Latest Research

Risk of Late Events Higher with Drug-Eluting Stents

Patients with drug-eluting stents should stay on clopidogrel to reduce the risk of late events

In patients with drug-eluting stents, but not those with bare-metal stents, extended clopidogrel and aspirin use may be needed to reduce the risk of late events such as cardiac death or myocardial infarction, according to two reports published in the Dec. 19 issue of the Journal of the American College of Cardiology and early online Dec. 5 in the Journal of the American Medical Association. An advisory panel to the U.S. Food and Drug Administration is scheduled to review the safety of drug-eluting stents this week.

Matthias Pfisterer, M.D., of the University Hospital and Bruderholzspital in Basel, Switzerland, and colleagues studied 746 patients with either drug-eluting or bare-metal stents. They found that cardiac death or heart attack occurred in 4.9 percent of drug-eluting stent patients at seven to 18 months after the discontinuation of clopidogrel compared to 1.3 percent of bare-metal stent patients.

Eric L. Eisenstein, D.B.A., of Duke University Medical Center in Durham, N.C., studied 4,666 patients with either drug-eluting or bare-metal stents. In drug-eluting stent patients, they found that those taking clopidogrel had a significantly lower two-year death rate than those not taking clopidogrel (2 percent versus 5.3 percent). In bare-metal stent patients, however, they found no significant difference in death rates between those taking clopidogrel and those not taking it (3.7 percent versus 4.5 percent).

"These findings have led us to the view that patients with drug-eluting stents should remain on clopidogrel and aspirin if at all possible until adequate studies are completed," state the authors of an accompanying editorial in the Journal of the American College of Cardiology.

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Mental Disorder Risk Increases in Postpartum Period

Psychiatric hospital admission or outpatient contact especially high during first three months

First-time mothers are at higher risk of developing postpartum depression, bipolar disorder and schizophrenia within the first three months of giving birth than at other times, researchers report in the Dec. 6 issue of the Journal of the American Medical Association.

Trine Munk-Olsen, M.Sc., of the University of Aarhus in Denmark, and colleagues analyzed data on 630,373 women and 547,431 men who became first-time parents between 1973 and 2005.

Compared with women who had given birth 11 to 12 months prior, new mothers had an increased risk for incident hospital admission for any mental disorder during the first three months after childbirth, with the highest risk 10 to 19 days postpartum (relative risk, 7.31).

New mothers had an increased risk for psychiatric outpatient contacts during the first three months after childbirth, again with the highest risk occurring 10 to 19 days postpartum (RR, 2.67). Fatherhood was not associated with any increased risk of hospital admission or outpatient contact.

"These collective data [Munk-Olsen et al and other studies] emphasize the importance of recognizing childbearing as a potent health factor in the life course of women," states an accompanying editorial, whose lead author took funding from Pfizer to study the pharmacokinetics of ziprasidone during pregnancy. "Childbearing influences the course of any disease state and acts as a biopsychosocial factor that may precipitate new episodes of illness. The data also provide evidence to inform and support universal screening for postpartum mood episodes."

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Whole-Body Scans Diagnose Stage of Colorectal Cancer

Preliminary research shows viability of PET/CT colonography with optical colonoscopy

Whole-body positron emission tomography (PET) and computed tomography (CT) scans may be a viable option for diagnosing colorectal cancer stage, according to preliminary research published in the Dec. 6 issue of the Journal of the American Medical Association.

Patrick Veit-Haibach, M.D., of University Hospital Essen in Germany, and colleagues compared the diagnostic accuracy of whole-body PET/CT, conventional CT staging alone and CT followed by PET (CT + PET) in 47 colorectal cancer patients with 50 lesions.

The researchers found that PET/CT colonography correctly determined stage in 37 (74 percent) of the lesions compared to 26 (52 percent) for CT alone and 32 (64 percent) for CT + PET.

"This preliminary report suggests that PET/CT colonography may be at least equivalent to CT + PET with respect to tumor staging in patients with colorectal cancer," the authors conclude. "Because an all-in-one staging modality has to offer both accurate TNM staging of the tumor in question and information on potentially present synchronous tumors, PET/CT colonography in conjunction with optical colonoscopy may be suitable for whole-body all-in-one tumor staging in patients with colorectal cancer."

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Rosiglitazone Shows Modest Benefit for Glycemic Control

Drug may have worse side effects than older, cheaper drugs

Rosiglitazone modestly improves glycemic control but may increase the risk of cardiovascular events, edema and weight gain compared with older and cheaper drugs, according to study findings published in the Dec. 7 issue of the New England Journal of Medicine.

Steven E. Kahn, M.B., Ch.B., from the Veterans Affairs Puget Sound Health Care System in Seattle, and colleagues randomized 4,360 patients with recently diagnosed type 2 diabetes to the thiazolidinedione rosiglitazone or to one of two older drugs, metformin or glyburide, for a median of four years. The researchers assessed time to treatment failure, defined as fasting plasma glucose greater than 180 mg/dL.

The risk of failure at five years with rosiglitazone treatment was significantly reduced by 32 percent compared with metformin and by 63 percent compared with glyburide. Compared with rosiglitazone, the risk of cardiovascular events was significantly reduced with glyburide, while the risks were similar with metformin. The study found significantly more weight gain and edema in patients taking rosiglitazone, but fewer gastrointestinal events and less hypoglycemia compared with metformin and glyburide, respectively.

"Given the modest glycemic benefit of rosiglitazone…and higher cost…metformin remains the logical choice when initiating pharmacotherapy for type 2 diabetes," states the author of an accompanying editorial.

The study was supported by grants from GlaxoSmithKline.

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Pioglitazone Benefits Nonalcoholic Steatohepatitis

Glucose tolerance, liver function improves with combination of drug and dietary changes

A hypocaloric diet plus pioglitazone significantly improves glucose tolerance and liver function in patients with nonalcoholic steatohepatitis, according to the results of a proof-of-concept study reported in the Nov. 30 issue of the New England Journal of Medicine.

Kenneth Cusi, M.D., of the University of Texas Health Science Center at San Antonio, and colleagues randomly assigned 55 patients with nonalcoholic steatohepatitis and impaired glucose tolerance or type 2 diabetes to a hypocaloric diet plus either pioglitazone (45 mg per day) or placebo for six months.

Patients receiving pioglitazone had better glycemic control and glucose tolerance, improved hepatic insulin sensitivity, normal liver aminotransferase and decreased serum aminotransferase levels, and reduced hepatic fat content. These patients also had significant improvements in histology in terms of steatosis, ballooning necrosis and inflammation, but not fibrosis. There were no adverse events apart from fatigue and lower-extremity edema in one patient taking pioglitazone.

"Until the results of large, controlled studies of at least one or two years' duration are available, dietary modification, exercise, and treatment of coexisting conditions should be the preferred strategy for managing nonalcoholic steatohepatitis," Arthur J. McCullough, M.D., from Case Western Reserve University in Cleveland, Ohio, comments in an accompanying editorial.

The study was partially supported by Takeda Pharmaceuticals.

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Intermittent HIV Therapy Increases Risk of Death

Increased risk due to fewer CD4+ T cells, higher viral load

Intermittent rather than continuous antiretroviral therapy significantly increases the risk of opportunistic infections and death in HIV-infected individuals, largely due to fewer CD4+ T cells and higher viral load, researchers report in the Nov. 30 issue of the New England Journal of Medicine.

Wafaa M. El-Sadr, M.D., from Columbia University in New York City, and colleagues randomly assigned 5,472 patients with HIV and more than 350 CD4+ T cells per cubic millimeter to either continual antiretroviral therapy or episodic antiretroviral therapy. The episodic antiretroviral therapy group was only treated when their CD4+ T-cell count dropped below 250 per cubic millimeter and therapy was stopped when counts increased to more than 350 per cubic millimeter.

The researchers found that significantly more patients receiving episodic antiretroviral therapy developed opportunistic infections (3.3 events per 100 person-years versus 1.3 per 100 person-years, hazard ratio 2.6). Patients in this group also had a significantly higher risk of death from any cause (HR, 1.8) or from cardiovascular, renal or hepatic disease (HR, 1.7). Lower numbers of CD4+ T cells and higher HIV RNA levels were primarily responsible, the authors note.

Intermittent therapy "may be appropriate in certain circumstances," Judith S. Currier, M.D., and Lindsey R. Baden, M.D., from the University of California Los Angeles, comment in an accompanying editorial. "Given the deleterious effects of uncontrolled HIV replication, we must continue to reevaluate the optimal criteria for the initiation of antiretroviral therapy."

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Industry Ties Common But Many Patients Unconcerned

About one-third of institutional review board members report financial ties with industry

About one-third of institutional review board (IRB) members report having financial relationships with industry, but most patients in cancer research trials report being unconcerned about financial ties of researchers or institutions with industry, according to the results of two surveys published in the Nov. 30 issue of the New England Journal of Medicine.

In the first study, Eric G. Campbell, Ph.D., of Massachusetts General Hospital in Boston, and colleagues surveyed 574 IRB members regarding their financial relationships with industry. The researchers found that 36 percent had at least one relationship with industry, although most (85.5 percent) never thought that this relationship affected other members' decisions. Fifteen percent reported that at least one protocol sponsored by their company or a competitor came before their IRB, of which 57.7 percent said they always reported the relationship and 64.5 percent said they never voted on the protocol.

In the second study, Ezekiel J. Emanuel, M.D., Ph.D., of the National Institutes of Health in Bethesda, Md., and colleagues interviewed 253 patients in cancer research trials regarding their attitudes about financial conflicts of interest with drug companies. The researchers found that more than 90 percent of patients were not concerned, with approximately 70 percent to 80 percent of patients reporting that they would have still enrolled in the trial if researchers had been paid to speak or consult (which most considered ethical), and a similar percentage said the same if the researcher or institution had received royalties or owned stock in the company.

"Trust in the clinical research enterprise is a fragile commodity," Elizabeth G. Nabel, M.D., from the National Institutes of Health, comments in an accompanying editorial. "We all must work to preserve and protect this public trust, and this will happen only if we make it our priority."

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Klebsiella oxytoca Linked to Antibiotic-Associated Colitis

K. oxytoca should be considered in differential diagnosis of intestinal pathogens

Klebsiella oxytoca may be a cause of antibiotic-associated hemorrhagic colitis, according to study findings published in the Dec. 7 issue of the New England Journal of Medicine.

Christoph Hogenauer, M.D., of the Medical University of Graz in Graz, Austria, and colleagues studied 22 patients who had suspected antibiotic-associated colitis and who were negative for Clostridium difficile. They also cultured stool samples from 385 healthy subjects for K. oxytoca.

The researchers found that six of the 22 patients showed colonoscopic evidence of antibiotic-associated hemorrhagic colitis, and that five of them had positive cultures for K. oxytoca but no other common enteric pathogens. They also found that all isolated K. oxytoca strains produced cytotoxin and identified K. oxytoca in 1.6 percent of the healthy subjects.

"Our study suggests that toxigenic K. oxytoca should be considered in the differential diagnosis of potential intestinal pathogens. When a patient with antibiotic-associated colitis is negative for C. difficile, stool samples should be cultured for K. oxytoca," the authors write. "We consider it important to draw attention to toxigenic K. oxytoca, since relatively young patients may have received a misdiagnosis of ischemic colitis with spontaneous resolution in the past, and since the diagnosis of antibiotic-associated hemorrhagic colitis has consequences for the care of such patients, who could be harmed by unnecessary treatment with drugs."

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Imatinib Response Durable in Chronic Myeloid Leukemia

Five-year study finds high rates of complete cytogenetic response and overall survival

In patients with chronic myeloid leukemia, imatinib treatment improves five-year outcomes in a high proportion of patients, according to a study in the Dec. 7 issue of the New England Journal of Medicine.

Brian J. Druker, M.D., of the Oregon Health and Science University Cancer Institute in Portland, and colleagues randomly assigned 553 patients to receive imatinib and 553 to receive interferon alfa plus cytarabine.

In the imatinib group, the researchers found rates of complete cytogenetic response of 69 percent by 12 months and 87 percent by 60 months. They also found that estimated overall survival was 89 percent in the imatinib group at 60 months, which is higher than that reported in any previously published prospective study of the treatment of chronic myeloid leukemia.

"Most patients in the interferon group either switched to imatinib or discontinued interferon," the authors write. "On the basis of an intention-to-treat analysis, there was no significant difference in overall survival between the group of patients who began their treatment with interferon and those who began their treatment with imatinib. Previous randomized studies of interferon alfa plus cytarabine, performed before the availability of imatinib, showed a five-year overall survival of 68 to 70 percent."

Several authors report having received consulting or lecturing fees from Novartis and other drug companies.

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Ancrod Ineffective for Stroke Beyond Three-Hour Window

Drug derived from snake venom associated with higher mortality, hemorrhage when given within six hours

Previous studies have found that ancrod, a drug derived from Malaysian pit viper venom, is effective for ischemic stroke if given within three hours of symptom onset, but a new study shows it is not effective when given beyond three hours but within six hours, and increases the risk of short-term mortality and intracranial hemorrhage. The findings are published in the Nov. 25 issue of The Lancet.

Michael G. Hennerici, M.D., of the University of Heidelberg in Mannheim, Germany, and colleagues randomized 1,222 patients to receive ancrod or placebo within six hours after stroke onset. Functional ability at three months was similar in the active treatment and placebo group (42 percent in both groups), but neurological recovery was worse and there were more hemorrhages in the ancrod group than in the placebo group.

Mortality at three months was higher in the ancrod group than in the placebo group (20 percent versus 14 percent). At 12 months, however, there was no significant difference. "On the basis of our findings, ancrod should not be recommended for use in acute ischemic stroke beyond three hours," the authors note.

"Although the study was unsuccessful, it delivers an important message: that time from onset of symptoms to treatment matters, and in [this trial] it was too long," Markku Kaste, M.D., of the University of Helsinki in Finland, writes in an accompanying editorial.

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Heart Attack Care Substandard in Medicaid Patients

Study finds that insurance status is associated with disparities in level of care and mortality rates

Among patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS), those on Medicaid receive lower-quality care and experience worse outcomes than those with HMOs or private insurance, according to study findings published in the Nov. 21 issue of the Annals of Internal Medicine.

James Calvin, M.D., of the Rush University Medical Center in Chicago, and colleagues assessed data on 37,345 NSTE ACS patients under age 65, including those on Medicaid, and 59,550 patients over age 65, including those on Medicare.

The researchers found that Medicaid patients were less likely than patients with HMOs or private insurance to receive aspirin, beta-blockers, clopidogrel, lipid-lowering agents, dietary counseling, smoking cessation counseling and referral for cardiac rehabilitation before discharge. They also found that Medicaid patients were more likely to experience delays in acute care. In patients under age 65, the unadjusted in-hospital mortality rates were significantly higher in Medicaid patients (2.9 percent versus 1.2 percent) while in patients over age 65, the rates for Medicare patients and those with HMOs or private insurance were not significantly different (6.2 percent versus 5.6 percent).

"Because improved use of evidence-based therapies for patients with NSTE ACS is associated with lower mortality rates, further investigation is needed to understand the root causes for these findings and to determine novel strategies to ameliorate health care disparities and reduce mortality rates for Medicaid patients," the authors conclude.

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Routine HIV Screening of Adults Is Cost-Effective

Screening not cost-effective if prevalence of undiagnosed HIV is below 0.2 percent

A cost-effectiveness analysis for routine HIV screening has determined that all U.S. adults should be screened unless the prevalence of undiagnosed HIV is below 0.2 percent, researchers report in the Dec. 5 issue of the Annals of Internal Medicine.

A. David Paltiel, Ph.D., from Yale School of Medicine in New Haven, Conn., and colleagues used a mathematical model to simulate the cost-effectiveness ratios (in discounted 2004 dollars per quality-adjusted life-year, or QALY) of adult HIV screening based on HIV transmission risk, with and without antiretroviral treatment.

Assuming an HIV prevalence of 1 percent, an annual incidence of 0.12 percent and moderately favorable assumptions on transmission, the researchers found that the cost-effectiveness ratios varied from $30,800 to $55,500 QALY gained for one-time screening or screening every three years, respectively. With a prevalence of 0.10 percent and an annual incidence of 0.014 percent, the cost-effectiveness ratio increased to $60,700 QALY gained for one-time screening.

"Routine, rapid HIV testing is recommended for all adults except in settings where there is evidence that the prevalence of undiagnosed HIV infection is below 0.2 percent," the authors conclude.

"Eventually, reminiscent of successful screening programs for syphilis and tuberculosis, the cost-effectiveness question for HIV will change from whether we should screen for HIV to when we should stop," states an accompanying editorial.

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Physician Organization Impacts Primary Care Quality

Integrated medical groups provide better quality than individual practice associations

Integrated medical groups provide higher-quality primary care than individual practice associations, according to the results of a study published in the Dec. 5 issue of the Annals of Internal Medicine.

Ateev Mehrotra, M.D., M.P.H., from RAND Health and the University of Pittsburgh School of Medicine in Pennsylvania, and colleagues compared the quality of primary care provided by integrated medical groups, or IMGs, with that provided by individual practice associations, IPAs, within 119 physician groups in a large health maintenance organization. The care of the 1.7 million enrollees was examined based on six quality measures.

IMGs performed significantly better in terms of the percentage receiving mammography (relative risk, 1.15), Pap smear screening (RR, 2.29), chlamydia screening (RR, 2.17) and diabetic eye screening (RR, 1.55). There were no significant differences in the percentage receiving an asthma controller medication or a beta-blocker after acute myocardial infarction. The differences could not be explained by IMGs' more frequent use of electronic medical records or quality-improvement strategies, the authors note.

"This study should not be considered evidence that, in general, medical groups provide higher-quality care than do IPAs," states Lawrence Casalino, M.D., of the University of Chicago, in an accompanying editorial, noting there were only 19 IMGs that were quite large, averaging 242 physicians each. However, the editorialist notes that the study "highlights critical, but largely unexplored, questions about the organization of physician practice."

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Desire for Antibiotics for Sore Throat May Reflect Pain

Analgesia may avoid need for antibiotics

Patients with sore throat who visit their family physician hoping for antibiotics may in fact want pain relief, suggesting that adequate analgesia may avoid the need for antibiotics, according to a report in the November/December issue of the Annals of Family Medicine.

Mieke L. van Driel, M.D., M.Sc., from Ghent University in Belgium, and colleagues surveyed 298 patients visiting a family physician for acute sore throat regarding the importance of different reasons for their visit. They also provided questionnaires to the 68 physicians who treated the patients.

The researchers found the most common reasons for a patient visit was to determine the cause of their symptoms, to find pain relief and to obtain information on disease course. Although the desire for antibiotics was ranked low, at 11th of 13 items, the desire for pain relief was a strong predictor of wanting antibiotics -- as were feeling unwell, having faith that antibiotics would speed recovery and being unconvinced that sore throat was a self-limiting disease.

"Our study suggests that patients with acute sore throat and who hope for antibiotics may in fact want treatment for pain," van Driel and colleagues conclude. "Trials are needed to test whether exploring patients' expectations about pain management and offering adequate analgesia can assist physicians in managing sore throats without prescribing antibiotics."

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Symptoms May Not Predict Rhinosinusitis Course

Best predictor of prognosis may be whether patient feels ill, less able to work

In patients with rhinosinusitis, the best predictor of prognosis may be whether the patient feels ill or less able to work, not typical signs and symptoms or abnormal radiographs, researchers report in the November/December issue of the Annals of Family Medicine.

An De Sutter, M.D., Ph.D., from Ghent University in Belgium, and colleagues assessed whether clinical signs and symptoms of rhinosinusitis or an abnormal radiograph could predict the course of illness in 300 patients with rhinosinusitis-like complaints who were participating in a clinical trial comparing placebo and amoxicillin. The investigators then analyzed whether antibiotic treatment had any beneficial effect.

The researchers found that only two baseline factors, a general feeling of illness (hazard ratio, 0.77) and reduced productivity (hazard ratio 0.68), were independently associated with longer illness. The prognosis was unaffected by antibiotics, according to the study.

"In a large group of average patients with rhinosinusitis, neither the presence of typical signs or symptoms, nor an abnormal radiograph, provided information with regard to the prognosis or the effect of amoxicillin," the authors conclude.

The study was funded by a grant from Eurogenerics of Belgium.

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Head, Stomach Pain Visits Similar Among Family Members

Visits to family doctors for headache, stomachache commonly reflect patterns within families

Appointments with family physicians for low-grade symptoms such as headache or stomachache are often similar among family members, particularly mothers and their young children, researchers report in the November/December issue of the Annals of Family Medicine.

Mieke Cardol, Ph.D., of the Netherlands Institute for Health Services Research in Utrecht, the Netherlands, and colleagues studied visits to 96 family practices made by families with at least one child aged 12 or younger over a one-year period.

The researchers found family patterns most striking in the visits of mothers and children. Especially for headaches and abdominal pain, much of the similarity in visit frequency by mothers and daughters could be attributed to a "powerful family-related influence or consultation behavior."

No specific diagnosis patterns were found within families; estimates of family similarity in young children's cases may be exaggerated by parents making appointments and verbally describing a child's health condition, the researchers report.

"Visits to family physicians for headaches or abdominal pain can be seen as indicators of consultation patterns in families," the authors write. "Family patterns related to minor ailments are likely to be a result of socialization. Family consultation patterns might point toward specific needs of families and consequently at a different approach to treatment."

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Connecting on Personal Level Tends to Satisfy Doctors

Doctors define success as restoring whole person more than preventing, treating disease

Family physicians feel most satisfied when they connect on a personal level with patients instead of focusing solely on technical diagnostic and treatment challenges, according to a report in the November/December issue of the Annals of Family Medicine.

Karen Fairhurst, Ph.D., of the University of Edinburgh, U.K., and a colleague studied recordings of patient visits and interviews with 19 general practitioners in Scotland.

The researchers found that physicians' satisfaction with patient consultations resulted more from interpersonal relationships than their technical abilities to diagnose and treat patients. Most satisfying were visits in which they relied on their personal knowledge of a patient to achieve success, which they tended to define as helping to restore the whole person more than preventing, treating or curing a disease.

Such positive experiences helped physicians feel that they were "good" doctors. While more negative experiences tended to challenge this "good doctor" identity, physicians tended to explain away more negative experiences by distancing themselves from the source or cause of the experience.

"The attributes of a satisfying encounter found in this study derive from a model of practice that prioritizes the distress of patients, which cannot be measured, above the technical and quantifiable in diagnosis and treatment," the authors write. "Preoccupation with that which is technical and measurable in health care system reforms risks defining a model of practice with purpose and meaning not congruent with doctors' experiences of their work and may result in further destruction of professional morale."

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Personal Breast Cancer History in One-Third of Interval Cancers

Almost half of invasive tumor detection initiated by woman

Almost one-third of women with interval cancers have a personal and/or family history of breast cancer, and many seek diagnosis themselves, researchers report in the November/December issue of the Annals of Family Medicine.

Patricia A. Carney, Ph.D., of Oregon Health and Science University in Portland, and colleagues surveyed family physicians who diagnosed 143 women with interval breast cancers within a year of a normal mammogram and 481 women with routine examination-detected breast cancers.

The researchers found that 30.1 percent of women with interval cancers had a personal or family history of breast cancer, versus 13.6 percent of those with examination-detected breast cancers. Some 49.5 percent of invasive tumors in interval cancer patients were found after women sought a doctor for a breast problem; 16.8 percent were detected during routine breast examinations.

Women most often scheduled visits (44 percent) when they had a lump and family and personal breast cancer histories.

"Women with interval cancers are most likely to initiate a visit to a primary care clinician when they have two or more breast concerns," the authors write. "These concerns are more likely to include having a lump and a personal and/or family history of breast cancer."

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Gallstone Risk Higher in Men Who Lose, Regain Weight

Fluctuating weight, independent of body mass index, is a risk compared to steady weight

Men who go through one or more cycles of losing and regaining weight have a greater risk of developing gallstones than men who maintain a steady weight, researchers report in the Nov. 27 issue of the Archives of Internal Medicine.

Chung-Jyi Tsai, M.D., of the University of Kentucky Medical Center in Lexington, and colleagues studied data on 24,729 men who intentionally lost weight then regained it periodically between 1988 and 1992, and during follow-up until 2002.

The researchers found that 1,222 men developed gallstones. Compared to those who maintained a steady weight, the relative risk of gallstones was 1.11 in light cyclers (those who had one or more episodes of losing and gaining 5 to 9 lbs.), 1.18 for moderate cyclers (10 to 19 lbs.), and 1.42 for severe cyclers (20 lbs. or more).

The relative risks of gallstones among those with two or more episodes of weight loss/gain were 1.10 for light cyclers, 1.28 for moderate cyclers, and 1.51 for severe cyclers, compared with those who maintained a steady weight.

"Our findings suggest that weight cycling, independent of body mass index, may increase the risk of gallstone disease among men," the authors write. "Larger weight fluctuation and more weight cycles are associated with greater risk."

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Statins for Primary Prevention Don't Reduce Mortality

Statin therapy reduces events, but not mortality, in patients without cardiovascular disease

Although statin therapy decreases major coronary and cerebrovascular events and revascularization procedures, it does not decrease all-cause mortality or death due to coronary heart disease in patients who do not have cardiovascular disease, according to study results published in the Nov. 27 Archives of Internal Medicine.

Paaladinesh Thavendiranathan, M.D., of the University of Toronto in Canada, and colleagues performed a meta-analysis of seven randomized clinical trials that included 42,848 patients. Ninety percent of the subjects had no cardiovascular disease when statin therapy was initiated.

Statin treatment reduced the risk of major coronary events by 29.2 percent, major cerebrovascular events by 14.4 percent and revascularization procedures by 33.8 percent. Their use had a non-significant effect (22.6 percent reduction) in relative risk for coronary heart disease mortality. There was no significant reduction in overall death. No increases in cancer, liver enzymes levels or creatine kinase were reported.

"In patients without cardiovascular disease, statin therapy decreases the incidence of major coronary and cerebrovascular events and revascularizations but not coronary heart disease or overall mortality," the authors conclude.

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Premenopausal Breast Cancer Risk Lower with High BMI

Body mass index of 27.5 or greater at age 18 associated with lower risk

A relatively large body mass index, or BMI, in young adulthood seems to protect against premenopausal breast cancer, according to a report published in the Nov. 27 issue of the Archives of Internal Medicine.

Karin B. Michels, Ph.D., of Harvard Medical School in Boston, and colleagues evaluated 1,398 cases of invasive breast cancer diagnosed between 1989 to 2003 in 113,130 premenopausal women. Height, weight, ovulation and menstrual cycle were among the variables analyzed.

The investigators found a linear inverse relationship between current BMI and breast cancer, with a hazard ratio of 0.81 for women with a BMI of 30 or more compared to women with a BMI between 20 and 22.4. The difference could not be attributed to menstrual cycle features or ovulatory disorders. A large body mass at 18 years was the strongest predictor for breast cancer. The adjusted hazard ratio was 0.57 for women with a BMI of 27.5 or greater at 18 years of age compared with women with a BMI between 20 and 22.4 at age 18.

"Large body size during early adulthood is inversely related to the incidence of breast cancer in premenopausal women. Factors related to ovulation, such as menstrual cycle characteristics, infertility due to an ovulatory disorder and probable polycystic ovary syndrome, do not seem to explain this association," the authors conclude.

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Flu Vaccines for Nursing Home Staff Protects Residents

Benefits seen in mild flu seasons even with incomplete vaccine coverage of staff

Influenza vaccination of nursing home staff can protect residents from influenza and its consequences, according to a report published online Dec. 1 in BMJ.

Andrew C. Hayward, Ph.D., of the University College London Centre for Infectious Disease Epidemiology in the United Kingdom, and colleagues examined the effects of flu vaccination of staff members at 44 nursing homes. In nursing homes where the researchers promoted vaccination, 48.2 percent of staff received a vaccine in 2003-2004 and 43.2 percent received the flu shot in 2004-2005. In control nursing homes where flu shots for staff were not promoted, 5.9 percent of staff were vaccinated in 2003-2004 and 3.5 percent were vaccinated in 2004-2005.

Levels of flu-like illness, physician consultations and death (-5 per 100 residents) from flu were lower among residents in intervention homes during the 2003-2004 flu season than in the control homes, the researchers report. There were no differences in levels of illness or death among nursing home residents in the two groups during the 2004-2005 flu season, which may be due to a milder flu season in general.

"Campaigns to promote influenza vaccination among health care workers or staff of long-term care facilities should emphasize the protection of vulnerable patients and residents as well as the benefits to the individual," the researchers conclude.

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Audiotape of NICU Physicians Helps Maternal Recall

Tapes have no bearing on mothers well-being or satisfaction with doctor, but do help recall

Women with infants in the neonatal intensive care unit, or NICU, tend to have better recall of their child's diagnosis, treatment and outcome if conversations with the neonatologist are recorded, according to study findings published online Dec. 1 in BMJ.

Tieh Hee Hai Guan Koh, M.D., of Townsville Hospital in Douglas, Queensland, Australia, and colleagues found that 91 percent of 102 mothers who received an audiotape listened to it. At day 10 and at four months, women in the audiotape group recalled more information about diagnoses, treatment and outcome than the 98 women in the control group who did not receive an audiotape.

Specifically, women who received tape recordings were 75 percent more likely than other women to recall treatment information at four months. Six mothers, all of whom were in the control group, could not remember anything from these conversations.

Ninety-six percent of women found the audiotapes helpful, although the taped conversations had no bearing on maternal well-being or satisfaction with the doctors, the report indicates.

"Providing the mothers of babies in NICUs with audiotapes of conversations with a neonatologist enhanced their recall of information (up to four months)," the researchers conclude. "It is practical to tape [these] conversations. In our study, the tapes were listened to both by the mother and by family members."

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Left Ventricle Size, Function Linked to Risk Factors

Smoking, diabetes, hypertension and body mass index linked to greater left ventricular mass

Modifiable cardiovascular risk factors are associated with subclinical changes in left ventricular geometry and function as measured by magnetic resonance imaging, researchers report in the Dec. 5 issue of the Journal of the American College of Cardiology. For example, smokers and diabetics without cardiovascular disease have higher left ventricular mass, lower stroke volume and lower ejection fractions than other patients.

Susan Heckbert, M.D., Ph.D., from the University of Washington Cardiovascular Health Research Unit in Seattle, and colleagues examined cardiovascular risk factors and measured left ventricular dimensions and systolic function in 4,869 participants from four ethnic/racial groups. The patients had a mean age of 62 and about half were women.

High systolic blood pressure and body mass index were associated with larger left ventricular mass and volume. In addition, smokers and diabetics had a higher left ventricular mass, (an additional 7.7 grams and 3.5 grams, respectively), and lower stroke volume and ejection fraction than other patients.

"The high degree of reproducibility of cardiac MRI should allow the detection of subtle deterioration or improvement in left ventricular size and function," the authors conclude.

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New, Not Recurrent, Depression a Risk After Myocardial Infarction

Myocardial infarction patients with ongoing or recurrent depression have little risk for additional events

Only patients who develop a new episode of depression in the year after a myocardial infarction have an elevated risk of new cardiovascular events compared with non-depressed patients, researchers report in the Dec. 5 issue of the Journal of the American College of Cardiology. Those with ongoing or recurrent depression are at no greater risk than other patients.

Peter de Jonge, Ph.D., of the University Medical Centre Groningen in the Netherlands, and colleagues assessed 468 patients with myocardial infarction to determine if incident and non-incident depression differentially affected cardiovascular events.

After controlling for confounders, those identified with an incident International Classification of Diseases-10 depressive disorder within a year of the initial myocardial infarction had a hazard ratio of 1.76 for new cardiovascular events. Those with non-incident depression did not have a higher risk of new events compared with non-depressed patients (HR, 1.39).

The authors of an accompanying editorial suggest that beta-blockers might benefit patients "who experience their heart attack as particularly traumatic, thereby perhaps decreasing onset of incident post-MI depression and related cardiovascular risk."

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Teen Boys More Likely to Have High Blood Pressure

Gender differences in systolic blood pressure increase as teens approach adulthood

During adolescence, boys are significantly more likely than girls to develop high systolic blood pressure, a novel finding that could lead to new strategies to reduce hypertension in young adult males, according to a report published online Dec. 4 in Circulation: Journal of the American Heart Association.

In 1999, Kaberi Dasgupta, M.D., of McGill University in Montreal, Canada, and colleagues began studying 1,267 seventh graders (614 boys and 653 girls), 844 of whom were reassessed in ninth and eleventh grades.

The researchers found that boys had a greater risk of high systolic blood pressure values compared to girls in seventh grade (odds ratio, 1.29), in ninth grade (OR, 1.98) and in eleventh grade (OR, 2.74). In both sexes, they also found that high systolic blood pressure values were positively associated with overweight (OR, 2.63) and sedentary behavior (OR, 1.17) and negatively associated with physical activity (OR, 0.92).

"The results of the present study demonstrate that not only are boys more likely than girls to have high systolic blood pressure in youth but that this risk difference increases in magnitude during the adolescent period, likely accounting for higher prevalence of hypertension among men compared with women in young and middle-aged adults," the authors conclude. "Greater understanding of sex differences in cardiovascular risk factors may ultimately lead to improved strategies for the prevention of cardiovascular disease in both women and men."

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