Networks: Infections, e-cigarettes, lipid guidelines, and MV
The newer vaccines in development against TB will have to be at least as good as the current BCG vaccine. Global challenges to the successful control of TB include the development of newer treatment drugs due to the presence of multi-drug (MDR) and extensively drug resistant (XDR) strains, efforts to halt the progression of HIV, improvement of hygiene and environmental factors of developing countries, and continued research into refinements of BCG, as well as newer vaccines against TB. Only by these combined efforts will the burden of TB be reduced by 50% by 2015 and have ultimate eradication by 2050(World Health Organization. 2011; https:// www.stoptb.org/assets/documents/global/plan.TB).
Dr. Richard Winn, FCCP
Vice-Chair
Cardiovascular Medicine and Surgery
ACC/AHA lipid guidelines spark controversy
Years in the making, the new lipid guidelines1,2 released by the American Heart Association (AHA) and the American College of Cardiology (ACC) to coincide with the AHA annual meeting in November ignited a firestorm of controversy.
The guidelines resulted from a complex process that stretched out 9 years from the publication of the consensus lipid guidelines in 2004. Convened and funded by the National Institutes of Health, the guidelines were eventually put out under the aegis of the AHA and ACC. The National Lipid Association, originally included in the process, ultimately declined to endorse them.
What was most controversial about the new guidelines was the move away from treating lipids to a specific target, instead focusing on which patients have been shown in randomized clinical trials to benefit from lipid-lowering therapy. These patients fall into 4 general categories:
1. Secondary prevention in patients with previous coronary or cerebrovascular events
2. With LDL cholesterol >190 mg/dL
3. Type II diabetics aged 40-75
4. Patients aged 40-75 with a 10-year risk of cardiovascular disease exceeding 7.5% according to a new algorithm
It was this last group that caused the most controversy. The classification has the potential to greatly increase the number of patients considered for lipid-lowering therapy, by as many as 45 million Americans.3 Drs. Paul Ridker and Nancy Cook published data that challenged the accuracy of the proposed algorithm, showing that when calibrated against patients in large randomized trials, it may overestimate the risk by as much as 75%-150%.3
Defenders of the algorithm pointed out that patients in clinical trials may be at lower risk than those in the general population, and that the algorithm, despite its flaws, is most likely more accurate than the previous algorithms that were derived from the Framingham population more than 30 years ago.
Other experts felt that the new guidelines overstressed randomized clinical trials to the exclusion of epidemiologic and population-based observational data, data they felt demonstrate convincingly that treatment to lower targets produces better outcomes even if clinical trials were not designed to not show statistically significant differences between patients who meet targets and those who have even more substantial lipid-lowering.
What remains unclear is whether the controversy about the guidelines will introduce unwanted uncertainty into the field, leading clinicians and patients to question the value of lipid-lowering as a preventive therapy, or whether disagreement will spur healthy discussions that will ultimately lead to more clarity and improved outcomes. Time will tell.
Dr. Steven M. Hollenberg, FCCP
Steering Committee Member
References
1. Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013 Nov 7. doi:pii: S0735-1097(13)06028-2. 10.1016/j.jacc.2013.11.002. [Epub ahead of print].
2. Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2013 Nov 12. [Epub ahead of print].
3. Ridker PM, Cook NR. Statins: new American guidelines for prevention of cardiovascular disease. Lancet. 2013; 382:1762-1765.
Clinical Pulmonary Medicine
e-Cigarettes: Promise or peril?
e-Cigarettes are battery-powered devices that convert nicotine and other ingredients into vapor, simulating the visual, sensory, and behavioral aspects of smoking without the combustion products accountable for smoking’s damaging effects. An ever-growing number of companies around the world manufacture a wide variety of e-cigarette brands, despite scant information on the safety of the ingredients for human inhalation. The electronic cigarette is an emerging phenomenon that is becoming increasingly popular with smokers worldwide. Users report buying them to help quit smoking, to reduce cigarette consumption, to relieve tobacco withdrawal symptoms due to workplace smoking restrictions, and to continue to have a "smoking" experience but with reduced health risks. Electronic cigarette sales increased from 50,000 in 2008 to 3.5 million in 2012.
