— Treating to LDL cholesterol targets is no longer recommended; 
rather, clinicians should determine whether a patient falls into one 
of four mutually exclusive high-risk groups and should initiate statin 
therapy as follows:

Patients with clinical atherosclerotic cardiovascular disease (ASCVD) 
should receive high-intensity (age, <75) or moderate-intensity (age, 
≥75) statin therapy.

Patients with LDL cholesterol levels ≥190 mg/dL should receive high-
intensity statin therapy.

Diabetic patients aged 40–75 with LDL cholesterol levels of 70–189 
mg/dL and without clinical ASCVD should receive at least moderate-
intensity statin therapy (and possibly high-intensity statin therapy 
when estimated 10-year ASCVD risk is ≥7.5%).

Patients without clinical ASCVD or diabetes but with LDL cholesterol 
levels of 70–189 mg/dL and estimated 10-year ASCVD risk ≥7.5% 
should receive moderate- or high-intensity statin therapy.

— High-intensity statin therapies are atorvastatin (40–80 mg) or 
rosuvastatin (Crestor; 20–40 mg). Moderate-intensity statin therapies 
include atorvastatin (10–20 mg), rosuvastatin (5–10 mg), 
simvastatin (20–40 mg), pravastatin (40–80 mg), and several others.

— With few exceptions, use of lipid-modifying drugs other than 
statins is discouraged.

— Ten-year ASCVD risk — which includes both coronary events and 
stroke — is determined using an online calculator that can be 
accessed through the AHA and ACC websites. For further discussion of 
the new risk-assessment tool, see NEJM JW Gen Med Nov 12 2013.

— Lifestyle modification is recommended for all patients, regardless 
of cholesterol-lowering drug therapy.

Yoga exercise reduced fatigue and inflammation associated with 
decreased physical function.

Breast cancer survivors frequently cite myriad symptoms, including 
fatigue, deconditioning, and depression. In addition, their 
cardiorespiratory fitness is about 30% lower than that of their 
sedentary, age-matched, cancer-free counterparts. Survivors benefit 
from regular exercise but often limit their physical activity because 
of pain and fatigue. Would less vigorous yoga exercise provide health 
benefits for such individuals?

To find out, investigators conducted a 3-month, randomized, controlled 
trial in which 200 breast cancer survivors were assigned to a yoga 
program (twice-weekly, 90-minute, hatha yoga workouts for 12 weeks) or 
to usual activities (controls). The primary outcomes were measures of 
inflammation associated with decreased physical function — 
interleukin (IL)-6, tumor necrosis factor (TNF)-α), and interleukin 
(IL)-1β — as well as scores on validated assessments of vitality, 
fatigue, and depression. Women reporting more than 5 hours of vigorous 
exercise per week or prior or current yoga practice were excluded.

Immediately after treatment, vitality was higher in the yoga group 
than in controls (P=0.01), but fatigue was not diminished. At 3 months 
after treatment, fatigue was lower in the yoga group (P=0.002), 
vitality was higher (P=0.01), and inflammatory measures were lower: 
IL-6 (P=0.027), TNF-α (P=0.027), and IL-β (P=0=.037). Measures of 
depression did not differ between groups.

Kiecolt-Glaser JK et al., J Clin Oncol 2014 Jan 27;

The American College of Chest Physicians recommends screening with low-
dose computed tomography — but only in a carefully defined population.

The American College of Chest Physicians has published a new clinical 
guideline on screening for lung cancer. The key recommendation is:

“For smokers and former smokers who are age 55 to 74 and who have 
smoked for 30 pack-years or more and either continue to smoke or have 
quit within the past 15 years, we suggest that annual screening with 
LDCT [low-dose computed tomography] should be offered . . . but only 
in settings that can deliver the comprehensive care provided to NLST 
[National Lung Screening Trial] participants.”

This cautious language reflects several points that the guideline 
addresses in detail. First, because the NLST is the only randomized 
trial that has shown a mortality benefit (JW Gen Med Jul 14 2011), the 
authors believe that screening should be limited to people whose age 
and smoking histories meet the NLST eligibility criteria.

Second, the authors acknowledge the problem of false positives — 
i.e., CT scans can identify abnormalities that generate additional 
tests and procedures in people who don’t have lung cancer (JW Gen Med 
May 22 2013). Further evaluation of patients with false-positive scans 
is costly, potentially anxiety-provoking, and potentially harmful if 
invasive tests are performed.

Third, the authors are concerned about screening that is done 
haphazardly in community practice settings. Many patients with benign 
nodules can be followed without undergoing biopsies, and very few 
patients with benign nodules should need surgery to establish 
benignity. When diagnostic surgery is required, video-assisted 
thoracic surgery is preferable. The authors believe that screening 
should be done only in centers where expert multidisciplinary 
management and follow-up are available.

In the randomized Women’s Health Initiative (WHI) study, postmenopausal women treated with estrogen-progestin hormone therapy (HT) had a higher incidence of breast cancer than the placebo group. (JAMA 2002;288:321).

An observational study paralleled the randomized trial, which showed the annual incidence of breast cancer was significantly higher in the HT users than in non users and it was highest when initiated at menopause. Unfortunately, some physicians still advice patients short term use of HT is safe in early post-menopause. (J Natl Cancer Inst 2013 Apr 17; 105:526).

From the National Cancer Institute-
"The use of antibiotics should be considered as an important element  
affecting microbiota composition. It has been demonstrated, and our  
present study has confirmed, that after antibiotic treatment the  
bacterial composition in the gut never returns to its initial  
composition,” “Thus, our findings raise the possibility that the  
frequent use of antibiotics during a patient’s lifetime or to treat  
infections related to cancer and its side-effects may affect the  
success of anti-cancer therapy.”

Surgeon General's Report on Smoking and Health - 
Approximately "...5.6 million American children ... will die prematurely from smoking-related diseases unless current smoking rates drop ..." according to  
the report which concludes that "... cigarette smoking kills nearly  
half a million Americans a year, with an additional 16 million  
suffering from smoking-related conditions [and a price tag of] more  
than $289 billion a year in direct medical care and other economic  
costs ..." - Besides lung cancer, the report adds "... diabetes,  
colorectal and liver cancer, rheumatoid arthritis, erectile  
dysfunction, age-related macular degeneration, and other conditions to  
the list of diseases that cigarette smoking causes. In addition, the  
report concludes that secondhand smoke exposure is now known to cause  
strokes in nonsmokers ...