaller than the study I'm going to show you today, and much less rigorous in terms of defining coronary heart disease and stroke," Dr. Rich-Edwards noted. Her report used data from the Nurses' Health Study II, which includes 116,640 female registered nurses, from 14 US states, who were aged 25 to 42 years at baseline in 1989.b"At the end of follow-up for this particular analysis in 2007, they were age 43 to 60, so take note, these are very early cardiovascular events for women," she said. The study's biennial questionnaire in 2001 asked women about their life experience with violence. "This allows us to look at events prospectively after they reported the violence to us, and retrospectively from the beginning of the study until 2001, when we asked the questions."For both periods, cardiovascular events were validated by medical records. Self-reported unvalidated events were also included; both previous studies used only self-reported events. After excluding those who did not return the violence questionnaire or who had a history of cancer, myocardial infarction, or stroke before baseline, the study group included 67,315 women free of cardiovascular disease or cancer. Child abuse was assessed using the Conflict Tactics Scale, a questionnaire that assesses levels of exposure. Spanking for discipline was not included as abuse. Physical abuse was classified as mild, moderate, or severe, depending on responses, and sexual abuse was classified as unwanted sexual touching or forced sexual activity while the woman was a child or teenager. Physical abuse, classified as mild, moderate, or severe, was reported by 54% of the cohort, and 9% reported severe physical abuse, the researchers report. Sexual abuse was reported by 33% of the women, and 11% reported forced sexual activity before age 18 years. They found that mild or moderate physical abuse in childhood and adolescence was not associated with cardiovascular disease, but a 46% increase in risk was seen in those with a history of severe physical abuse after adjustment for age, race, parental cardiovascular history, body type of the girl at age 5 years, and parental education, Dr. Rich-Edwards noted. After further adjustment for risk factors in adulthood that are likely themselves to be linked to a history of abuse, including smoking, alcohol use, body mass index, diabetes, and hypertension, the association between physical abuse and cardiovascular events was "dampened," she noted. "In fact, 47% (95% confidence interval, 24% - 71%) of the association between severe physical abuse and adult cardiovascular disease is explained by these established cardiovascular risk factors." The relationship with sexual abuse was stronger. Women with a history of forced sexual activity had a 56% increase in risk for cardiovascular events; there was no increased risk seen with sexual touching only. When the researchers adjusted for cardiovascular risk factors in adulthood, the relationship was again mitigated, but not as much as with physical abuse; these risk factors accounted for about 38% of the excess risk (95% confidence interval, 25% - 53%). "So just shy of 40% of the association between forced sex in childhood and cardiovascular disease in adulthood is explained by established risk factors, which is a lot left unexplained," Dr. Rich-Edwards noted. Additional analyses showed that the associations were stronger for women without adult abuse, and for stroke than for myocardial infarction. Simultaneous adjustment for both sexual and physical abuse again dampened both associations "modestly," the researchers note. There was also a relationship between case confirmation and risk for cardiovascular events, with the lowest risk seen in the "definite" confirmed cases of physical and sexual abuse, although the association with forced sex was still statistically significant. When they included definite, probable, and unconfirmed cases of physical and sexual abuse, hazard ratios increased to 1.77 for physical abuse and 2.06 for forced sex (P < .05 for both). "I think what this points to is, first and foremost, the need for prevention; not only the prevention of child abuse, but in pediatrics offices and other agencies that spot child abuse, understanding that it's not just a short-term problem, but there's really a long tail of chronic disease that ensues from this," Dr. Rich-Edwards concluded. About 40% of the increased risk appears to stem from lifestyle risk factors, so those events might be prevented, "just by applying what we know." In the adult primary care setting, where these women will most probably first be seen, it is important that physicians talk about the issue, and let women know that, "though they may have had their bodies disrespected as children, there's a lot they can do as adults to take good care of themselves," she said. Tailored approaches for these women taking into account their experiences might also be developed. "Finally, the fact that we can explain only about half of it through our known pathways means we have a lot more work to do in terms of understanding the other ways in which this early psychosocial stress is literally embodied," she concluded. Factors like stress reactivity, for example, which appears heightened in women with a history of abuse, are just beginning to be investigated now. Asked for comment on these findings, Donna K. Arnett, PhD, professor and chair of epidemiology at the University of Alabama, Birmingham, and president-elect of the American Heart Association, called these results "disturbing on a number of levels." "First, the prevalence of abuse is much higher than many of us realize, and that it's associated with these other cardiovascular risk factors and other cardiovascular disease in later life provides a compelling case that we need to address this early in childhood said" Dr. Arnett. "We need to screen for it, we need to understand it, and we need to intervene at the cause, which is this physical or sexual abuse in children, so that we prevent downstream cardiovascular disease." Interestingly, known cardiovascular disease risk factors did not entirely account for the increased risk, particularly for the sexual abuse, she noted, "and that's one that gets underreported, because it's often unseen."

Autism

Autism may be an advantage in some settings and should not be viewed as a defect that needs suppressing, according to a provocative article published online November 2 in Nature.


Recent data and my own personal experience suggest it's time to start thinking of autism as an advantage in some spheres, not a cross to bear," said author Laurent Mottron, MD, PhD, from the University of Montreal's Centre for Excellence in Pervasive Development Disorders. According to the article, the definition of autism itself is biased, being characterized by "a suite of negative characteristics," focusing on deficits that include problems with language and social interactions. However, in certain settings, such as scientific research, people with autism exhibit cognitive strength."We think that the kind of strengths and cognitive profile that we find in autistics are much more specific than scientists usually acknowledge," said Dr. Mottron."Unfortunately, there is no gold standard for the diagnosis of autism. Clinical diagnoses are reliable among scientists, but it is just a consensus...everybody may fail."He noted that as a result of a diagnosis, many individuals with autism end up working at repetitive, menial jobs despite their potential to make more significant contributions to society."After 18 years of age they're not kids anymore, and they're forgotten," he said. "People have a cliché, that if he's autistic you can do nothing with him. That's not true. The fact that you have some terrible autistic life is not representative of autism in general. Dr. Mottron has 8 individuals with autism people in his research group including 4 assistants, 3 students, and 1 researcher, Michelle Dawson, whom he met almost 10 years ago during a television documentary about autism. Following the show, Ms. Dawson experienced problems in her job as a postal worker and was asked by Dr. Mottron to edit some of his papers. "She gave exceptional feedback, and it was clear that she had read the entire bibliography," Dr. Mottron noted. Her single-minded autistic abilities to discern patterns out of mountains of data and instant recall of correct information made her perfectly suited to a career in science, he said. Though lacking a formal doctorate, Ms Dawson has since coauthored 13 papers and several book chapters. Dr. Mottron said Ms. Dawson and other individuals with autism have convinced him that more than anything, people with autism "need opportunities, frequently support, but rarely treatment." As a result, he believes that "autism should be described and investigated as an accepted variant within human species, not as a defect to be suppressed." Dr. Mottron noted that autistic brains do function differently, relying less on verbal centers and demonstrating stimulation in regions that process both visual information and language. Advantages may include spotting a pattern in a distracting environment, auditory tasks such as discriminating sound pitches, detecting visual structures, and mentally manipulating complex 3-dimensional shapes. Individuals with autism also perform Raven's Matrices at an average of 40% faster than nonautistics, using their analytical skills to complete an ongoing visual pattern. Other benefits of autism include the ability to simultaneously process large amounts of perceptual information as data sets and the presence of instantaneous and correct recall. Because data and facts are of paramount importance to people with autism, they also tend not to get bogged down in career politics or seek popularity via promotional publishing; online essays such as those posted by Ms. Dawson in her blog may instead receive unintentional acclaim. "I no longer believe intellectual disability is intrinsic to autism," Dr. Mottron said, noting that intelligence in people with autism should be measured with nonverbal tests. In his article, Dr. Mottron cites recent data, including an epidemiological study that showed the disorder is 3.5 times more prevalent than common statistics suggest. He noted that the study showed that many of those with autism have "no adaptive problems at all," and can function relatively normally. However, he added, a focus on "normocentrism" prevails in some countries. France, for example, has proposed mandatory interventions aimed at forcing children with autism to adopt "typical" learning and social behaviors, rather than allowing them to make the most of their differently wired brains. Dr. Mottron finds such a concept concerning. "There is no current treatment for autism, just educational strategies that do not put the emphasis on learning abilities for nonsocial information...We need to take their learning style for what it is and feed it," he said.


"What we know is that if we reach these individuals at a young age, when their brains are malleable, we can cognitively redirect the transmission of information via the corpus callosum to the speech areas in the left hemisphere of the brain, and oftentimes speech and language will kick in." She continued: "The audio processing of music in the brain combined with the forward, backward, and side-to-side movements stimulate and activate the dormant areas of the brain that, in autism, do not generally receive transmission of neurons. "Movement and music, when combined with gross motor and visual processing, oftentimes helps the areas of the brain of the individual with autism to work together to allow for a whole-brain processing approach," she added.


"I think it's critically important to acknowledge the potential strengths associated with autism, but it's equally important, if not more important, to reiterate the notion of the right to effective treatment, said " Jonathan Tarbox, PhD, BCBA-D, director of research and development at the Center for Autism and Related Disorders, Tarzana, California. "If an individual with autism is having a difficult time in their life because they don't know how to do something that they want to do, and there is a proven effective method to teach that skill, then we as fellow humans have a moral and ethical responsibility to provide the treatment that addresses it," he said. Behavioral intervention programs, he said, should be used in a supportive environment to treat skill deficits in individuals with autism wanting to learn, similar to those used for literacy and mathematics. He added that autism is no different: People who have skill deficits and want to learn have a right to effective treatment. Dr. Tarbox took exception to Dr. Mottron's contention that individuals with autism need opportunity more than treatment. Environmental support, he said, does create opportunity. In addition, he noted that research shows that early intensive behavioral intervention increases the ability to communicate and function independently. "How can a newly found ability to communicate not be considered an opportunity?" he said. One of Dr. Mottron's main points is that the performance of individuals with autism on visual intelligence tests is often overlooked, showing that the true intelligence of people with autism is higher overall than verbal intelligence tests would indicate. "This is, of course, true, but true intelligence is of little relevance to a person's everyday quality of life. What really matters is one's ability to do what one wants to do in life independently; that is, without having to rely on support from others," said Dr. Tarbox. "There are many people, autistic and nonautistic, who have superior intelligence but still have much difficulty in life and suffer for it. Unfortunately, vocal language is the medium with which most humans interact, so deficits in one's ability to vocally communicate are going to create barriers for people." Dr. Mottron also states that no education programs are tailored to the unique ways that people with autism learn. However, Dr. Tarbox noted that there are "many tens of thousands of special education teachers, speech and language pathologists, and applied behavior analysts working to change what they do to help individuals with autism learn." The aim of behavioral interventions, he added, is not to try to teach individuals with autism to adopt typical learning and behavior but, rather, to teach skills that help increase independence. Such programs, he said, "teach skills that open doors for individuals with autism, but they do not dictate which door to take."
"I think what Dr. Mottron was getting to is the idea that autism is a different way of being, not necessary a disordered way of being, and the difference can give us strengths and abilities that other people may not have," said Stephen M. Shore, EdD, assistant professor at Adelphi University in Long Island, New York."At the same time, there are many challenges that come with being on the autistic spectrum, such as sensory issues, communication, interacting with others. These things are challenges, and we do have to address them," Dr. Shore noted.


Diagnosed himself with autism at age 2 and a half years, and nonverbal until age 4 years, Dr. Shore was originally recommended for institutionalization. With the help of family and others, he completed a doctoral dissertation at Boston University in Massachusetts that was focused on matching best practice to the needs of people on the autism spectrum. He now spends his time researching, teaching, writing books, and conducting autism workshops around the world. According to Dr. Shore, the best way to address those issues is to find a way to use a person's strengths to overcome their challenges. "There is a point in time when you have to get off the remediation and start moving on to finding a way the person can be successful in communication," he said. Methods may include use of a computer keyboard, rather than a pen, to write, or pointing at pictures to communicate, he said. Adjusting the environment also plays a vital role and often benefits people without autism. "Many autistics have sensory issues and perceive fluorescent lights as most people strobe lights, which will really affect productivity at work and school," Dr. Shore said. "Research shows that everybody's productivity is affected by fluorescent lamps, so everyone benefits by using alternate lighting." With respect to the plethora of methodologies used to address autism in children, Dr. Shore notes that the wide variety of diversity within the autism spectrum disorders necessitates a tailored approach. Parents and educators are encouraged to pick one or more approaches that best suits the child's needs and abilities. This may include use of Applied Behavioral Analysis, Treatment and Education of Autistic and Related Communication-Handicapped Children, Daily Life Therapy, the Miller Method, the Developmental/Individual Difference/Relationship-based method, relationship development intervention, and social communication/emotional regulation. "You can have a right or wrong approach on an individual basis, but not on a generic basis," he said.