New therapies help obsessive-compulsive, tic disorders

Dr. Susan Perlmutter of the National Institutes of Health in Bethesda, Maryland, and colleagues report that both treatments ''gave rapid and sustained improvements'' in symptoms of obsessive-compulsive and tic disorders.

The cause of obsessive-compulsive disorders and tic disorders is unknown, but some studies have indicated that streptococcal infections may play a role. Antibodies generated by the immune system to attack the bacteria may also attack cells of the nervous system, which can result in inflammation and symptoms of the disorders.

To see if therapies that modify the immune system could block or remove the antistreptococcal antibodies, the investigators administered either plasma exchange (a type of therapy where blood is filtered to reduce antibody concentrations), intravenous immunoglobulin, or (an inactive) placebo to 29 children aged 5 to 14 years.

Significant improvements in obsessive-compulsive symptoms, tic severity and psychosocial function were seen at one month and persisted for up to a year in 82% of patients (14 out of 17) who received either plasma exchange or immunoglobulin therapy. Plasma exchange was determined to be better than immunoglobulin, especially for treating obsessive-compulsive disorder.

However, the treatments may not be as good as they sound, according to Dr. Harvey Singer of the Johns Hopkins University School of Medicine in Baltimore, Maryland. Singer makes the following criticisms in an accompanying editorial: the association between streptococcal infections and obsessive-compulsive and tic disorders is controversial; the mechanism of the therapies in this study are unknown; and it is not known what role psychiatric drugs played in this study because ``they were decreased in dose or discontinued in only about half the patients.''

Therefore, Singer advises that ``active immunomodulatory therapy is not ready for routine use'' and should be used now only in study settings.

SOURCE: The Lancet 1999;354:1137-1138, 1153-1158.

Silent strokes may be linked to depression

``Depression may indicate the presence of small blockages, called lesions, of the blood vessels in the brain that could provide a warning of a potential stroke before it happens,'' the study's lead author, Dr. David C. Steffens, of Duke University Medical Center in Durham, North Carolina, said in a news release.

The formation of these blockages is called a silent stroke, because it does not cause the symptoms of stroke, such as severe headache, numbness, dizziness or paralysis. However, these blocked blood vessels prevent the brain from getting all the oxygen-rich blood it needs.

In a study of 3,660 men and women who underwent testing for depression and a brain scan called magnetic resonance imaging (MRI), Steffens and colleagues found that participants who were depressed were more likely to have a large number of small lesions in the part of the brain called the basal ganglia. The study findings are published in the October issue of the journal Stroke.

``Patients with depression seem to have lesions in the deep part of the brain,'' Steffens told Reuters Health in an interview. These lesions probably interrupt the process by which different regions of the brain communicate with one another, which may explain why they may be related to depression, he said.

The research ``puts a different twist on the treatment of depression, particularly in the elderly,'' Steffens said. While antidepressants may still be needed, in some older patients who are depressed, better control of risk factors for stroke may help relieve or even prevent depression, according to Steffens.

Based on the findings, which confirm earlier reports, elderly people, especially those who are at high risk for heart disease and stroke, should be screened for depression, Steffens concludes.

SOURCE: Stroke 1999;30:2159-2166.

Psychology - disease connection refuted

After an analysis of 46 studies that looked at a potential link between breast cancer and psychological health, researchers from Roswell Park Cancer Institute in Buffalo, New York, and the University of Illinois at Urbana-Champaign found that anxious or depressed women, women who experienced a difficult childhood and women who do not express their feelings of anger, are no more likely to develop breast cancer than other women without psychological complaints.

``The results reported herein speak against the conventional wisdom that personality and stress factors influence the development of breast cancer,'' Dr. Michael A. Zevon and colleagues write in the journal Health Psychology.

These research findings also call into question the notion ''that there is an element of controllability in personal illness such that by changing some aspect of one's personality or behavior, one can change one's physical health and/or risk of illness,'' the authors note.

In the current study, the investigators looked at how eight measures of psychological health -- anxiety/depression, childhood environment, conflict-avoidant style, denial/repression coping, expression of anger, extraversion, separation/loss and stressful events -- affected breast cancer risk.

Women who reported anxiety/depression, an unhappy childhood, not expressing their anger or hostility and those who are introverted were not found to be at greater risk of developing breast cancer. However, women whose coping strategy is based on denial and repression, have experienced separation and/or loss, and have a history of stress in their lives may be modestly more likely to develop breast cancer.

To an even lesser degree, women who tend to shun conflict may also be at increased risk of breast cancer, the study authors found.

``It is important to note, however, that association is not causation, and based on the current data we should not infer that by changing these factors women can substantially alter their risk of breast cancer,'' Zevon explains in a press statement. ``Overall, the current data continue to support the primacy of biology, rather than personality or life experiences, in the development of breast cancer.''

SOURCE: Health Psychology 1999;18:1-12.

Systolic BP reading important in hypertension

According to principal investigator, Dr. Daniel Levy of the National Institutes of Health, and colleagues, ``our data indicates that systolic blood pressure plays a greater role than diastolic blood pressure in determining both blood pressure stage and eligibility for therapy.''

Blood pressure is recorded as two numbers separated by a diagonal (130 / 80, for example). The unit of measure in blood pressure is millimeters of mercury, abbreviated as mm Hg. The systolic measure reflects how hard the heart is working during a beat while the diastolic indicates pressure in major arteries when the heart rests between beats. A reading of 140 mm Hg systolic or greater, is considered to represent high blood pressure; the same diagnosis is applied when the diastolic reading is 90 mm Hg or above.

Conventionally, the diastolic number has been viewed as a more sensitive indicator of hypertension. It is the diastolic reading that commonly influences clinical decision-making regarding degree of disease present, and what therapeutic steps should be taken.

``The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-VI) classifies blood pressure into stages on the basis of the levels of both systolic (SBP) and diastolic (DBP) blood pressure levels,'' Levy and colleagues explain in the September issue of Hypertension. ``When a disparity exists between SBP and DBP stages, patients are classified into the higher stage ('up-staged').''

Such disparities are not uncommon, the authors note. Nearly 1,300 of 3,656 study subjects -- or 35.4% -- displayed ''disparate levels of systolic blood pressure and diastolic blood pressure.'' In the current study, this type of disparity presented the researchers with an opportunity to explore which measure, systolic or diastolic, is a better yardstick for identifying and classifying hypertensive individuals.

The investigators found that ``among the entire sample... knowledge of the SBP alone correctly classified the (blood pressure) stage in 96% whereas knowledge of DBP alone correctly classified only 68%.''

In a subset of patients characterized by blood pressure readings that were either at the high end of normal or frankly hypertensive, ``knowledge of only the SBP (allowed investigators) to classify (blood pressure stage) correctly in 91% of subjects versus 22% for DBP,'' according to the report.

As to the significance of these findings, Levy and his team speculate that ``future (blood pressure treatment) guidelines might consider acknowledging a greater role for SBP than for DBP in determining blood pressure stage, risk of cardiovascular events, eligibility for therapy, and benefits of treatment.''

In a statement to the press, officials at the National Institutes of Health's National Heart, Lung, and Blood Institute commented that an update of the JNC-VI blood pressure guidelines will be issued later this year ``based on this and other recent research that confirms the importance of identifying, treating, and controlling systolic hypertension.''

``The message from this study is that you cannot ignore systolic pressure,'' said Dr. Claude Lenfant, director of the National Heart, Lung and Blood Institute in the statement. ``For years, treatment strategies have focused on lowering a patient's diastolic pressure... (but) this practice excludes the elderly, who tend to have higher systolic pressures and lower diastolic pressures -- and who have the least-controlled blood pressure of all patients.''

SOURCE: Hypertension 1999;34:381-385.

Moderate wine drinking lowers heart disease, cancer risk

Reporting in the September 13th issue of the Archives of Internal Medicine, researchers now suggest that, in terms of health risks, moderate consumption of wine is better overall than beer.

Dr. Serge Renaud of the Institut National pour la Sante et la Recherche Medicale in Bordeaux, France, and colleagues used a questionnaire to evaluate the drinking habits of 36,250 men, aged 40 to 60 years.

The investigators found that persons reporting a moderate consumption of wine -- 2 to 3 drinks per day -- had a significantly lower risk of death from all causes than did persons who consumed no alcoholic beverages. Moderate wine consumption also reduced the risk of death due to cancer, coronary heart disease, and cardiovascular disease.

While moderate beer drinking was not associated with lower all-cause mortality, it ``was associated with (a) lower relative risk for cardiovascular diseases,'' the authors write. In contrast to the protective effects of moderate consumption, heavy consumption of both beer and wine resulted in an increased risk of death in drinkers compared with abstainers.

The study authors explain ``that French men who consumed 2 to 5 drinks of wine per day had a significant 29% to 33% reduction in overall mortality relative to abstainers.''

Based on earlier studies, the researchers speculate that lower cancer rates in wine drinkers may be due to resveratrol, a compound found in wine which is believed to have cancer-preventing properties. ``Another possibility is that beer contains specific carcinogenic substances,'' such as nitrosamines, they add. Until 1990, nitrosamines were found in relatively high concentrations in both US and European beers.

``If nitrosamines are responsible for the (cancer-causing) effect of beer... a change will be observed in the association between beer drinking and cancers (in the next decade),'' Renaud and colleagues write.

The investigators emphasize that moderate consumption of wine is best and recommend following the 1995 US dietary guidelines, which advise ``if you drink alcoholic beverages, do so in moderation, with meals, and when consumption does not put you or others at risk.''

SOURCE: Archives of Internal Medicine 1999;159:1865-1870.

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