Latest Research

October 5, 2007

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

Nocturnal Hemodialysis Improves Cardiac Health

Dialyzing six nights per week associated with improvements in left ventricular mass and blood pressure

Dialysis patients randomized to receive hemodialysis six nights a week experienced improvements in left ventricular mass, blood pressure and select measures of quality of life compared to those undergoing conventional hemodialysis, researchers report in the Sept. 19 issue of the Journal of the American Medical Association.

Bruce F. Culleton, M.D., of the University of Calgary in Alberta, Canada, and colleagues randomized 52 hemodialysis patients to receive either nocturnal hemodialysis six times weekly or conventional hemodialysis three times weekly, and measured subsequent left ventricular mass (using magnetic resonance imaging), patient-reported quality of life, blood pressure, mineral metabolism and use of medications.

After the six-month study period, researchers found that nocturnal hemodialysis was associated with a significant decrease in left ventricular mass, improvements in blood pressure and mineral metabolism, and a reduction in or discontinuation of antihypertensive medications compared to the conventional hemodialysis group. In addition, individuals undergoing nocturnal hemodialysis reported improvements in select quality of life measures. There was no significant difference in adverse events between the two groups.

This study "is important for nephrology, clearly demonstrating reduced left ventricular hypertrophy with nocturnal hemodialysis," according to an editorial. This data "suggests that nocturnal hemodialysis may help improve the high morbidity and mortality of North American dialysis patients."

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Medical Schools Vary in Approach to Case Reports

Most institutions do not require board approval for case reports; some do for research, privacy issues

Most medical school institutional review boards (IRBs) don't treat individual case reports as "research," as it's defined by the United States Government Code of Federal Regulations, according to a research letter published in the Sept. 19 issue of the Journal of the American Medical Association.

Mukta Panda, M.D., of the University of Tennessee College of Medicine in Chattanooga, and colleagues surveyed 124 medical schools in the continental United States. They elicited information -- in most cases from IRB officers -- about whether a single case report requires IRB approval before publication or presentation, and if so, whether the institution considers a case report to be "research," whether the IRB functions as a privacy board, and whether it requires a review due to research requirements or privacy rules.

Based on data from 116 schools, the researchers found that most (78 percent) did not require IRB approval for a case report. Of the schools that did require approval, 40 percent of the boards served only as IRBs, and the rest functioned as an IRB and privacy board. Twenty-four percent conducted reviews because they considered case reports to be research, 32 percent due to privacy issues, and 44 percent for both reasons.

This study "indicates that, de facto, most medical school IRBs do not consider a single case report to represent research under the federal definition," the authors write. "Further research should consider what it is that needs protection in a case report, and who is responsible for overseeing that protection: the authors, the IRB of the authors' institution, or the publishing journal."

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Device Reduces Atrial Arrhythmia After Heart Failure

Upgrade to cardiac resynchronization therapy-defibrillator beneficial

Patients with heart failure and left ventricular dysfunction who are upgraded to a cardiac resynchronization therapy-defibrillator have reduced atrial tachyarrhythmia, according to study findings published in the Sept. 25 issue of the Journal of the American College of Cardiology.

David G. Benditt, M.D., from the University of Minnesota Medical School in Minneapolis, and colleagues examined the impact of cardiac resynchronization therapy on the susceptibility of patients with left ventricular systolic dysfunction to atrial tachyarrhythmia. They studied 28 patients who were upgraded from a conventional dual-chamber pulse generator to cardiac resynchronization therapy-defibrillator due to worsening heart failure.

After one year of follow-up, considerably more patients were free of atrial tachyarrhythmia compared with three months before the upgrade (90 percent versus 14 percent). Cardiac resynchronization therapy also significantly reduced the number of atrial tachyarrhythmia episodes per year and their maximum duration, improved left ventricular ejection fraction, and reduced the number of hospital stays due to heart failure or arrhythmia.

"Although the reduction in atrial arrhythmia seems impressive, one cannot yet consider an ancillary antiarrhythmic benefit of cardiac resynchronization therapy as an independent indication for its increased use in patients with congestive heart failure," Angel Rodrigo Leon, M.D., from Emory University School of Medicine in Atlanta, writes in an accompanying editorial. "The indications for cardiac resynchronization therapy will still rest on its effect on ventricular function, mortality, and functional improvement."

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New Lung Cancer Guidelines Do Not Support Screening

Experts cite a lack of evidence that screening reduces mortality

New lung cancer guidelines from the American College of Chest Physicians (ACCP), published as a supplement in the September issue of CHEST, recommend against screening for lung cancer, even in high-risk populations, due to lack of evidence that screening reduces mortality.

Developed and reviewed by 100 multidisciplinary panel members, the evidence-based guidelines offer 260 recommendations regarding the prevention, screening, diagnosis, staging and treatment of lung cancer.

The guidelines recommend against screening for lung cancer using low-dose computed tomography (LDCT), chest radiographs, or sputum cytologic evaluation, even in smokers or those at high risk for cancer, since available data does not show a mortality benefit. The only exception where screening is recommended is in the context of a well-designed clinical trial.

"Even in high-risk populations, currently available research data do not show that lung cancer screening alters mortality outcomes," comments W. Michael Alberts, M.D., chair of the ACCP lung cancer guidelines and chief medical officer at H. Lee Moffitt Cancer Center and Research Institute in Tampa, Fla. "We hope that one day we can find a useful and accurate tool for general lung cancer screening, but, at this time, the evidence does not support the use of LDCT screening."

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Repeat Prenatal Low-Dose Corticosteroids Probably Safe

Two studies show no general effect on development, but one suggests cerebral palsy link

Repeat doses of prenatal corticosteroids do not significantly increase the risks for major adverse neurodevelopmental outcomes or delayed growth in children, but higher doses may be linked to an increased rate of cerebral palsy, according to two studies published in the Sept. 20 issue of the New England Journal of Medicine.

Caroline Crowther, of the University of Adelaide in North Adelaide, Australia, and colleagues assessed 1,085 children at 2 years of age whose mothers had been randomly assigned to receive repeat injections of prenatal corticosteroid or placebo. The investigators found that repeat corticosteroid treatment did not affect survival free of major neurosensory disability or growth.

Ronald Wapner, M.D., of Columbia University in New York City, and colleagues assessed 556 children at ages 2 to 3 years whose mothers received repeat prenatal injections of corticosteroids or placebo. They found no significant group differences in Bayley Scales of Infant Development results or anthropometric measurements but identified six cases (2.9 percent) of cerebral palsy in the repeat-corticosteroid group compared to one case (0.5 percent) in the placebo group.

"Further study of neurodevelopmental performance in school-age children is warranted, including the possible increased risk of cerebral palsy," states the author of an accompanying editorial. "Pending the availability of such data, if a decision is made to give repeat courses of corticosteroids, it may be prudent to consider the use of lower doses."

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Left Atrial Size Indicator of Diastolic Function, Cardiac Risk

Surrogate marker can be measured during stress echocardiography

Left atrial size, a surrogate marker of diastolic function, is an independent risk factor for myocardial infarction and cardiac death, according to the results of a study published in the Sept. 25 issue of the Journal of the American College of Cardiology. Left atrial size can be measured during stress echocardiography and used as a "powerful" prognostic indicator, the authors write.

Farooq A. Chaudhry, M.D., of Columbia University College of Physicians and Surgeons in New York City, and colleagues conducted a study of 2,705 patients who underwent stress echocardiography. Left atrial enlargement was defined as size indexed to body surface area of at least 2.4 centimeters per meter squared.

Patients with left atrial dilation had a greater risk of cardiac events (relative risk, 1.8) than those with normal left atrial size, after correcting for ischemia and left ventricular systolic dysfunction.

"Left atrial size is a powerful prognosticator and should be routinely used in the prognostic interpretation of stress echocardiography," the authors conclude.

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Gene Variation Linked to Greater Risk of Scleroderma

Patients more likely to carry polymorphism in connective-tissue growth factor gene

The G-945C polymorphism in the connective-tissue growth factor gene is strongly associated with systemic sclerosis, making it a candidate gene for scleroderma, according to study findings published in the Sept. 20 issue of the New England Journal of Medicine.

Carmen Fonseca, M.D., of the Royal Free and University College Medical School in London, U.K., and colleagues genotyped the G-945C polymorphism in two groups, the first consisting of 200 systemic sclerosis patients and 188 controls, the second consisting of 300 systemic sclerosis patients and 312 controls.

In both groups, the researchers found that patients were significantly more likely than controls to have the GG genotype (odds ratio, 2.2). They also found a significant association between homozygosity for the G allele and the presence of both anti-topoisomerase I antibodies and fibrosing alveolitis (odds ratios, 3.3 and 3.1, respectively).

"These data provide new insight into the pathogenesis of systemic sclerosis, including clues to the mechanisms leading to specific disease subtypes," the authors conclude. "Moreover, they may also be relevant to mechanisms underlying a wide range of other human disorders with a fibrotic component."

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Mutations Found in Patients with Hyper-IgE Syndrome

Gene is a regulator of interleukin-6

Mutations in a signaling protein that regulates interleukin-6 have been found in patients with inherited and sporadic cases of hyper-IgE syndrome, a rare immunodeficiency syndrome characterized by dermatitis, boils, infections and bone abnormalities, according to a report published online Sept. 19 in the New England Journal of Medicine.

Steven M. Holland, M.D., from the National Institutes of Health in Bethesda, Md., and colleagues examined cytokine secretion in leukocytes from patients with hyper-IgE syndrome, leading them to sequence the STAT3 gene.

The researchers found that stimulated mononuclear cells from these patients produced significantly higher levels of tumor necrosis factor-alpha as well as significantly lower levels of monocyte chemoattractant protein 1 in response to interleukin-6. Noting that STAT3 is a downstream mediator of interleukin-6, they found missense mutations and single-codon in-frame deletions in the STAT3 gene in 50 familial and sporadic cases of the disease.

"Mutations in STAT3 underlie sporadic and dominant forms of the hyper-IgE syndrome, an immunodeficiency syndrome involving increased innate immune response, recurrent infections, and complex somatic features," Holland and colleagues conclude.

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Progress Made in Tissue-Engineered Heart Valves

Researchers experiment with ways to 'grow' heart valves with a patient's own cells

Pre-coating a biodegradeable scaffold with extracellular matrix proteins can help guide the type of tissue formed when engineering heart valves, according to the results of an animal study published online Sept. 10 in Circulation: Journal of the American Heart Association.

Virna L. Sales, M.D., of Children's Hospital Boston, and colleagues pre-coated polyglycerol sebacate valve scaffolds with extracellular matrix proteins and seeded them with progenitor cells derived from sheep to assess how the different proteins would affect cellular growth and differentiation.

Pre-coating of scaffolds resulted in increased cellularity of valves and greater production of extracellular matrix proteins compared to uncoated controls. Furthermore, the type of coating affected the phenotypes of progenitor cells. The researchers also showed that engineered valves were more pliable than unseeded scaffolds.

These findings may help researchers engineer tissue valves with appropriate characteristics so they can eventually be implanted into children, eliminating the need for repeat valve replacements as children grow. "Scaffold pre-coating with extracellular matrix proteins can allow more precise 'engineering' of cellular behavior in the development of tissue-engineered heart valve constructs by altering extracellular matrix production and cell phenotype," the authors conclude.

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Minimally Invasive Valve Surgery Beneficial to Patients

Mortality is low and satisfaction is high in patients who have undergone previous cardiac surgeries

In patients who have undergone previous cardiac surgery, minimally invasive, video-assisted keyhole valve surgery is associated with high patient satisfaction and lower mortality than open-chest valve surgery, according to study findings published in a cardiovascular surgery supplement to the Sept. 4 issue of Circulation: Journal of the American Heart Association.

Filip P. Casselman, M.D., Ph.D., of the Department of Cardiovascular and Thoracic Surgery at the OLV Clinic in Aalst, Belgium, and colleagues studied outcomes in 80 patients (mean age 65 years) who underwent minimally invasive surgery to repair or replace mitral and/or tricuspid heart valves.

During and immediately after the surgery, 3.8 percent of the patients died, significantly lower than the 16 percent death rate expected from open-chest valve surgery in such high-risk patients. Patient survival rates were 93.6 percent at one year and 85.6 percent at four years. The researchers also found that all but one of the patients preferred the minimally invasive surgery over their previous open-heart operations.

"Cornerstones of the technique are adequate vascular access and optimal myocardial protection," the authors conclude. "This technique has become our standard technique to correct atrioventricular valvular disease both in primary and reoperative procedures."

One of the authors serves as consultant to Cardioversion and Edwards Lifesciences.

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Racial Disparities Seen in Emergency Asthma Care Needs

Regardless of disease severity, blacks are more likely to visit emergency departments or be hospitalized

Among those with asthma, black patients are significantly more likely than white patients to visit the emergency department or be hospitalized regardless of disease severity, according to a report in the Sept. 24 issue of the Archives of Internal Medicine.

Sara E. Erickson, M.D., of the University of California San Francisco, and colleagues studied 678 patients -- including 154 blacks and 524 whites -- who were hospitalized for asthma between 2000 and 2004. The researchers interviewed the patients after discharge, gathered U.S. Census socioeconomic data on patient neighborhoods and conducted follow-up interviews after a median of 1.9 years.

Despite identifying no racial difference in asthma severity, physical health status or controller medication use, blacks were significantly more likely than whites to present at emergency departments for asthma symptoms (35.7 percent versus 21 percent) and be hospitalized for asthma (26.6 percent versus 15.3 percent).

"Further efforts to investigate the basis for these racial disparities should be undertaken, including closer examination of provider preferences or beliefs about caring for black patients, and more in-depth study of patient characteristics, including cultural beliefs and behaviors related to asthma," the authors conclude. "These findings also support genetic differences or predispositions, including beta2-adrenergic receptor polymorphisms, as a possible explanation for racial disparities in asthma outcomes."

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Black and Latino Diabetics Lag Whites in Glycemic Control

Among older diabetics, improving medication adherence may help correct some of disparity

In the United States, blacks and Latinos older than 55 with diabetes mellitus have worse glycemic control than whites -- a racial disparity partly attributable to potentially modifiable factors such as medication adherence and emotional distress, according to study findings published in the Sept. 24 issue of the Archives of Internal Medicine.

Michele Heisler, M.D., of the University of Michigan in Ann Arbor, and colleagues conducted a nationally representative survey of 1,901 individuals aged 55 and older with diabetes mellitus to investigate racial and ethnic differences in blood sugar control and contributing factors.

Black and Latino respondents had significantly worse glycemic control than white respondents. Mean glycosylated hemoglobin values were 8.07 in blacks and 8.14 in Latinos, compared to 7.22 in whites. Medication adherence was lower in blacks and diabetes-specific emotional distress was higher in Latinos compared to whites.

"These findings suggest useful targets for interventions seeking to reduce racial/ethnic disparities and to improve overall diabetes outcomes," the authors write. "However, this extensive set of socioeconomic, clinical, health care and self-management measures still explained only a small portion of the racial/ethnic disparities in glycemic control. The major contributors to the large and recalcitrant disparities in glycemic control remain elusive."

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Acupuncture May Benefit Patients with Low Back Pain

Verum acupuncture, sham acupuncture may be nearly twice as effective as conventional therapy

In patients with low back pain, both traditional Chinese verum acupuncture and sham acupuncture may be more effective than conventional therapy, researchers report in the Sept. 24 issue of the Archives of Internal Medicine.

Michael Haake, Ph.D., M.D., of the University of Regensburg in Bad Abbach, Germany, and colleagues randomly assigned 1,162 patients to receive verum acupuncture, sham acupuncture or conventional therapy.

After six months, the researchers found that the response rate -- which was defined as a 33 percent improvement in pain or a 12 percent improvement in functional ability -- was 47.6 percent in the verum acupuncture group, 44.2 percent in the sham acupuncture group and 27.4 percent in the conventional therapy group.

"The superiority of both forms of acupuncture suggests a common underlying mechanism that may act on pain generation, transmission of pain signals, or processing of pain signals by the central nervous system and that is stronger than the action mechanism of conventional therapy," the authors write. "The underlying mechanism may be a kind of super-placebo effect produced by placebo and all non-specific factors working together. Nevertheless, the effectiveness of acupuncture cannot be attributed merely to a placebo effect because there is no reason to believe that the action mechanism of conventional therapy is the result solely of the placebo effect."

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One-Fifth of U.S. Adults Get Preventive Health Exams

Yearly exams cost health care system $7.8 billion

Approximately 44.4 million U.S. adults receive a preventive health exam each year at a total cost to the health care system of almost $8 billion, despite the fact that major clinical organizations do not recommend them, according to research published in the Archives of Internal Medicine on Sept. 24.

Ateev Mehrotra, M.D., of the University of Pittsburgh, analyzed data from 8,413 primary care visits between 2002 and 2004 to estimate the annual rate of preventive health exams (PHEs) and preventive gynecologic exams (PGEs) based on patient demographics, the frequency of preventive services provided and the total cost of these visits at Medicare reimbursements rates.

An estimated 44.4 million adults underwent a PHE each year and 19.4 million women underwent a PGE. Older patients and those with health insurance were more likely to receive a preventive exam. Preventive services were performed in more than half of all PHEs, and 83 percent of PGEs, though the majority of total preventive services occurred at other visits. The total cost associated with PHEs and PGEs was $7.8 billion.

"Our findings provide a foundation for continuing national deliberations about whether adults should see physician for these examinations and about their appropriate content," the authors conclude.

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Hospitalist Care Linked to Shorter Hospital Stays

Average patient stays are nearly one day less with hospitalist care than with conventional care

Hospitalized patients who are under the care of a hospital-based general physician -- or hospitalist -- may have shorter stays than those under conventional hospital care, according to the results of a study in the Sept. 24 issue of the Archives of Internal Medicine.

William N. Southern, M.D., of the Albert Einstein College of Medicine, Bronx, N.Y., and colleagues reviewed 2002-2004 data on 9,037 discharges from a teaching hospital, including 2,913 (32.2 percent) patients who were cared for by hospitalist teams and 6,124 (67.8 percent) who were cared for by non-hospitalist teams.

The researchers found that the average length of stay was significantly shorter in the hospitalist group than in the non-hospitalist group (5.01 days versus 5.87 days). They also found no significant group differences in rates of hospital readmission or mortality rates.

"We identified several patient groups in whom this association was particularly strong: patients who require close clinical monitoring, those in whom real-time adjustment of therapy is critical, those with high overall acuity, and those in whom complex discharge planning is necessary," the authors conclude.

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Familiar Doctor Linked to More Satisfaction for Urgent Care

Survey respondents prefer to see their own physicians compared to EDs, walk-in clinics

Patients who receive urgent medical care from family physicians or after-hours clinics affiliated with their physicians are more likely to be satisfied with the encounter than patients who use other sources of urgent care, according to research published in the September/October issue of the Annals of Family Medicine.

Michelle Howard, Ph.D., of McMaster University in Hamilton, Ontario, Canada, and colleagues analyzed survey data from 5,722 patients in Thunder Bay, Ontario. The city has a 24-hour emergency department, walk-in clinics that are open after regular hours, some physicians groups that offer evening and weekend care and nurse-staffed telephone triage. The researchers asked respondents about their recent use of urgent care services and their satisfaction based on a seven-point scale.

Respondents reported highest satisfaction with family physicians (mean score of 6.1) and physicians' after-hours clinic (score of 5.6, which wasn't significantly different). Sites that provided less satisfaction were emergency departments (5.3), telephone services (4.7) and walk-in clinics or more than one service (4.7).

"The finding that patients are most satisfied receiving care for a self-defined urgent health problem from their own physician or an after-hours clinic staffed in part by their own physician supports increasing financial and human resources to enhanced access to practice-based primary care services," the authors conclude.

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Most Depressed Patients Not Assessed for Suicide Risk

Advertising might encourage more depressed patients to ask physicians for help

A little more than one-third of physicians treating depressed patients investigate the possibility that the patient will commit suicide, researchers report in the September/October issue of the Annals of Family Medicine.

Peter Franks, M.D., of the University of California-Davis in Sacramento, and colleagues analyzed the degree to which 152 northern California and Rochester, N.Y. physicians investigated suicidal tendencies in patients who had two conditions -- major depression and adjustment disorder -- and who made three antidepressant requests between May 2003 and May 2004.

The physicians investigated suicidal tendencies in 36 percent of 298 patient appointments. Physicians asked more questions in academic environments, when they had personal experience with depression, when patients described major depression versus adjustment disorder, or when patients requested antidepressants.

Some issues not associated with physicians' specialties influenced their decision to explore patients' suicidal tendencies, including gender, interaction style, or confidence in treating depression.

"When seeing patients with depressive symptoms, primary care physicians do not consistently inquire about suicidality," the authors write. "Their inquiries into suicidal thinking may be enhanced through advertising or public service messaging that prompts patients to ask for help."

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Prehypertension Can Worsen with Anger and Stress

Among middle-aged, risk is greater for progression to full-blown hypertension or heart disease

Prehypertensive individuals who have problems with anger or stress in middle-age are at greater risk of progressing to full-blown hypertension or heart disease as they age, according to a report in the September/October issue of the Annals of Family Medicine.

Marty S. Player, M.D., of the University of South Carolina in Charleston, and colleagues analyzed data collected in the Atherosclerosis Risk in Communities Study on 2,334 prehypertensive men and women, aged 45 to 64, who were free of cardiovascular disease at enrollment. Participants answered questionnaires regarding their psychosocial status and were followed-up for four to eight years.

Men with high trait anger scores were found to have a 1.5 times greater chance of developing hypertension than those with low to moderate scores. High trait anger scores among men were also associated with a 90 percent greater likelihood of progression to incident coronary heart disease. An association between long-term psychological stress and risk of incident coronary heart disease was observed among both men and women.

"This study serves to further characterize individuals with prehypertension and adds to the growing evidence of the role of psychological factors in the development of cardiovascular disease," the authors conclude.

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Diabetes Risk Linked to Omega-3 Intake in Childhood

Diets with more omega-3s associated with lower risk of developing the disease

Consumption of omega-3 fatty acids is associated with reduced risk of type 1 diabetes in children, according to a two-part study reported in the Sept. 26 Journal of the American Medical Association.

Jill M. Norris, Ph.D., of the University of Colorado at Denver, and colleagues assessed the diets of 1,770 children, aged 1 year and older, who were at risk for diabetes (mean follow-up age, 6.2 years). The subjects, participants in the Diabetes Autoimmunity Study in the Young (DAISY), were regularly tested for antibodies to pancreatic islet antigens. In a second study, the same team took blood samples from a 244-child DAISY subset to compare the risk of islet autoimmunity with the polyunsaturated fatty acid content of red blood cells.

In the first study, total omega-3 fatty acid intake was inversely associated with having at least one autoantibody and with the risk of developing multiple antibodies or type 1 diabetes (hazard ratios of 0.45 and 0.23, respectively). In the second study, increased levels of omega-3 fatty acids in the erythrocyte membranes was associated with decreased risk of islet autoimmunity (hazard ratio 0.63).

"We suggest that increased intake of omega-3 fatty acids will lead to increased membrane concentration of these fatty acids," the authors write, "resulting in increased levels of anti-inflammatory resolvins and protectins, to bring chronic inflammation to a homeostatic end point."

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Coronary Disease Linked to Colorectal Neoplasms

Association is stronger in patients with history of smoking or metabolic syndrome

Patients with coronary artery disease are also at greater risk for colorectal neoplasms, according to a report in the Sept. 26 issue of the Journal of the American Medical Association.

Annie On On Chan, M.D., Ph.D., of the University of Hong Kong, China, and colleagues recruited patients who reported for coronary angiography at three Hong Kong hospitals between 2004 and 2006. These were divided into a group of 206 patients who tested positive for coronary artery disease (CAD) and 208 who tested negative. Both groups subsequently received colonoscopies, as did a control group that was age and sex-matched to the CAD-positive group. All participants were asymptomatic for colonic disease.

Colorectal neoplasms were discovered in 34 percent of the CAD-positive group compared to 18.8 percent of the CAD-negative group and 20.8 percent of the control group. Advanced colorectal lesions were found in 18.4 percent of the CAD-positive group versus 8.7 percent of the CAD-negative group and 5.8 percent of the control group.

There were nine adenocarcinomas found in the CAD-positive group (4.4 percent) versus one (0.5 percent) in the CAD-negative group and three (1.4 percent) in the control group. A history of smoking and metabolic syndrome were strongly linked to advanced colorectal lesions and CAD.

Chronic inflammation resulting from underlying risk factors "may be the culprit for the simultaneous development of the two conditions," the authors write.

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Depression Management Pays On-the-Job Dividends

Workers who get help managing depression work longer, retain jobs

A treatment program in which trained mental health clinicians regularly telephoned depressed employees improved clinical and workplace outcomes, according to the results of a randomized trial reported in the Sept. 26 issue of the Journal of the American Medical Association.

Philip S. Wang, M.D., of the National Institute of Mental Health in Bethesda, Md., and colleagues recruited 604 depressed workers 18 and older who worked for 16 large companies covered by a large managed health care company. About half the participants enrolled in a telephone treatment program and the remainder received standard care. Care managers assessed the needs of program participants, then encouraged them to enroll in various forms of outpatient treatment, including psychotherapy, cognitive therapy and medication. The care managers also helped participants enroll in treatment programs and discussed treatment with providers.

Program participants had significantly less depression at both six- and 12-month assessments than those in the standard care group. Those in the program group also showed a 2.6-hour improvement per week in overall work functioning, thanks to increased job retention and increased hours worked.

"Learning how to optimize personal and societal gains by improving access to quality depression care across diverse communities through employer, practice and community-based programs and policy changes is a next agenda for evidence-based action," conclude the authors of an accompanying editorial.

Several study authors report financial ties to drug companies.

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HDL Predicts Risk of Major Cardiovascular Events

Relationship observed even in patients whose LDL has been lowered by statins

Levels of high-density lipoprotein (HDL) cholesterol predict the risk of major cardiovascular events even in patients whose low-density lipoprotein (LDL) cholesterol has been substantially lowered by statins, according to study findings published in the Sept. 27 issue of the New England Journal of Medicine.

Philip Barter, M.D., Ph.D., from the Heart Research Institute in Sydney, Australia, and colleagues examined the risk of a first major cardiovascular event in 9,770 patients based on levels of HDL cholesterol and LDL cholesterol during the third month of treatment with statins.

The researchers found that HDL cholesterol levels were a significant inverse predictor of major cardiovascular events. This relationship was reduced to borderline significance after taking the effect of statin treatment on LDL cholesterol levels into account, but was still significant even in patients with LDL cholesterol levels below 70 mg/dL.

"In this post-hoc analysis, HDL cholesterol levels were predictive of major cardiovascular events in patients treated with statins," Barter and colleagues conclude. "This relationship was also observed among patients with LDL cholesterol levels below 70 mg per deciliter."

The study was supported by Pfizer.

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Vaccine Preservative Not Linked to Neurological Deficits

Study did not examine autism spectrum disorders

Early mercury exposure from thimerosal is not associated with later deficits in neuropsychological outcomes in children, although autism spectrum disorders were not examined, according to a report in the Sept. 27 issue of the New England Journal of Medicine.

William W. Thompson, Ph.D., from the U.S. Centers for Disease Control and Prevention in Atlanta, and colleagues assessed 42 neuropsychological outcomes (excluding autism spectrum disorders) in 1,047 children aged 7 to 10 years and their association with mercury exposure from thimerosal prenatally, within 28 days of birth and during the first seven months.

The researchers found few significant associations between mercury exposure and neuropsychological outcomes, most of which were small and almost equally divided between positive and negative effects. For example, performance on one measure of language was better and performance on one measure of attention and executive functioning was worse in children with higher prenatal exposure. Similar associations were observed in children with higher exposure in the seven months after birth.

"Our study does not support a causal association between early exposure to mercury from thimerosal-containing vaccines and immune globulins and deficits in neuropsychological functioning at the age of 7 to 10 years," Thompson and colleagues conclude.

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Antibodies Increase Risk of Kidney Transplant Rejection

Increase observed even in well-matched patients

The presence of antibodies against a particular surface antigen increases the likelihood of kidney transplant rejection, even when the patient and kidney are well matched, researchers report in the Sept. 27 issue of the New England Journal of Medicine.

Peter Stastny, M.D., from the University of Texas Southwestern Medical Center in Dallas, and colleagues measured antibodies against major-histocompatibility-complex class I-related chain A (MICA) in preimplantation serum samples from 1,910 transplant recipients of kidneys from deceased organ donors.

The researchers found that 11.4 percent of patients had anti-MICA antibodies. The mean one-year graft survival rate was significantly higher in patients without antibodies (93.0 versus 88.3 percent). The difference in mean one-year graft survival was more pronounced in the 326 recipients who were well matched for human leukocyte antigen (95.1 versus 83.2 percent).

"Although human leukocyte antigen remains the cornerstone of transplantation immunology, the exploration of MICA antigens and their corresponding antibodies may be seen as a new tool set for understanding the rejection of kidney transplants," Willy A. Flegel, M.D., from University Hospital in Ulm, Germany, writes in an accompanying editorial.

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