Latest Research

July 20, 2007

A summary of the "must-read" articles from the journals in that pile on your desk.

School Nurses Key to Cardiac Risk Prevention in Young

Community-based settings ideal for educating youngsters about health

Nurses who work in schools and other community settings are in an ideal position to assess children and young people for cardiovascular disease risk factors and promote cardiovascular health, according to a position paper published online June 25 in Circulation: Journal of the American Heart Association.

Laura L. Hayman, Ph.D., R.N., of New York University in New York City, and colleagues write that evidence from randomized controlled trials points to the importance of primary prevention of cardiovascular disease early in life. They note that nurses who work in schools and preschools are in a good position to assess children for cardiovascular disease risk factors.

In addition, nurses can play a key role in promoting lifestyle behaviors that protect cardiovascular health, providing the basis for lifelong heart health, the paper states.

"Not all children receive regular physical examinations or well-child care outside of that provided by schools," Hayman points out in a statement. "Because they're knowledgeable about resources in their communities, school nurses are well positioned to provide appropriate referrals for children and their families once a risk factor is identified."

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Measuring Heart Conduction Identifies Those with Blockage

Measurement of intracardiac conduction during surgery helps identify those who may need a pacemaker after surgery

Measuring intracardiac conduction during surgery for hypertrophic obstructive cardiomyopathy can identify patients at risk of complete heart block and who may need a pacemaker, according to the results of a study published in the June 19 issue of the Journal of the American College of Cardiology.

Thorsten Lawrenz, M.D., from Klinikum Bielefeld-Mitte in Bielefeld, Germany, and colleagues examined changes in intracardiac conduction in 172 patients with hypertrophic obstructive cardiomyopathy during transcoronary ablation of septal hypertrophy (TASH). The goal was to determine which patients might be at greater risk for conduction abnormalities and, therefore, dependent on a pacemaker after the surgery.

The researchers found that 20.1 percent of patients had a complete heart block during TASH, which was more likely in older patients and those with a pre-existing bundle branch block. Delayed complete heart block (one to six days after surgery) occurred in 8.7 percent of patients and was significantly associated with a lack of retrograde atrioventricular nodal conduction after TASH, older age, complete heart block during surgery, and prolonged heart conduction (QRS) duration before or after surgery. Delayed complete heart block did not occur in any patients with intact retrograde conduction after TASH. Pacemakers were permanently implanted in 20 patients, the report indicates.

"Measurement of intracardiac conduction during TASH improves the safety of the procedure by enabling identification of patients who are at risk of complete heart block after TASH," Lawrenz and colleagues conclude. "The duration of prophylactic temporary pacemaker backup should be prolonged up to day 6 after TASH in patients at increased risk (patients with retrograde atrioventricular block and at least one additional risk factor)."

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Cervical Cancer Vaccine Shows 90 Percent Efficacy

Short time frame of study limits scope of interpretation, critics suggest

Prophylactic vaccination against the human papillomavirus (HPV) types 16 and 18 has 90 percent efficacy against cervical cancer, according to a report published online June 28 in The Lancet.

Jorma Paavonen, M.D., of the University of Helsinki in Finland, and colleagues conducted a randomized controlled trial of 18,525 women aged 15 to 25 years, 9,258 of whom received the HPV16/18 vaccine, while 9,267 were vaccinated against hepatitis A. Three doses of the vaccines were given, with the second dose one month after the first and the third dose at six months.

The primary endpoint of the study was cervical intraepithelial neoplasia 2+ associated with HPV16 or HPV18 among women who were negative for both subtypes at baseline. The women were followed up for a mean 14.8 months, during which time the vaccine group had two cases of cervical intraepithelial neoplasia 2+ associated with HPV16 or HPV18 while the control group had 21 cases.

In an accompanying editorial, Jessica A. Kahn, M.D., of the University of Cincinnati College of Medicine in Ohio, and Robert D. Burk, M.D., of the Albert Einstein College of Medicine, Bronx, New York, comment on the study's limitations. "The follow-up was brief, given that cervical carcinogenesis often evolves over several decades. However, the data will probably be substantiated with longer follow-up and accrual of additional endpoints."

Several authors are employed by or have received funding from GlaxoSmithKline and/or Merck & Company.

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Glycemic Load Can Increase Risk of Heart Disease

Diets should shift from low fat to reduced glycemic load

High dietary glycemic load increases the risk of cardiovascular disease, according to a report in the July 3 issue of the Journal of the American College of Cardiology.

Joline Beulens, M.Sc., of University Medical Center Utrecht in the Netherlands, and colleagues conducted an average nine-year follow-up of 15,714 women, aged 49 to 70, without diabetes or cardiovascular disease at baseline in the Dutch European Prospective Investigation into Cancer and Nutrition (EPIC) cohort to study the association of dietary glycemic load with cardiovascular disease.

After adjusting for cardiovascular disease risk factors, the investigators found that dietary glycemic load was independently associated with a 1.47-fold increased risk for cardiovascular disease. In addition, dietary glycemic index was linked to an increased risk for coronary heart disease. The risks for each were higher among overweight and obese women compared with normal weight women.

"Because multiple lines of evidence implicate high glycemic load in adverse metabolic effects that increase risk of diabetes and cardiovascular disease, it is time to shift the diet-heart paradigm away from restricted fat intake and toward reduced glycemic load," writes Frank Hu, M.D., Ph.D., from Harvard School of Public Health in Boston, in an accompanying editorial.

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Retinal Arteriolar Narrowing Linked to Cardiac Remodeling

Narrow vascular caliber associated with doubling in risk for concentric remodeling

Narrow retinal arteriolar caliber is an independent risk factor for left ventricular remodeling suggesting that microvascular disease may contribute to cardiac remodeling, according to a report in the July 3 issue of the Journal of the American College of Cardiology.

Tien Yin Wong, M.D., Ph.D., from the University of Melbourne, Australia, and colleagues conducted a cross-sectional, population-based study of 4,539 participants, aged 45 to 85 years, to examine the relationship of retinal vascular signs with left ventricular mass, volume and concentric remodeling. Retinopathy and retinal vascular calibers were measured from photographs and cardiac magnetic resonance imaging was used to measure heart parameters.

The investigators found that after controlling for multiple risk factors, narrow retinal caliber was independently associated with up to a 2.06-fold increase in concentric remodeling. Retinopathy was also associated with a 1.31-fold increase in concentric remodeling.

"Our study shows that in generally healthy middle-age adults without a history of clinical cardiovascular disease, narrower retinal arteriolar caliber, and to a lesser extent wider retinal venular caliber and retinopathy, are associated with increased left ventricular concentric remodeling," the authors write. "These data may lend further support to the potential microvascular role in the pathogenesis of early cardiac remodeling and subsequent development of heart failure."

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Probiotic Drink Reduces Antibiotic-Related Diarrhea

Probiotics may reduce morbidity, health care costs and mortality in patients over 50

Among elderly people being treated with antibiotics, those given a probiotic beverage may be less prone to diarrhea, according to a report published online June 29 in BMJ.

Mary Hickson, research dietician at Imperial College London in the United Kingdom, and colleagues studied 135 hospitalized patients who were receiving antibiotics and compared the effects of a 100-gram probiotic drink containing Lactobacillus casei, Streptococcus thermophilus and Lactobacillus bulgaricus twice daily to prevent antibiotic-associated diarrhea versus a control sterile milkshake.

The researchers found that 19 of 56 (34 percent) in the placebo group had antibiotic-related diarrhea, versus seven of 57 (12 percent) on probiotics, yielding a 0.25 odds ratio for the probiotic drink, and an absolute risk reduction of 21.6 percent. Among patients in the placebo group, 17 percent had diarrhea caused by Clostridium difficile versus none in the probiotic group.

"Consumption of a probiotic drink containing L. casei, L. bulgaricus, and S. thermophilus can reduce the incidence of antibiotic-associated diarrhea and C. difficile-associated diarrhea," the authors write. "This has the potential to decrease morbidity, health care costs and mortality if used routinely in patients aged over 50."

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Liquid-Based Cytology Detects More Cervical Cancer

Reduces percentage of unsatisfactory smears

Liquid-based cytology detects more cervical cancers than conventional cytology in Pap smears and also reduces the percentage of unsatisfactory smears, according to the results of two studies published online June 29 in BMJ.

In the first study, Elizabeth Davey, M.B.B.S., M.P.H., from the University of Sydney in Australia, and colleagues compared the accuracy of conventional cytology and liquid-based cytology using a computerized reading system, the ThinPrep Imager, on Pap smear samples from 55,164 Australian women.

The researchers found that the computerized system detected 1.29 times more high-grade squamous disease per 1,000 women screened compared with conventional cytology. Only 1.8 percent of slides were unsatisfactory for imaging compared with 3.1 percent for conventional cytology. More of the image-read slides contained low-grade cytological abnormalities, the report indicates.

In the second study, Guglielmo Ronco, M.D., Ph.D., from the Centre for Cancer Prevention in Turin, Italy, and colleagues randomized 45,174 Italian women to liquid-based cytology or conventional cytology to detect cervical cancer of grade 2 or higher in Pap smears.

Ronco's team found that liquid-based cytology detected more lesions but was not significantly better than conventional cytology in detecting lesions of grade 2 or higher. There was a large reduction in unsatisfactory smears, the authors note.

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Protein May Be Marker for Coronary Artery Disease in Men

Lipopolysaccharide-binding protein involved in immune recognition of pathogens

Lipopolysaccharide-binding protein, a protein involved in immune recognition of pathogens, may be an independent predictor of coronary artery disease in men, researchers report in the July 3 issue of the Journal of the American College of Cardiology.

Philipp M. Lepper, M.D., from the University Hospital of Bern in Switzerland, and colleagues examined whether lipopolysaccharide-binding protein (LBP) could be a biomarker for coronary artery disease in 247 men undergoing elective coronary angiography. Forty patients without coronary artery disease served as controls.

The researchers found that serum LBP was significantly higher in the 69.6 percent of men with confirmed coronary artery disease and was a significant and independent predictor of coronary artery disease after adjusting for other variables.

"Lipopolysaccharide-binding protein might serve as a novel marker for coronary artery disease in men," Lepper and colleagues conclude. "The present results underlie the potential importance of innate immune mechanisms for coronary artery disease."

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Thiazolidinediones Appear OK for Heart Failure Patients

Findings should keep TZDs out of 'black box' warning for diabetics with heart failure

The use of thiazolidinediones (TZDs) is not associated with an increased risk for mortality or even hospitalization in patients with diabetes confounded by heart failure, according to a report in the July 3 issue of the Journal of the American College of Cardiology.

David Aguilar, M.D., of Baylor College of Medicine in Houston, Texas, and colleagues retrospectively examined data from a national cohort of 7,147 veterans with diabetes and heart failure, but who were still ambulatory, to study the relationship between TZD use and outcomes in this patient group.

Overall, 11.4 percent of the population, or 818 patients, were receiving TZDs while 65.8 percent (4,700 patients) were not receiving any insulin sensitizers. Hospitalization rates for heart failure over a two-year follow-up period were found to be similar for the two groups, at around 16 percent. Within the same time, 20.5 percent of patients receiving TZDs and 25.4 percent of those not receiving insulin-sensitizing medications died.

The results "should at least keep TZDs out of the dreaded 'black box' warning for HF, and even raise the question of whether we should expand the clinical application of TZDs in left ventricular dysfunction and heart failure rather than limit or restrict such," writes Carl V. Leier, M.D., of Ohio State University in Columbus, and a colleague in an accompanying editorial.

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Obese Elderly At Lower Risk of Active TB Than Non-Obese

Tuberculosis patients of normal weight at higher risk of active tuberculosis than those who are overweight

Obesity is associated with a lower risk of active tuberculosis in elderly patients with the lung infection, according to the results of a study conducted in Hong Kong and published in the June 25 issue of the Archives of Internal Medicine.

Chi C. Leung, M.B.B.S., of the University of Hong Kong, and colleagues used the Hong Kong territory's tuberculosis registry to conduct a five-year analysis of 42,116 subjects aged 65 or over. The investigators looked at whether or not patients developed active tuberculosis and compared the patients based on their body mass index (BMI).

The researchers found that participants who were obese (BMI of 30 or more) and overweight (BMI of 25 to 29) had a much lower risk of having active tuberculosis (hazard ratio 0.36 and 0.55, respectively) than participants with normal weight (BMI of 18.5 to 24).

"Obesity is associated with a lower risk of active pulmonary tuberculosis in the older population of Hong Kong," the authors write. "The presence of such a strong but selective association across the whole spectrum of BMI could have major biological, clinical and/or epidemiological implications."

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Novel Therapy for Stress Incontinence

Autologous myoblast and fibroblast cell injections show promise

In patients with stress urinary incontinence, injections of autologous myoblasts and fibroblasts may reverse the condition, according to the results of a study published in the June 30 issue of The Lancet.

Hannes Strasser, M.D., of the Medical University of Innsbruck in Innsbruck, Austria, and colleagues conducted a study of 63 women with urinary stress incontinence, 42 of whom were randomized to receive transurethral injections of autologous myoblasts and fibroblasts, while 21 received conventional endoscopic collagen injections.

Follow-up after 12 months revealed that 38 of the 42 women who underwent autologous cell treatment were completely continent, compared with just two in the collagen group. Mean sphincter radius increased from 2.13 millimeters (mm) at baseline for all patients to 3.38 mm for the autologous cell group and 2.32 mm for the collagen group. There was also an increase in contractility of the sphincter in the autologous cell group compared to the collagen group.

"After a median follow-up of three years no severe side-effects or scars have been reported, and postoperative results have not changed," the authors write. "Data from multicenter trials with larger numbers of patients are also needed to assess whether the application of autologous cells into the rhabdosphincter and the urethra could become a standard treatment for urinary incontinence."

Some of the authors of this study own businesses directed toward the development of autologous cells, however, none of those businesses were involved in the design of this study, interpretation of the data or in writing of this paper.

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High Serum Myeloperoxidase May Predict Heart Disease

Study may explain why coronary artery disease occurs in seemingly healthy patients

High serum levels of myeloperoxidase -- an inflammatory protein that damages the cardiovascular system -- may predict the development of coronary artery disease in apparently healthy patients, according to the results of a study published in the July 10 issue of the Journal of the American College of Cardiology.

Matthijs Boekholdt, M.D., Ph.D., of the Academic Medical Center in Amsterdam, the Netherlands, and colleagues conducted an eight-year case-control study of 1,138 apparently healthy subjects who developed coronary artery disease and 2,237 matched controls who stayed free of coronary artery disease.

The researchers found significantly higher myeloperoxidase levels in cases than in controls. They also found that those in the highest quartile for myeloperoxidase concentration were significantly more likely to develop coronary artery disease than those in the lowest quartile (odds ratio 1.49). After adjusting for traditional risk factors, they found that the top quartile still had an elevated risk (OR, 1.36). The risk remained significant even in subjects with acceptable levels of low-density lipoprotein cholesterol, high-density lipoprotein cholesterol or C-reactive protein.

"It is clear that elevation of inflammatory markers, such as myeloperoxidase and C-reactive protein, and their interactions precede the onset of coronary artery disease by years," the authors conclude. "This underscores the potential relevance of exploration of anti-inflammatory strategies."

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Conflict Does Not Fuel Spread of HIV

Areas affected by war, widespread rape and forced displacement do not have higher incidence of the disease

Although it has been suggested that HIV incidence is increased by conflict and the widespread rape and population displacement that accompanies it, populations affected by war do not have a greater incidence of HIV infection than those not affected by war, according to a report published in the June 30 issue of The Lancet.

Paul B. Spiegel, M.D., of the office of the United Nations High Commissioner for Refugees in Geneva, Switzerland, and colleagues analyzed data from 295 published articles, of which 88 had original data on prevalence of HIV, and 65 of which contained data from seven selected African countries affected by conflict: the Democratic Republic of Congo, southern Sudan, Rwanda, Uganda, Sierra Leone, Somalia and Burundi.

While prevalence in rural areas of the seven countries remained low and stable, prevalence in urban areas affected by conflict declined at a similar rate to that of urban areas unaffected by conflict. There was no evidence of increased HIV prevalence during times of conflict.

The authors caution against extrapolating their findings to other countries. "Although some conclusions from the seven African countries studied here might apply to other countries affected by conflict, every situation is unique and should be examined according to context. Generalizations should be avoided, since they probably led to the original unsubstantiated assumptions that we investigated," they conclude.

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Children with Cerebral Palsy Have Regular Quality of Life

Policies should encourage full participation in society

Children aged 8 to 12 years with cerebral palsy have a quality of life that is similar to that of their peers in the general population, according to a study published in the June 30 issue of The Lancet.

Allan F. Colver, M.D., of Newcastle University in Newcastle upon Tyne, United Kingdom, and colleagues conducted a study of 818 children with cerebral palsy aged 8 to 12 years, of whom 318 were interviewed while the remainder completed a questionnaire to self-report their quality of life.

In terms of psychological well-being, self-perception, social support, school environment, perception of financial resources and social acceptance, the children's quality of life was unaffected by cerebral palsy.

However, there were some impairments that negatively affected quality of life: limited self-mobility was associated with poorer physical well-being; intellectual impairment was associated with worse moods and emotions; speech impairment negatively affected relationships with parents; and pain reduced quality of life across all categories.

"Parents can be reassured that most children aged 8 to 12 years with cerebral palsy will have similar quality of life to other children," the authors conclude. "This finding should guide social and educational policy to ensure that disabled children participate fully in society. Because of its association with quality of life, children's pain should be carefully assessed."

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Dark Chocolate Intake May Reduce Blood Pressure

Improvements seen in patients with upper-range prehypertension or stage 1 hypertension

Daily consumption of a small amount of dark chocolate may benefit patients with above-optimal blood pressure, according to the results of a randomized trial published in the July 4 issue of the Journal of the American Medical Association.

Dirk Taubert, M.D., Ph.D., of the University Hospital of Cologne in Cologne, Germany, and colleagues randomly assigned 44 adults aged 56 to 73 with untreated upper-range prehypertension or stage 1 hypertension to eat either 6.3 grams of dark chocolate containing 30 milligrams of polyphenols per day for 18 weeks or an equivalent amount of polyphenol-free white chocolate.

In the dark chocolate group, the researchers found that mean systolic blood pressure decreased by 2.9 mm Hg; mean diastolic blood pressure decreased by 1.9 mm Hg; and hypertension prevalence fell from 86 percent to 68 percent. The changes were associated with a sustained increase of S-nitrosoglutathione and the appearance of cocoa phenols in plasma. They also found that white chocolate had no effect on blood pressure or plasma biomarkers.

"Adoption of small amounts of flavanol-rich cocoa into the habitual diet is a dietary modification that is easy to adhere to and therefore may be a promising behavioral approach to lower blood pressure in individuals with above-optimal blood pressure," the authors conclude. "Future studies should evaluate the effects of dark chocolate in other populations and evaluate long-term outcomes."

The study was funded by the University Hospital of Cologne.

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Von Hippel-Lindau Disease Linked to Hearing Loss

In patients with endolymphatic sac tumors, hearing loss can occur suddenly or insidiously

In patients with von Hippel-Lindau disease, irreversible sensorineural hearing loss associated with endolymphatic sac tumors may occur suddenly or gradually, suggesting a need for early intervention, according to a study published in the July 4 issue of the Journal of the American Medical Association.

John A. Butman, M.D., Ph.D., of the Clinical Center of the National Institutes of Health in Bethesda, Md., and colleagues studied 35 patients who had endolymphatic sac tumors in 38 ears.

The researchers found that sensorineural hearing loss occurred in all seven ears with otic capsule invasions and in 27 (87 percent) of the other 31 ears. In these 31 ears, sensorineural hearing loss occurred suddenly in 14 (52 percent) and gradually in 13 (48 percent). The researchers also found that tumor size was not associated with sensorineural hearing loss or vestibulopathy.

"This study demonstrates that audiovestibular morbidity is frequently associated with small tumors (those not invading the otic capsule) and occurs by mechanisms that include intralabyrinthine hemorrhage and hydrops," the authors write. "Since significant audiovestibular dysfunction, including deafness, can occur suddenly in a manner that is not related to tumor size, early surgical intervention may be warranted."

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Higher Cabin Pressure May Cut Air Travel Discomfort

Study also suggests acute mountain sickness unrelated to cabin pressure

Barometric pressures experienced during commercial air travel are insufficient to induce acute mountain sickness but still cause a significant amount of discomfort in unacclimatized passengers, researchers report in the July 5 issue of the New England Journal of Medicine. Increasing cabin pressure may help reduce this discomfort, the authors suggest.

J. Michael Muhm, M.D., from the Boeing Company in Seattle, and colleagues at Oklahoma State University in Tulsa, Okla., conducted a prospective, single-blind, controlled hypobaric-chamber study where 502 adult volunteers were exposed to barometric pressures equivalent to terrestrial altitudes of 650 to 8,000 feet for up to 20 hours. Aircraft are designed to maintain a pressure equivalent to 8,000 feet at their maximum operating altitude.

The investigators found that oxygen saturation dropped by a maximum of 4.4 percentage points at 8,000 feet and correlated with increasing discomfort, as measured by questionnaire. The incidence of acute mountain sickness was 7.4 percent but did not vary among different altitudes. Men and persons older than 60 years were less likely to complain of discomfort. One serious adverse hypoxemic event occurred during the study.

"On the basis of our findings, we conclude that maintaining a cabin altitude of 6,000 ft or lower (equivalent to a barometric pressure of 609 mm Hg or higher) on long-duration commercial flights will reduce the occurrence of discomfort among passengers," the authors write.

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Preimplantation Genetic Testing May Reduce Birth Rate

Prescreening for aneuploidy reduces ongoing pregnancies by 30 percent in older women

Preimplantation genetic screening may reduce the rate of ongoing pregnancies and live births in women 35 and older who are undergoing in vitro fertilization, according to a report in the July 5 issue of the New England Journal of Medicine.

Sjoerd Repping, Ph.D., from the University of Amsterdam in the Netherlands, and colleagues conducted a multicenter, randomized, double-blind controlled trial comparing three cycles of in vitro fertilization, with and without the use of preimplantation genetic testing. The women were 35 to 41 years and ongoing pregnancy at 12 weeks' gestation was the primary outcome. Prescreening was expected to improve the effectiveness of in vitro fertilization in these women.

The investigators found that only 25 percent of the 206 women assigned to preimplantation testing had an ongoing pregnancy at 12 weeks compared to 37 percent of 202 women assigned to the control group. Live birth rates were 24 percent and 35 percent, respectively.

"Given the findings of [the study], preimplantation genetic diagnosis for aneuploidy screening should not be performed solely because of advanced maternal age," writes John Collins, M.D., of McMaster and Dalhousie Universities in Canada, in an accompanying editorial. "Its use for [recurrent unexplained miscarriage and recurrent implantation failure] should be restricted to research studies pending evidence of effectiveness."

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Inappropriate PSA Screening Common in VA Hospitals

Many physicians ignore recommendation against screening asymptomatic men over age 75

Many physicians do not follow evidence-based guidelines for prostate-specific antigen (PSA) screening, according to a report in the July 9 issue of the Archives of Internal Medicine.

B. Price Kerfoot, M.D., of Harvard Medical School in Boston, and colleagues studied 1997-2004 data from the Veterans Health Administration on 181,139 patients at seven hospitals and the 4,823 health care providers who ordered their tests.

The researchers found a mean percentage of inappropriate tests by health care providers of 18.4 percent in patients older than age 75 and 0.8 percent in patients younger than age 40. They also found that urologists, male physicians, those who infrequently order tests and physicians affiliated with specific hospitals were more likely to order inappropriate tests. They also found that older male physicians were especially likely to order inappropriate tests.

"How can the current levels of inappropriate PSA screening be reduced? Improving patient knowledge about PSA screening is an important first step," the authors write. "Systems-level changes may also be an effective method by which to improve PSA screening practices. For example, a computerized ordering system could alert practitioners when they attempt to order a PSA test on an age-inappropriate patient."

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Magazine's Ranking Omits Some Top Heart Hospitals

Analysis of U.S. News & World Report shows comparable outcomes in non-ranked hospitals

The U.S. News & World Report rankings of "America's Best Hospitals for Heart and Heart Surgery" fall short in identifying all the top hospitals for heart attack patients, researchers report in the July 9 issue of the Archives of Internal Medicine.

Oliver J. Wang, M.D., of the Yale University School of Medicine in New Haven, Conn., and colleagues used 2003 Medicare administrative data to compare outcomes in 13,662 patients in 50 ranked hospitals and 254,907 patients in 3,813 non-ranked hospitals.

The researchers found that risk-standardized, 30-day mortality rates were lower in ranked than in non-ranked hospitals (16 percent versus 17.9 percent), although about one-third of the ranked hospitals fell outside the best performing quartile. They also found that 11 ranked hospitals (22 percent) and 28 non-ranked hospitals (0.73 percent) had a standardized mortality ratio significantly less than 1.

"Hospitals rated as superior to their peers should not boast too proudly or become complacent," state the authors of an accompanying editorial. "They need to understand the potential inconsistency and fallibility of quality-ranking systems. And they need to realize that regardless of their true rank, their goal should not be to merely beat their peers in the ratings but to strive for optimum performance. In this type of quality competition, the real winners are the patients."

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Incretin Safe, Effective Treatment for Type 2 Diabetes

Incretin mimetics or enhancers comparable to other hypoglycemic agents

Incretin therapy is an effective alternative to current hypoglycemic agents for treatment of patients with type 2 diabetes, according to a meta-analysis published in the July 11 issue of the Journal of the American Medical Association.

Anastassios Pittas, M.D., from Tufts-New England Medical Center in Boston, and colleagues reviewed MEDLINE and clinical trial databases to identify randomized controlled trials testing the efficacy and safety of incretin mimetics or enhancers in treatment of adults with type 2 diabetes.

After combining data from 29 studies that met inclusion criteria, the investigators found that incretins lowered hemoglobin A1C by up to 0.97 percent compared to placebo and were non-inferior to other hypoglycemic agents. Glucagon-like peptide 1 analogues were associated with greater weight loss compared to placebo or insulin. Adverse events included gastrointestinal side effects, infection and headache.

"Incretin therapy offers an alternative option to currently available hypoglycemic agents for non-pregnant adults with type 2 diabetes, with modest efficacy and a favorable weight-change profile," the authors write. "Careful postmarketing surveillance for adverse effects, especially among the DPP4 inhibitors, and continued evaluation in longer-term studies and in clinical practice are required to determine the role of this new class among current pharmacotherapies for type 2 diabetes."

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Arthritis Medication Linked to Lower Diabetes Rates

Antimalarial drug hydroxychloroquine reduces incident diabetes in adults with rheumatoid arthritis

The commonly used antirheumatic medication hydroxychloroquine is associated with a reduced risk of diabetes in patients with rheumatoid arthritis compared with other antimalarials used to treat autoimmune diseases, according to a report in the July 11 issue of the Journal of the American Medical Association.

Mary Chester Wasko, M.D., from the University of Pittsburgh, and colleagues conducted a prospective, multicenter observational study of 4,905 adults with rheumatoid arthritis to determine the association between hydroxychloroquine use and self-reported diabetes.

The investigators found the incidence rates of diabetes were 5.2 per 1,000 patient-years of observation for hyroxychloroquine users compared with 8.9 per 1,000 for never users. After multiple adjustments, the hazard ratio for diabetes was 0.62 with hydroxychloroquine use compared with never users, and was strongly related to length of use.

"Antimalarial drugs may have a role in treating rheumatoid arthritis not only to suppress synovitis but also to reduce the likelihood of developing glucose intolerance and dyslipidemia," the authors write.

Some authors report serving as consultants or investigators during drug company-sponsored studies of rheumatoid arthritis and osteoarthritis.

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Prophylactic Antibiotics May Be Harmful for Child UTIs

Antibiotic-resistant disease higher in children with urinary tract infections exposed to prophylactic antimicrobials

Prophylactic antimicrobial treatment of children with recurring urinary tract infections has unclear benefits and may result in a higher incidence of drug-resistant disease, according to study findings published in the July 11 issue of the Journal of the American Medical Association.

Patrick Conway, M.D., from the University of Pennsylvania in Philadelphia, and colleagues measured the incidence of first and recurrent urinary tract infections in a cohort of children from primary care practices to identify risk factors for recurrent urinary tract infection, to study the association between prophylactic antimicrobial use and recurrent urinary tract infection and to identify risk factors for antimicrobial resistance.

Among 74,974 children in the cohort, 611 had a first urinary tract infection and 83 had a recurrent urinary tract infection. Risk factors for recurrence included white race (hazard ratio, 1.97), age 3 to 4 years (HR, 2.75) and high-grade vesicoureteral reflux (HR, 4.38). Prophylactic treatment was not associated with a decreased risk for recurrent urinary tract infection but was associated with a 7.5-fold higher risk of antimicrobial resistance.

"Given…previous findings and the unfavorable risk/benefit ratio demonstrated by the current study, we think it is prudent for clinicians to discuss the risks and unclear benefits of prophylaxis with families as they make family-centered decisions about whether to start prophylactic antimicrobials or to closely monitor a child without prescribing antimicrobial prophylaxis after a first urinary tract infection," the authors write.

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Diet Linked to Respiratory Function in Adolescents

Low dietary intake of fruits, fatty acids increases risk of poor respiratory function

Adolescents with low dietary intake of fruit and certain fatty acids are at higher risk of poor respiratory function, researchers report in the July issue of Chest.

Jane S. Burns, Sc.D., from the Harvard School of Public Health in Boston, and colleagues examined the relationship between dietary factors -- such as fruits, vegetables, vitamins and omega-3 fatty acids -- and respiratory health in 2,112 twelfth-grade students in the United States and Canada in 1998-1999. Students completed a semiquantitative food frequency questionnaire and a questionnaire on respiratory function. Forced expiratory volume in one second (FEV-1) was also measured.

The researchers found that students with low fruit intake had a lower FEV-1 and a higher risk of chronic bronchitic symptoms (odds ratio 1.36) than students with high fruit intake. Low intake of omega-3 fatty acids increased the risk of chronic bronchitic symptoms (OR, 1.37), wheeze (OR, 1.34) and asthma (OR, 1.68). Students who smoked and had low vitamin C intake were at higher risk of respiratory symptoms than smokers with higher vitamin C intake.

"Adolescents with the lowest dietary intakes of antioxidant and anti-inflammatory micronutrients had lower pulmonary function and increased respiratory symptoms, especially among smokers, suggesting that adequate dietary intake may promote respiratory health and lessen the effects of oxidative stress," Burns and colleagues conclude.

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Shorter Treatment Less Effective for Some Types of Hepatitis C

Sustained virologic response observed only after standard 24 weeks

Patients infected with certain genotypes of hepatitis C virus (HCV) have a higher sustained virologic response to treatment with peginterferon and ribavirin when they are treated for the standard 24 weeks rather than 16 weeks, according to the results of a study in the July 12 issue of the New England Journal of Medicine.

Mitchell L. Shiffman, M.D., from Virginia Commonwealth University Medical Center in Richmond, and colleagues randomized 1,469 patients with HCV genotype 2 or 3 to either 16 or 24 weeks of treatment with 180 μg of peginterferon alfa-2a weekly and 800 mg of ribavirin daily.

The researchers found that 24 weeks after the end of treatment, significantly fewer patients on the 16-week course had a sustained virologic response (less than 50 IU per mL, 62 versus 70 percent, odds ratio 0.67). Patients on the shorter course of treatment also had significantly higher rates of relapse (31 versus 18 percent). In patients with undetectable levels of HCV RNA by week 4, the sustained virologic response rate was significantly lower in patients on the shorter course of treatment (79 percent versus 85 percent).

"Treatment with peginterferon and ribavirin for 16 weeks in patients infected with HCV genotype 2 or 3 results in a lower overall sustained virologic response rate than treatment with the standard 24-week regimen," Shiffman and colleagues conclude.

The study was supported by Roche.

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Jogger with iPod Suffers Indirect Lightening Strike

Combo of sweat, metal earphones directed current to head, causing burns and fractures

Jogging in a thunderstorm with an iPod and being indirectly struck by lightning led to burns, hearing loss and fractures in a case reported in the July 12 issue of the New England Journal of Medicine.

Eric J. Heffernan, M.B., and colleagues from Vancouver General Hospital in Canada described the case of a 37-year-old man who had been jogging in a thunderstorm and listening to his iPod. Lightning struck a nearby tree and threw him eight feet away from the tree, witnesses reported.

The patient was brought to the emergency department with burns on his chest, neck and the sides of his face, according to the authors. There were substantial burns in the external auditory meatus bilaterally, corresponding to the position of his earphones, and he had a severe conductive hearing deficit. Both of the patient's tympanic membranes were ruptured, which were treated by perichondrial grafting, and he had a mandibular fracture, which was repaired by internal fixation.

"Although people may be struck directly by lightning, it is more common for the lightning to jump to a person from a nearby object, such as a tree -- a phenomenon known as a side flash," Heffernan and colleagues write. "Although the use of a device such as an iPod may not increase the chances of being struck by lightning, in this case, the combination of sweat and metal earphones directed the current to, and through, the patient's head."

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BRCA Mutations Do Not Affect Risk of Breast Cancer Death

No significant increase in the risk of death seen in Israeli women with BRCA mutation and invasive cancer

The presence of a mutation in the BRCA genes has no significant effect on the risk of death from breast cancer in women with invasive breast cancer, according to a study conducted in Israel and published in the July 12 issue of the New England Journal of Medicine.

Gad Rennert, M.D., Ph.D., of Carmel Medical Center in Haifa, Israel, and colleagues examined breast cancer outcomes based on the presence of three founder mutations in the BRCA1 or BRCA2 genes in Israeli women diagnosed with invasive breast cancer in 1987-1988.

The researchers found that 10 percent of the women of Ashkenazi Jewish descent carried a mutation. Medical records were available for 1,545 women, which showed that the risk of death from breast cancer was not significantly different in carriers and non-carriers (adjusted hazard ratio 0.76 for BRCA1 carriers, 1.31 for BRCA2 carriers).

"Breast cancer-specific rates of death among Israeli women are similar for carriers of a BRCA founder mutation and non-carriers," Rennert and colleagues conclude.

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Neural Tube Defects Drop After Folic Acid Fortification

Prevalence of defects fell by about half after folic acid introduction in Canada

The prevalence of neural tube defects fell by nearly half after folic acid fortification of foods was introduced in Canada in 1998, according to a study in the July 12 issue of the New England Journal of Medicine.

Philippe De Wals, Ph.D., from Laval University in Quebec, Canada, and colleagues examined the effect of folic acid fortification of foods in Canada on the prevalence of neural tube defects. Fortification was introduced in 1998 and the study examined 1.9 million live births, stillbirths and pregnancy terminations due to fetal anomalies from 1993-2002.

The researchers found there were 2,446 subjects with neural tube defects over this period. The prevalence of neural tube defects fell by 46 percent after folic acid fortification was introduced, from 1.58 to 0.86 per 1,000 births. The decrease was greatest in areas of Canada where the rate of defects was high before fortification, and fortification removed most geographical differences in prevalence.

"Food fortification with folic acid was associated with a significant reduction in the rate of neural tube defects in Canada," De Wals and colleagues conclude.

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Prepared jointly by the editors of Medical Economics and HealthDay's Physicians' Briefing (www.physicianbriefing.com)