Latest Research

December 7, 2007

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

Presidential Candidates Put Health Care Back on Agenda

Democrats favor comprehensive plans while Republicans offer less detail

After a hiatus since the Clinton administration, comprehensive health care reform is back on the agenda for both Democratic and Republican presidential hopefuls, according to an article published in the Nov. 22 issue of the New England Journal of Medicine.

Jonathan Oberlander, Ph.D., of the University of North Carolina, Chapel Hill, writes that both parties tackle the issue of health care very differently. The three top-tier Democratic candidates have all released similar plans with key elements including mandatory employee insurance or a tax in lieu, universal access to health care insurance, expansion of coverage for low-income citizens and rollbacks of tax cuts for high-income families.

Republican candidates have not released such detailed or comprehensive plans. Common elements include deregulation of medical insurance, expanded health savings accounts, and changes to tax policy aimed at improving access and controlling costs. Some plans include incentives to low-income families to buy private insurance.

"The 2008 presidential election will not resolve the debate over health care reform, but the results will go a long way toward determining the future of U.S. health policy," Oberlander writes. "Still, it is clear that there is a wide partisan gap on health care reform that reflects ideological divisions over the roles that government or market forces should play in the health care system."

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Physicians Devote Extra Time to Non-Reimbursable Care

Study finds that an extra day per week goes toward services not covered by Medicare

In caring for elderly patients with chronic illnesses, physicians spend an average of one full day per week providing services that are not reimbursed by Medicare, according to a report published in the Nov. 20 issue of the Annals of Internal Medicine.

Jeffrey Farber, M.D., of the Mount Sinai School of Medicine in New York City, and colleagues collected data from 16 doctors using a form to document non-reimbursable interactions such as medication refills, family counseling and pharmaceutical pre-approvals during 472 separate interactions with patients aged 67 to 101.

The researchers found that each average episode of non-reimbursed care lasted just 10 minutes, but added up to 7.8 hours each week. They also found that 36 percent of the interactions involving a new medical symptom resulted in either a new prescription or a change of medication and that 27 percent resulted in a previously unscheduled office visit.

"By developing a method to document the amount of time spent providing care outside of face-to-face patient interactions, we demonstrate that providers and researchers can feasibly gather empirical data on the number and nature of non-reimbursed care activities," the authors conclude. "Further work in this field in broader clinical settings is important to inform debates about reimbursement reform."

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No-Shows in Residency Practices Can Be Managed

Commitment to well-established techniques keeps missed appointments to a minimum

"No-show" appointments in family medicine residency practices can be held to below 10 percent when staff members consistently and effectively use well-established methods of patient management, according to a report in the November/December issue of the Annals of Family Medicine.

Bradley J. Johnson, M.D., of the University of Oklahoma Health Sciences Center in Oklahoma City, and colleagues reviewed questionnaires completed by 141 family medicine residency practice administrators. Follow-up interviews were conducted with 14 administrators in practices with low no-show rates (defined as "rate exemplars") and eight administrators from practices that were able to maintain high visit rates despite no-shows ("management exemplars"). No-shows were defined as those "missing a scheduled appointment without calling to cancel."

Methods used by rate exemplars to minimize no-show rates included patient education (when each appointment was made, after each no-show, etc.), patient reminders, patient sanctions (including being required to walk in without appointments), open access, emphasis on continuity and scheduling rules. Strategies used by management exemplars to maintain high visit rates despite no-shows included overbooking, use of walk-ins and work-ins, and maintaining flexible schedules so that all patients who wanted to be seen were seen.

The authors note that both rate exemplars and management exemplars who were interviewed "seemed to be committed to reducing the number or impact of no-shows."

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New Prediction Tool Targets Osteoporosis in Older Men

Age, weight, and history of chronic obstructive pulmonary disease used as variables

A new clinical prediction model for the risk of osteoporosis targets 44 percent of U.S. men aged 50 and older for confirmatory dual-energy x-ray absorptiometry (DXA) scans, researchers report in the November/December issue of the Annals of Family Medicine.

Angela J. Shepherd, M.D., of the University of Texas Medical Branch in Galveston, and colleagues analyzed risk factor data on 2,995 men 50 years of age and older in the National Health and Nutrition Examination Survey III, who had a valid DXA test. A simplified scoring algorithm called the Male Osteoporosis Risk Estimation Score (MORES) was developed using a multivariable logistic regression model and validated for clinical utility as a tool for prevention of hip fracture.

The researchers report that the weighted prevalence of osteoporosis was 4.8 percent. Because low weight was the strongest predictor of osteoporosis, the MORES model "supports DXA testing in all men aged 50 and older who weigh 70 kg (154 pounds) or less," the authors write. "Men aged 56 years and older with a history of chronic obstructive pulmonary disease also met DXA screening thresholds. Age alone was not a criterion for screening."

Shepherd and colleagues conclude that "Analysis of the number needed-to-screen to prevent one additional hip fracture indicate that the MORES provides a reasonable approach to men older than 60 years and perhaps even in men older than 55 years."

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New Guidelines for Atrial Fibrillation Therapy Challenged

Editorial says digoxin should not be replaced as mainstay of heart rate control

New guidelines that replace digoxin as the mainstay treatment for control of heart rate in patients with chronic atrial fibrillation have been challenged in an editorial published in the Nov. 24 issue of BMJ.

Theodora Nikolaidou, research fellow, and Kevin S. Channer, M.D., of the Royal Hallamshire Hospital in Sheffield, England, object to new joint guidelines issued by the American College of Cardiology, the American Heart Association and the European Society of Cardiology. The authors reviewed 57 studies, including 25 randomized, double-blind controlled trials, which assessed digoxin, beta-blockers, calcium antagonists and combinations of these for heart rate control in chronic atrial fibrillation. Trial sizes ranged from six participants to 136.

The editorialists argue that little evidence exists that monotherapy with either beta-blockers or calcium channel blockers improves exercise tolerance compared with digoxin. They also believe there is little evidence that monotherapy with either of the two alternative medications improves heart control rate at rest and during exercise compared with digoxin alone.

"We believe that the combination of digoxin and a beta-blocker or calcium antagonist should be recommended as first line management," the authors conclude. "We emphasize that it is safest to start treatment with digoxin first."

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Fatigue, Headaches Common at 11 Weeks After Childbirth

Research on moms finds support, less job stress associated with better postpartum health

Eleven weeks after giving birth, new mothers still had an average of 4.1 childbirth-related symptoms, most often fatigue, according to a prospective cohort study published in the November/December issue of the Annals of Family Medicine.

Pat McGovern, Ph.D., of the University of Minnesota in Minneapolis, and colleagues analyzed data from 661 mothers of singleton infants, who were interviewed at five and 11 weeks postpartum, by which time half had returned to work. The investigators were examining personal and employment-related factors associated with postpartum health in working mothers.

The researchers found that 43.4 percent of mothers reported fatigue at 11 weeks, although this was a drop from 63.8 percent at five weeks. Other common symptoms at 11 weeks included headache (41.6 percent), back or neck pain (37.8 percent), and runny or stuffy nose (36 percent). Social support from family and friends was associated with better postpartum mental health. Lower levels of job stress, more coworker support, and more perceived control over work and home activities were associated with better postpartum health.

"Physicians evaluating postpartum women may want to discuss strategies to promote health, including identification of sources of social support at home and work. Postpartum evaluations should include screening for anxiety and depression and evaluation of fatigue and other physical symptoms, including those related to job stress. Physicians should discuss with women their plans for return to work and possible need for intermittent leave under [the Family and Medical Leave Act]," the authors write.

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Early Life Experience Has Little Bearing on Later Activity

Physical activity of mother among a few modest associations noted in British study

Few characteristics of early childhood are reliable predictors of physical activity in 11- and 12-year-old children, according to a report published Nov. 23 in BMJ Online First.

Calum Mattocks, a research associate at the University of Bristol in the United Kingdom, and colleagues followed children whose mothers had participated in the Avon longitudinal study of parents and children between 1991-1992. Mothers, their partners and eventually their children answered questionnaires regarding health, lifestyle and social circumstances. At age 11, the children were asked to wear an actigraph accelerometer for a period of one week in order to measure physical activity. The study sample consisted of 5,451 children (2,593 boys and 2,858 girls).

Among factors showing a modest association with physical activity in childhood were the mother's body mass index before pregnancy, the mother's physical activity during pregnancy, parity and season of birth. None of the indicators of physical activity at age 0-2 years (activity at 6 months or time outside at 24 months) was associated with later physical activity.

The findings "may have implications when developing guidelines for interventions to increase physical activity, as focusing on modifiable early life factors may have only a modest effect on later levels of physical activity. We have shown that children are slightly more active if their parents are active early in the child's life," the authors write. "Encouraging physical activity in parents may also influence their children to become more active, with the added advantage that physically active parents are healthier."

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Depression Linked to Low Bone Mass in Younger Women

Bone mineral deficits are similar to those associated with smoking, low calcium intake

In premenopausal women, the presence of major depressive disorder may be associated with lower bone mineral density, according to a report published in the Nov. 26 issue of the Archives of Internal Medicine.

Farideh Eskandari, M.D., of Case Western Reserve University in Cleveland, Ohio, and colleagues compared baseline bone mineral density measurements in 89 premenopausal women with major depressive disorder and 44 healthy controls.

Compared to controls, the researchers found that women with major depressive disorder were more likely to have low bone mineral density at the femoral neck (17 percent versus 2 percent), total hip (15 percent versus 2 percent) and lumbar spine (20 percent versus 9 percent). They also found that women with major depressive disorder had higher mean levels of 24-hour pro-inflammatory cytokines and lower levels of anti-inflammatory cytokines.

"The bone mineral density deficits are of clinical significance and comparable in magnitude to those resulting from established risk factors for osteoporosis, such as smoking and reduced calcium intake," the authors conclude. "The possible contribution of immune or inflammatory imbalance to low bone mineral density in premenopausal women with major depressive disorder remains to be clarified."

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Carb-Rich Diets May Increase Risk of Diabetes in Women

But eating more cereal fiber may lower the risk

Carbohydrate-rich and high glycemic index diets are associated with an increased risk of developing type 2 diabetes in Chinese and black women, whereas adding cereal fiber to the diet may protect against diabetes in black women, according to two studies published Nov. 26 in the Archives of Internal Medicine.

Raquel Villegas, Ph.D., of Vanderbilt University Medical Center in Nashville, Tenn., and colleagues followed 64,227 Chinese women for nearly five years, interviewing the women periodically about dietary habits. Dietary carbohydrate and rice intake were associated with an increased risk of type 2 diabetes, with a relative risk of 1.28 for carbohydrates and 1.78 for rice for women in the highest versus lowest quintiles of intake.

In a second study, Supriya Krishnan, of Boston University, and colleagues surveyed 40,078 black women in the United States regarding dietary habits and followed them for eight years. Among women with body mass index less than 25, a glycemic index in the highest quintile carried almost twice the risk of developing diabetes, while cereal fiber intake in the highest quintile decreased the risk by 59 percent compared to those in the lowest quintiles.

"A simple change from white bread (two slices provides 1.2 g of fiber) to whole wheat bread (two slices provides 3.8 g of fiber) or substituting a cup of raisin bran (5.0 to 8.0 g of fiber) or oatmeal (4.0 g of fiber) for a cup of corn chex (0.5 g of fiber) or rice chex (0.3 g of fiber) will move a person from a low fiber intake category to a moderate intake category, with a corresponding 10 percent reduction in risk," Krishnan and colleagues write.

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Coronary Risk Profiles Help Patients Achieve Lipid Targets

Better knowledge of coronary risk was associated with improved cholesterol levels

Discussing individualized coronary risk profiles appears to help patients achieve lipid goals, according to an article published in the Nov. 26 issue of the Archives of Internal Medicine.

Steven A. Grover, M.D., of McGill University in Montreal, Quebec, Canada, and colleagues randomized 3,053 patients with dyslipidemia to receive either usual care or a 12-month intervention involving ongoing feedback from their primary care physicians on their calculated coronary risk and the change in this risk that lifestyle changes, drug treatment or both would accomplish.

Despite similar statin dosages, patients informed of their coronary risk profile had significantly, though modestly, greater reductions in low-density cholesterol levels (LDL) and total cholesterol to high-density lipoprotein cholesterol (HDL) ratios compared to those receiving usual care. After adjustment for baseline lipid values, patients in the coronary risk profile group were more likely to reach their lipid targets. The magnitude of benefit of risk profiles was greatest in patients at highest cardiovascular risk.

In the coronary profile group, "patient behavior seems to have been modified as the odds of reaching lipid targets increased approximately 25 percent after adjustment for statin dose and baseline lipid levels. This suggests greater adherence with statins or other lifestyle changes," the authors write.

This study was funded by Pfizer Canada. In addition, several authors report financial ties to the pharmaceutical industry.

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Patients with Implantable Defibrillators Can Safely Drive

Low risk of shock while driving

Patients with implantable cardioverter-defibrillators (ICDs) are at low risk of shock while driving compared with other activities, according to a study published in the Dec. 4 issue of the Journal of the American College of Cardiology.

Christine M. Albert, M.D., of Brigham and Women's Hospital in Boston, and colleagues examined the risk of ICD shocks for ventricular tachycardia or ventricular fibrillation during and up to 60 minutes after an episode of driving compared with other activities in 1,188 patients.

The researchers observed 193 shocks over a median follow-up of 562 days. The absolute risk was estimated at one per 25,116 person-hours spent driving. The risk of shock while driving was low (relative risk 1.05). The risk was high within one hour of driving (relative risk 2.24), with most shocks occurring within 30 minutes after driving (RR, 4.46).

The study "is a welcome reassurance that driving can safely be resumed by many patients with ICDs, adding increased quality of life to the increased quantity of life these remarkable devices now provide," Blair P. Grubb, M.D., from the University of Toledo in Ohio, writes in an accompanying editorial.

Albert and colleagues have received grant support and honoraria from pharmaceutical and medical equipment companies, including Boston Scientific.

AbstractFull Text (subscription or payment may be required)Editorial

High Testosterone Associated with Lower Mortality

Correlation is observed for risk of death from all causes, cardiovascular disease and cancer

Men with higher concentrations of endogenous testosterone appear to enjoy lower risks of mortality from all causes, including cardiovascular disease and cancer, according to a report published online Nov. 26 in Circulation: Journal of the American Heart Association.

Kay-Tee Khaw, M.D., of the University of Cambridge School of Clinical Medicine in Cambridge, United Kingdom, and colleagues followed men who had been surveyed and examined between 1993 and 1997 as part of the European Prospective Investigation into Cancer in Norfolk study. In 2003, the investigators compared 825 deceased men who had been free of cardiovascular disease and cancer in the original study with a control group of 1,489 men who were still living. Their blood samples were retrieved from storage and assayed for total testosterone, dehydroepiandrosterone sulfate, and sex hormone binding globulin.

Men in the highest quartile of testosterone levels had an approximately 25 percent to 30 percent lower risk of total mortality compared with those in the lowest quartile. The magnitude of effect was similar for deaths due to cardiovascular causes and cancer, and was changed very little after adjustment for cardiovascular risk factors.

"We concur with the conclusions from recent reviews that although the data appear reassuring, definitive assessment of the long-term effects of testosterone replacement therapy on health will require large-scale controlled trials," the authors write.

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Factors in Diabetics' Artery Calcification Examined

Prior calcification, poor glycemic control increase risk for coronary arteries

Type 2 diabetic patients have a higher risk of coronary artery calcification if they have prior calcification, poor glycemic control or take statins, researchers report in the Dec. 4 issue of the Journal of the American College of Cardiology.

Dhakshinamurthy Vijay Anand, from Wellington Hospital in London, United Kingdom, and colleagues examined factors affecting the progression of coronary artery calcification in 398 patients with type 2 diabetes without prior coronary disease or symptoms.

The researchers found that 53 percent of patients had coronary artery calcification at baseline, 29.6 percent had progression, and 0.8 percent had regression. Independent predictors of coronary artery calcification progression were baseline calcification (odds ratio 6.38 for coronary artery calcification greater than 400), glycated hemoglobin greater than 7 (OR, 1.95) and statin use (OR, 2.27).

"Baseline coronary artery calcification severity and suboptimal glycemic control are strong risk factors for coronary artery calcification progression in type 2 diabetic subjects," Anand and colleagues conclude.

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Techniques Can Locate Culprit Plaque in Heart Attack

Ultrasound, thermography more useful than angiography

Ultrasound and thermography can be more useful than angiography in locating the culprit plaque in patients with acute myocardial infarction, particularly those with total occlusion of the coronary artery, according to study findings published in the Dec. 4 issue of the Journal of the American College of Cardiology.

Takuro Takumi, M.D., from Kagoshima City Hospital in Japan, and colleagues examined whether the maximal temperature site (measured by thermal wire) coincided with the culprit plaque (measured by intravascular ultrasound) in the left anterior descending coronary artery of 45 consecutive patients with a first anterior acute myocardial infarction.

The researchers found that 25 patients had total occlusion of the coronary artery while the remaining 20 patients had reperfusion. The maximal temperature site was more distal to the most stenotic or occlusive site by angiography. In patients with reperfusion, the culprit plaques determined by ultrasound, angiography and thermography were in relatively close proximity. In contrast, in patients with occlusion, the angiographic occlusive site was more proximal to the culprit plaque as determined by ultrasound and thermography.

"The fact that there was a good correlation between the maximal temperature site and that of intravascular ultrasound adds additional validation to the use of thermography for the detection of culprit plaques in vivo and suggests that modalities aimed at detecting temperature as a surrogate for inflammation might be useful for localizing the culprit plaque," Aloke V. Finn, M.D., from Emory University School of Medicine in Atlanta, and colleagues write in an accompanying editorial.

AbstractFull Text (subscription or payment may be required)Editorial

Statewide Initiative Improves Time to Reperfusion in STEMI

Second study reports harmful effect of glucose-insulin-potassium infusion shortly after STEMI

A statewide campaign targeting the treatment of ST-segment elevation myocardial infarction (STEMI) improved average time to reperfusion, according to the results of a new study, and a second study reports the possible early harmful effect of glucose-insulin-potassium (GIK) infusions in patients with acute STEMI. Both studies are published in the Nov. 28 issue of the Journal of the American Medical Association.

James G. Jollis, M.D., of Duke University in Durham, N.C., and colleagues compared time to reperfusion in 2,089 patients with acute STEMI treated at 65 North Carolina hospitals three months prior to and three months after a quality implementation project. The intervention significantly improved door-to-device time in patients treated at percutaneous coronary intervention (PCI) hospitals and door-to-needle time in patients treated with thrombolysis at non-PCI hospitals.

Rafael Diaz, M.D., of the Etudios Cardiologica Latin America in Rosario, Argentina, and colleagues analyzed data from the OASIS-6 GIK trial, which randomized 2,748 patients with acute STEMI to receive either a GIK infusion or no infusion, as well as combined data on 22,943 patients with acute STEMI from the OASIS-6 and CREATE-ECLA GIK trials. The researchers found that in the combined trial results, the risk of death and composite death or heart failure was elevated in the first three days in patients receiving GIK, which may have been related to increased levels of glucose, potassium and net fluid gain post-infusion.

These results "have demonstrated that GIK infusion does not produce a favorable clinical effect in patients with STEMI. Moreover, GIK therapy appears to initially increase the rate of death postinfarction," Diaz and colleagues write.

The OASIS-6 trial was funded by Sanofi-Aventis, Organon, and GlaxoSmithKline.

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High-Trauma Fractures Linked to Osteoporosis

Additional study describes algorithm predicting risk of hip fracture in older women

New research shows that high-trauma fractures in older individuals are associated with low bone mineral density and increase the risk of subsequent fractures, while a new clinical algorithm can help predict the five-year risk of hip fracture in postmenopausal women. These research findings are published in two studies in the Nov. 28 issue of the Journal of the American Medical Association.

In the first study, Dawn C. Mackey and colleagues at the San Francisco Coordinating Center, California Pacific Medical Center Research Institute, analyzed data from a total of 14,017 older U.S. adults to investigate the association between bone mineral density (measured by dual-energy x-ray absorptiometry) and risk of high-trauma fractures. The researchers found that high-trauma fractures were associated with low bone mineral density, and individuals sustaining high-trauma fractures were at an increased risk of subsequent high-trauma and low-trauma fractures.

In the second study, John Robbins, M.D., of the University of California at Davis in Sacramento, and colleagues analyzed data from 93,676 postmenopausal women to create a model predicting five-year risk of hip fracture, and then tested the model in 10,750 women with bone mass density measurements. Eleven factors were predictive of hip fracture within five years: age, self-reported health, physical activity, weight, height, race/ethnicity, history of fracture after age 54, parental hip fracture, current smoking, corticosteroid use and treated diabetes. Incorporation of these factors into an algorithm allowed the prediction of the five-year risk of hip fracture across ethnicities.

"Fractures previously defined as due to high trauma, such as those from a blunt injury in a motor vehicle crash or a fall from a chair, can no longer be dismissed as being unrelated to osteoporosis," writes the author of an associated editorial.

Several authors of both studies report receiving research support, consulting fees and other financial incentives from various pharmaceutical companies.

Abstract - MackeyFull Text (subscription or payment may be required)Abstract - RobbinsFull Text (subscription or payment may be required)Editorial

Simple Techniques Can Control Respiratory Infections

Personal hygiene, barrier measures and isolation of infected persons recommended

Handwashing, wearing gloves, gowns and masks, and isolation of infected people are effective measures for reducing the spread of respiratory tract infections, according to a review of studies published Nov. 27 in BMJ Online First.

Tom Jefferson, Ph.D., of the Cochrane Vaccines Field in Alessandria, Italy, and colleagues scanned medical databases for reports on public health interventions to control the spread of respiratory viruses. A total of 138 papers, completed in a variety of institutional and non-institutional settings over a span of four decades, were reviewed. Vaccine and antiviral interventions were excluded. The authors report that the quality of the studies was highly mixed.

Simple public health measures seemed to be most effective at reducing virus transmission, especially when implemented as part of a structured program that included education and instruction. Successful techniques included frequent handwashing (with or without antiseptics), wearing masks, gowns and gloves, and isolating people who might be infected. Combining these measures produced the best results.

An accompanying editorial by Martin Dawes, M.D., of McGill University in Montreal, Canada, concludes, "Governments should continue to fund research to confirm the findings of this review and to investigate other areas of uncertainty that it identifies in the management of people with suspected influenza."

AbstractFull TextEditorial

New Drug Raises Platelet Counts in ITP and Cirrhosis

Eltrombopag appears to be well tolerated, more research needed

Eltrombopag, an oral thrombopoietin-receptor agonist that stimulates platelet production, may be useful in raising low platelet counts associated with idiopathic thrombocytopenic purpura (ITP) and hepatitis C virus (HCV)-related cirrhosis, according to two articles published in the Nov. 29 issue of the New England Journal of Medicine.

James B. Bussel, M.D., of Weill Cornell Medical College of Cornell University in New York City, and colleagues randomized 118 patients with chronic refractory or relapsed ITP and platelet counts less than 30,000 per cubic millimeter to receive either eltrombopag (30, 50, or 75 mg daily) or placebo. The researchers found that eltrombopag increased platelet counts in a dose-dependent manner, while rates and severity of adverse events did not differ from placebo.

In a second study, John G. McHutchinson, M.D., of Duke University in Durham, N.C., and colleagues randomized 74 patients with HCV-related cirrhosis and platelet counts between 20,000 to 70,000 per cubic millimeter to receive either eltrombopag (30, 50, or 75 mg daily) or placebo for a total of 16 weeks, with antiviral therapy begun at week 4 if possible. Eltrombopag increased platelet counts in a dose-dependent manner, permitting the initiation of antiviral therapy in the majority of eltrombopag-treated patients.

"The results reported for thrombopoietin-receptor agonists are too preliminary for any definitive statement about applications in clinical practice, but they surely encourage further work in this direction," writes Robert S. Schwartz, M.D., in an accompanying editorial.

Abstract - BusselFull Text (subscription or payment may be required)Abstract - McHutchinsonFull Text (subscription or payment may be required)Editorial

Cancer Risk from CT Scans May Be Underestimated

One-third of all ordered CT scans may be medically unnecessary

The growing use of computed tomography (CT) scans may have serious public health implications, as radiation exposure associated with these scans may increase the risk of cancer, particularly in children, according to an article published in the Nov. 29 issue of the New England Journal of Medicine.

David J. Brenner, Ph.D., and Eric J. Hall, of Columbia University in New York City, reviewed the use of CT scanning and its clinical implications, including radiation-related cancer risk.

Roughly 62 million CT scans are performed each year in the United States. The increase in CT-related radiation exposure may result in a future public health burden, and the authors predict that, in the next few decades, 1 to 2 percent of all cancers may be attributable to radiation from CT scans. To combat this, physicians can take the practical steps of reducing the CT-related radiation dose in individual patients, using other imaging modalities without radiation risk, such as ultrasound or MRI when possible, or simply prescribing fewer CT scans.

"From an individual standpoint, when a CT scan is justified by medical need, the associated risk is small relative to the diagnostic information obtained. However, if it is true that about one-third of all CT scans are not justified by medical need, and it appears to be likely, perhaps 20 million adults and, crucially, more than 1 million children per year in the United States are being irradiated unnecessarily," the authors write.

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Patent Foramen Ovale Linked with Cryptogenic Stroke

Paradoxical embolism is likely cause of stroke in older and younger patients

Patent foramen ovale is independently associated with cryptogenic stroke in both older and younger patients, according to an article published in the Nov. 29 issue of the New England Journal of Medicine.

Michael Handke, M.D., of University Hospital Freiburg in Freiburg, Germany, and colleagues performed transesophageal echocardiography on 227 patients with cryptogenic stroke and 276 control patients with stroke of known cause in order to determine the association between patent foramen ovale and cryptogenic stroke in both younger (under 55 years) and older patients.

Individuals with cryptogenic stroke were significantly more likely to have a patent foramen ovale than those with stroke of known cause, both for younger patients (43.9 percent versus 14.3 percent) and older patients (28.3 percent versus 11.9 percent). An even stronger association was noted between the presence of patent foramen ovale with concomitant atrial septal aneurysm and cryptogenic stroke. Controlling for age, plaque thickness, hypertension and coronary artery disease revealed that patent foramen ovale was independently associated with cryptogenic stroke in younger (odds ratio 3.70) and older patients (odds ratio 3.00).

"There is an association between the presence of patent foramen ovale and cryptogenic stroke in both older patients and younger patients. These data suggest that paradoxical embolism is a cause of stroke in both age groups," the authors conclude.

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