Latest Research

December 1, 2006

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

Midlife Self-Care Extends Men's Life Span into 80s, 90s

Avoidance of risk factors in middle-age increases men's probability of reaching a ripe old age

Middle-aged men who avoid common risk factors for chronic disease have a better chance of achieving an "exceptional" survival, defined as living to age 85 and beyond without physical or mental impairment, according to a study published in the Nov. 15 issue of the Journal of the American Medical Association.

Bradley J. Willcox, M.D., of the Pacific Health Research Institute in Honolulu, Hawaii, and colleagues conducted a 40-year study of 5,820 Japanese-American men, of whom 2,451 (42 percent) survived to age 85. Eleven percent were defined as exceptional survivors because they did not have any of six major chronic diseases and had no physical and cognitive impairment.

The researchers found that overall and exceptional survival were associated with high grip strength, as well as avoidance of overweight, hyperglycemia, hypertension, smoking and excessive alcohol consumption. They also found that exceptional survival was associated with high education and avoidance of hypertriglyceridemia. Their analysis suggested that men with no risk factors have significantly higher probabilities of reaching age 85 than men with six or more risk factors (69 percent versus as low as 22 percent) and of exceptional survival (55 percent versus 9 percent).

"These risk factors can be easily measured in clinical settings and are, for the most part, modifiable," the authors conclude. "This may be especially important for men, few of whom survive to oldest-old age.

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Drug Combination Helps Men with Overactive Bladder

Randomized controlled trial suggests patients unresponsive to standard treatment might benefit from switch

A combination of extended-release tolterodine and tamsulosin appears to be safe and effective in treating men with overactive bladder, according to a randomized, industry-funded trial reported in the Nov. 15 issue of the Journal of the American Medical Association.

Steven Kaplan, M.D., of Weill Cornell Medical College in New York City, and colleagues studied the safety and efficacy of tolterodine extended release (ER), tamsulosin, or both in 879 men with overactive bladder and benign prostatic hyperplasia. Patients were randomized to placebo, each drug alone, or the combination.

The investigators found that 80 percent of patients randomized to a combination of tolterodine ER plus tamsulosin reported treatment benefit compared with 71 percent receiving tamsulosin alone, 65 percent receiving tolterodine ER alone and 62 receiving placebo. The combination group reported significant reductions in urgency urinary episodes with and without incontinence, micturitions per 24 hours, and micturitions per night.

The authors conclude that men bothered by lower urinary tract symptoms including overactive bladder and who are unresponsive to α-adrenergic receptor antagonists or antimuscarinic agents might benefit from switching to tolterodine ER plus tamsulosin.

The study was funded by Pfizer and some of the authors are employees or have received compensation from the company.

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Prostate-Specific Antigen Test Overused in Elderly Men

More than half are being tested despite guidelines, study finds

Despite guidelines suggesting the test does elderly patients more harm than good, U.S. physicians routinely perform prostate-specific antigen (PSA) screenings on males over 70, according to a report in the Nov. 15 Journal of the American Medical Association. The findings were presented Nov. 14 at a special American Medical Association men's health news briefing in New York City.

In the study, Louise C. Walter, M.D., and colleagues at the University of California San Francisco examined 2003 U.S. Department of Veterans Affairs data on nearly 600,000 male veterans, aged 70 or over, who were treated at 104 VA facilities nationwide.

Fifty-six percent of these elderly patients received a PSA test in 2003. Although the rate of testing did decline with advancing patient age, the percentage of men receiving the test did not fall with worsening health -- 34 percent of men aged 85 and older rated in "best health" were screened versus 36 percent deemed to be in worst health.

The researchers conclude that rates of PSA screening among the elderly "should be much lower than current practice given the known harms of screening."

In his editorial, Peter C. Albertsen, M.D., of the University of Connecticut Health Center in Farmington, adds that many elderly men have an exaggerated fear of the danger from prostate cancer and the effectiveness of treatment for their age group. According to Albertsen, physicians must counsel these patients that, "When the [PSA] test is applied to older men, the benefits are not likely to exceed the potential harms."

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Six-Month Testosterone Therapy May Not Affect Prostate

Study found little impact on tissue androgens or other biomarkers

Six months of testosterone replacement therapy (TRT) normalizes serum androgen levels in older men with late-onset hypogonadism while having little effect on prostate tissue, according to a report in the Nov. 15 Journal of the American Medical Association. The findings were announced Nov. 14 at a special American Medical Association men's health briefing in New York City.

The study, led by Leonard S. Marks, M.D., of University of California Los Angeles School of Medicine and the Urological Sciences Research Foundation in Culver City, Calif., included 44 men ranging from 44 to 78 years of age. All had low serum testosterone (below 300 ng/dL) and related symptoms, and were randomized to receive 150 mg of testosterone enanthate or placebo every two weeks for six months.

Forty of the participants underwent prostate biopsy at baseline and at the end of the trial. TRT boosted serum testosterone to the mid-normal range, while those on placebo recorded no such change, the researchers report. Men receiving TRT displayed no significant rise in prostate tissue levels of either testosterone or dihydrotestosterone. The investigators also detected no change in prostate histology, tissue biomarkers, gene expression, or cancer incidence or severity in patients receiving TRT.

Larger, longer trials are needed to confirm the findings, the researchers stressed. However, based on the findings, they conclude that TRT "does not appear to induce any major biological change in the gland. The prostate risks to men undergoing TRT may not be as great as once believed, especially if the results of pretreatment biopsy are negative."

The study was funded by grants from the U.S. National Institutes of Health, Watson Laboratories of Salt Lake City, and Solvay Pharmaceuticals of Marietta, Ga.

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Adjuvant Radiotherapy May Fight Advanced Prostate Cancer

Decade-long study finds significant decrease in tumor recurrence, but not deaths

A 10-year randomized, prospective clinical trial may provide guidance on the use of adjuvant radiotherapy after radical prostatectomy in men with pathologically advanced prostate cancer. The study, published in the Nov. 15 issue of the Journal of the American Medical Association, found the treatment could reduce prostate-specific antigen relapse and disease recurrence, but not overall patient survival.

As reported at a special American Medical Association men's health briefing in New York City on Nov. 14, Ian M. Thompson, Jr., M.D. and colleagues from the University of Texas Health Science Center at San Antonio, tracked outcomes for 425 men with pathologically advanced prostate cancer who had undergone radical prostatectomy. Patients were randomized to either 60 to 64 Gy external-beam radiation or usual care plus observation.

Over a median 10.6 years of follow-up, the researchers noted significant differences between cases and controls in terms of prostate-specific antigen relapse-free survival (10.3 years versus 3.1 years, respectively) and disease recurrence (13.8 years versus 9.9 years). However, no significant difference was found in terms of metastasis-free survival or overall survival between the two groups, with 71 deaths recorded in those receiving radiotherapy versus 83 deaths for those who did not get the treatment.

Adverse effects were significantly higher in those receiving radiotherapy (23.8 percent) compared to those who did not (11.9 percent), and included rectal and urethral complications and urinary incontinence.

"The results of this study may provide guidance for clinicians and patients considering options for adjuvant therapy for pathologically advanced disease," the authors write.

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AHA: Pioglitazone Best for Slowing Artery Wall Expansion

Slower carotid intima-media thickness changes seen with pioglitazone

Pioglitazone slows the progression of carotid artery wall thickness in patients with type 2 diabetes mellitus better than glimepiride, according to a report published online Nov. 13 in the Journal of the American Medical Association. The findings were presented at the American Heart Association's Scientific Sessions in Chicago.

Theodore Mazzone, M.D., of the University of Illinois College of Medicine in Chicago, and colleagues conducted a randomized, double-blind, controlled multicenter trial to compare the effects of pioglitazone versus glimepiride on changes in common carotid artery intima-media thickness (CIMT) in 462 adult patients with type 2 diabetes mellitus.

The investigators found that at 24, 48 and 72 weeks of treatment, pioglitazone produced a smaller change in CIMT in the left and right common carotid arteries, and slowed progression of maximum CIMT compared with glimepiride. The effect was apparent across multiple subgroups including those based on age, sex, blood pressure and body mass index.

"We found that, compared with glimepiride, pioglitazone reduced CIMT progression, a validated surrogate end point for coronary artery disease and cardiovascular risk," the authors conclude. While this study was conducted with individuals having good blood pressure, low LDL-cholesterol levels and regular statin use, additional studies are needed to determine whether routine use of pioglitazone instead of glimepiride substantially reduces major cardiovascular events.

The authors report multiple financial disclosures.

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AHA: Pharmacy Program Helps Elderly Adhere to Medications

Custom daily-dosed blister packs improve adherence, clinical outcome

A pharmacy care program that includes custom blister-packed medications helps elderly patients adhere to their chronic medications better than usual care, according to a report released online Nov. 13 by the Journal of the American Medical Association. The findings were presented at the American Heart Association's Scientific Sessions in Chicago.

Allen J. Taylor, M.D., and colleagues at Walter Reed Army Medical Center, Washington, D.C., conducted a multiphase trial to test the efficacy of the customized program on medication adherence and clinical measures in the elderly. The study included 200 patients taking a mean of nine medications, many of which were for hypertension and hyperlipidemia.

Medication adherence improved from 61.2 percent at baseline to 96.9 percent after six months of the treatment program, and showed significant improvements in systolic blood pressure and low-density lipoprotein cholesterol levels. Patients then randomized to continue the program sustained high levels of adherence while those switched to usual care dropped to 69.1 percent adherence after another six months and had higher blood pressures.

The results suggest that programs like these should improve health outcomes in at-risk populations such as the elderly, the authors note. In an accompanying editorial, Ross J. Simpson, Jr., M.D., Ph.D., writes, "Multifaceted interventions that incorporate structural and counseling components and include appropriately skilled and motivated pharmacists appear useful to promote medication adherence and persistence."

Taylor reports receiving grant support and honoraria from various pharmaceutical companies.

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Correcting Anemia in Kidney Disease May Not Be Beneficial

Full correction of anemia may increase risk of adverse events

For patients with chronic kidney disease, fully correcting anemia may increase the risk of adverse events, according to two studies published in the Nov. 16 issue of the New England Journal of Medicine.

Ajay K. Singh, M.B., B.S., from Brigham and Women's Hospital in Boston, and colleagues assigned 1,432 patients with chronic kidney disease to a dose of epoetin alpha that maintained their hemoglobin at either 13.5 grams per deciliter (715 patients) or 11.3 g/dL (717 patients). The researchers found 125 events occurred in the high-hemoglobin group, compared with 97 events in the low-hemoglobin group. "The use of a target hemoglobin level of 13.5 g/dL (as compared with 11.3 g/dL) was associated with increased risk and no incremental improvement in the quality of life," Singh and colleagues write.

Tilman B. Drueke, M.D., from the Hopital Necker in Paris, France, and colleagues assigned 603 patients with stage 3 or 4 chronic kidney disease to treatment with epoetin beta to maintain their hemoglobin between 13 to 15 g/dL (normal range) or between 10.5 to 11.5 g/dL (subnormal range). The risk of cardiovascular events was similar in both groups. Maintaining hemoglobin in the normal range significantly increased the need for dialysis but significantly improved general health and physical function.

The first study was supported by Ortho Biotech Clinical Affairs and Johnson & Johnson Pharmaceutical Research and Development. The second study was supported by F. Hoffmann-La Roche.

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AHA: Tolvaptan Can Relieve Hyponatremia

Side effects include dry mouth, increased thirst and increased urination

The vasopressin V2-receptor antagonist tolvaptan is effective in relieving hyponatremia, according to the results of a study published online Nov. 14 in the New England Journal of Medicine. The findings were reported at the American Heart Association's Scientific Sessions in Chicago.

Robert W. Schrier, M.D., of the University of Colorado Health Sciences Center in Denver, and colleagues randomly assigned 448 patients with hyponatremia (serum sodium less than 135 mmol per liter) to placebo or 15-mg oral tolvaptan daily. The tolvaptan dose was increased to 30-mg or 60-mg daily as needed based on serum sodium concentration. Changes in the serum sodium average daily area under the curve were monitored from baseline to day 4 and baseline to day 30.

There was a significant increase in serum sodium at both day 4 and day 30 in patients taking tolvaptan, although hyponatremia returned once tolvaptan was discontinued after day 30. Patients taking tolvaptan reported increased thirst, increased urination and dry mouth, the report indicates.

"The study is encouraging in terms of the efficacy of tolvaptan as a V2-receptor antagonist and its use, at least during a limited period, in the outpatient setting," Richard M. Hays, M.D., from the Albert Einstein College of Medicine, Bronx, New York, writes in an accompanying editorial. But, he adds, "careful oversight of the use of this agent is required."

The study was supported by the Otsuka Maryland Research Institute.

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Paclitaxel-Coated Balloon Catheter Reduces Restenosis

Preliminary data suggests promise of catheter-based drug delivery in in-stent restenosis

In patients with coronary in-stent restenosis, treatment with paclitaxel-coated balloon catheters may significantly reduce the risk of restenosis, according to a study published online Nov. 13 in the New England Journal of Medicine.

Bruno Scheller, M.D., of the Universitatsklinikum des Saarlandes in Homburg/Saar, Germany, and colleagues randomly assigned 52 patients to receive treatment with either a balloon catheter coated with paclitaxel or an uncoated balloon catheter during coronary angioplasty.

At six months, the researchers found that the mean in-segment late luminal loss was 0.03 in the coated balloon group compared to 0.74 in the uncoated balloon group. They also found that only one patient (5 percent) in the coated balloon group had restenosis compared to 10 patients (43 percent) in the uncoated balloon group. At 12 months, they also found a lower rate of major adverse cardiac events (4 percent versus 31 percent).

"The report by Scheller et al. suggests that catheter-based drug delivery is a potentially promising approach to in-stent restenosis and demonstrates that old avenues of investigation may yield new solutions to persisting problems," concludes the author of an accompanying editorial. "Although these data are preliminary and do not yet confirm the clinical validity of this approach, it may be that we can make progress in this field by going 'back to the future.'"

Authors of the study report being co-inventors of a patent application that was used in the trial. Bavaria Medizin Technologie supported the trial.

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AHA: Better Never Than Late Reperfusion After MI

Reperfusion three to 28 days after myocardial infarction offers no benefit and may even be harmful for patients who are stable

Stable patients with totally occluded coronary arteries do not benefit from percutaneous coronary intervention when given three to 28 days after a myocardial infarction and may even be harmed by the practice, according to a study presented at the American Heart Association's Scientific Sessions in Chicago. The findings were also published online Nov. 14 in the New England Journal of Medicine.

Judith Hochman, M.D., of New York University School of Medicine, and colleagues from the Occluded Artery Trial (OAT) randomized 2,166 stable patients to optimal medical therapy or angioplasty plus stenting. During a mean three-year follow-up, patients treated with late reperfusion did no better than medication-treated patients in terms of mortality, repeat myocardial infarction and heart failure. And there was a trend towards more repeat myocardial infarctions in the reperfusion-treated group.

In a second study, a subset of the OAT trial known as TOSCA-2 (Total Occlusion Study of Canada), Vladimir Dzavik, M.D., of the University Health Network in Toronto reported on 381 patients who received late reperfusion or medication. Ninety-three percent of infarct-related arteries could be opened with angioplasty plus stenting and 83 percent were open one year later. In comparison, 25 percent of arteries spontaneously opened in medication-treated patients. However, both groups had similar ejection fractions after one year.

"If you are a stable patient there is no benefit to open that artery late, days to weeks after that heart attack," said Hochman. The authors emphasized that high-risk patients were excluded, including those with left main or 3-vessel disease, angina at rest or low-threshold angina, cardiogenic shock or major heart failure. "We are not in any way saying that patients who are having significant severe symptoms and have an occluded artery, that they should not have PCI," said Dzavik.

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AHA: Door-to-Balloon Time Reduction Strategies Examined

Researchers identify six effective strategies, but find that most hospitals aren't using them

In managing heart attack patients with ST-segment elevation, several hospital strategies can reduce door-to-balloon time, but few hospitals use them to meet the gold standard of 90 minutes or less, according to a report released online Nov. 13 and published in the Nov. 30 issue of the New England Journal of Medicine.

Elizabeth H. Bradley, Ph.D., of the Yale University School of Medicine in New Haven, Conn., and colleagues surveyed 365 hospitals.

The researchers identified six effective strategies: emergency medicine physicians activate the catheterization laboratory (mean reduction, 8.2 minutes); a single call to a central page operator activates the laboratory (13.8 minutes); the emergency department activates the catheterization laboratory while the patient is en route to the hospital (15.4 minutes); the staff arrives in the catheterization laboratory within 20 minutes of being paged (19.3 minutes); an attending cardiologist is always on site (14.6 minutes); and emergency department and catheterization laboratory staff use real-time data feedback (8.6 minutes).

"It is now time to act," conclude the authors of an accompanying editorial. "The Centers for Medicare and Medicaid Services, the American College of Cardiology, the American Heart Association, the National Quality Forum, and many other public and private groups are aligned to move forward with efforts to improve the time to reperfusion."

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Google Useful to Help Doctors Diagnose Difficult Cases

Wider Internet access on wards and in clinics are helping the Web become an important tool for doctors

The increasing availability of Internet access on hospital wards and in outpatient clinics is enabling more and more doctors to access the Web and use the search engine Google to help diagnose difficult cases, according to a study published online Nov. 10 in

BMJ

.

Hangwi Tang, M.D., and a colleague from Princess Alexandra Hospital in Brisbane, Australia, identified three to five search terms for 26 cases of disease reported in the New England Journal of Medicine and then Google-searched each case without knowing the correct diagnoses.

Searches using Google resulted in a correct diagnosis in 15 cases (58 percent). "We suspect that using Google to search for a diagnosis is likely to be more effective for conditions with unique symptoms and signs that can easily be used as search terms," the authors comment. "Searches are less likely to be successful in complex diseases with non-specific symptoms or common diseases with rare presentations," they add.

The authors emphasize that for patients, Google is likely to be less effective as a search engine for disease diagnosis as the efficiency of the search depends on the knowledge base of the searcher, which affects the selection of documents.

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Lifestyle Changes Cut Type 2 Diabetes in High-Risk People

Intense diet and exercise counseling cuts transition to type 2 diabetes in overweight subjects

Intensive diet and exercise counseling can reduce disease incidence for patients at high risk of type 2 diabetes mellitus, even long after counseling is discontinued, according to results from an extended follow-up the Finnish Diabetes Prevention Study published in the Nov. 11 issue of

The Lancet

.

Jaana Lindstrom, M.Sc., of the University of Helsinki in Finland, and colleagues randomly assigned 522 overweight men and women with impaired glucose tolerance to intensive lifestyle intervention or a control group to see whether these changes could reduce risk of progression to type 2 diabetes.

After a mean follow-up of seven years, incidence of type 2 diabetes was 4.3 per 100 person-years for the intervention group and 7.4 per 100 person-years for the control group. The success of the program was linked to weight loss, increased physical activity, reduced saturated fat and increased fiber intake.

"The evidence for sustainability of lifestyle benefit presented by the [study] investigators supports their argument for urgent widespread establishment of community-based diabetes prevention programs," Ronald Goldberg, M.D., of the University of Miami, writes in an accompanying editorial.

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AHA: One COX-2 Has Heart Risk Similar to Naproxen in Study

Merck-funded, randomized trial conducted in osteoarthritis, rheumatoid arthritis patients

A randomized trial suggests that one COX-2 inhibitor, etoricoxib, may be no more likely to cause thrombotic cardiovascular events than diclofenac when used to treat osteoarthritis or rheumatoid arthritis patients, according to an industry-funded report presented at the American Heart Association's Scientific Sessions in Chicago and published online Nov. 13 in The Lancet. In addition, etoricoxib may be less likely to cause upper gastrointestinal events, such as perforations, ulcers and bleeding.

Christopher Cannon, M.D., of Brigham and Women's Hospital in Boston, presented the results of the MEDAL (Multinational Etoricoxib and Diclofenac Arthritis Long-term) program. In the study, 34,701 patients were randomized to etoricoxib at 60 mg/day (osteoarthritis) or 90 mg/day (osteoarthritis or rheumatoid arthritis) for a mean of 18 months, or diclofenac at 150 mg/day. Half of patients took a proton pump inhibitor and one-third took aspirin.

There were no significant differences between the drugs in terms of fatal thrombotic cardiovascular events (hazard ratio, 0.96), cardiac events (HR, 0.90), cerebrovascular events (HR, 1.08) or peripheral events (HR, 0.92). Confirmed upper gastrointestinal events were lower in the etoricoxib group (HR, 0.69).

Although other studies have found that etoricoxib can increase the risk of cardiovascular events, those studies were observational, said Cannon. In response to the trial, the AHA issued a statement that said, "Current evidence indicates that selective COX-2 inhibitors have important adverse cardiovascular effects including increased risk for heart attack, stroke, heart failure and hypertension."

The trial was sponsored by Merck.

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Few Primary Care Doctors Prescribe Preventive Tamoxifen

Not all patients who could benefit are getting the drug

Although tamoxifen has been approved for use as a preventive measure against breast cancer, few primary care physicians are prescribing the drug, researchers report in the Nov. 13 issue of the Archives of Internal Medicine.

Katrina Armstrong, M.D., of the University of Pennsylvania in Philadelphia, and colleagues surveyed 350 primary care physicians including those who specialize in family medicine, obstetrics and gynecology, and general internal medicine. As well as being asked about past prescription of the drug, they were posed hypothetical situations to gauge their likelihood of prescribing the drug and what factors affected their decision.

In all, 96 physicians (27.4 percent) had prescribed tamoxifen at least once in the past year as a breast cancer preventive measure. Having prescribed the medication was associated with the physician having a family member with the disease and having patients who requested information about the drug. Another significant predisposing factor was the belief that tamoxifen's benefits outweighed the risks. Primary care physicians did not give as much weight to a woman's risk of endometrial cancer as they did to familial breast cancer status.

The authors express surprise at the proportion of doctors who had prescribed the drug in the last 12 months, and conclude that the proportion is "lower than might be expected based on the estimated proportion of women who would experience a net benefit from tamoxifen."

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Influenza Vaccination Linked to Risk for Guillain-Barre

Small but significant increased risk after immunization in adults

A small but statistically significant increase in adult hospitalization for Guillain-Barre syndrome is linked to influenza vaccination, according to the results of a Canadian study published in the Nov. 13 issue of the Archives of Internal Medicine.

David N. Juurlink, M.D., Ph.D., of the University of Toronto, and colleagues evaluated April 1992 to March 2004 Ontario province population-based studies to determine whether influenza immunization is associated with Guillain-Barre syndrome.

Of 1,601 adult hospital admissions due to Guillain-Barre syndrome, in 269 cases the disease was diagnosed within 43 weeks of influenza vaccination. The estimated relative rate of the syndrome during weeks two through seven compared to the control interval (weeks 20 through 43) was 1.45. Separate time-series evaluation showed no evidence of seasonality and no statistically significant increase in admissions due to Guillain-Barre after influenza vaccine.

"Influenza vaccination is associated with a small but significantly increased risk for hospitalization because of Guillain-Barre syndrome," the authors conclude.

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Study Finds Colonoscopy Still Underused in Veterans

Another study questions use of colonoscopy in younger patients with comorbidity and poor life expectancy

Although colonoscopy usage has significantly increased over the past several years, fecal occult blood testing dominates colorectal cancer (CRC) testing in veterans, one study finds, while another questions the benefit of colorectal screening in younger patients with reduced life expectancy. Both studies are published in the Nov. 13 Archives of Internal Medicine.

Hashem B. El-Serag, M.D., of Baylor College of Medicine in Houston, and colleagues evaluated 1998-2003 Veterans Administration CRC screening methods data and found that while the total number of colonoscopies increased from 24,955 in 1998 to 55,199 in 2003, the proportion of subjects screened with colonoscopy declined from 5.7 percent to 4.7 percent and fecal occult blood testing increased from 81.7 percent to 90.4 percent.

"It is likely that CRC screening with fecal occult blood testing will result in poorer clinical outcomes for veterans," according to an accompanying editorial.

In another Veterans Affairs study using 1996-2004 data, Shahnaz Sultan, M.D., of Duke University in Durham, N.C., and colleagues found that of 861 young patients (defined as patients 50 to 64 years of age), 45.9 percent had CRC testing within five years. Of these, screening was high in patients with moderate (44.9 percent) and severe (45.8 percent) comorbidities. Of the 52 patients who died during the five-year follow-up, 71.2 percent (37 patients) had CRC screening.

"Comprehensive assessment of health status and comorbidity should guide cancer screening decisions, especially in individuals with reduced life expectancy who may obtain the least benefit from screening," the authors conclude.

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Primary Care Physicians Miss Signs of Cardiac Ischemia

About 11 percent of symptomatic patients aren't sent to the hospital before developing acute myocardial infarction

Primary care clinicians often miss early chances to send patients with cardiac ischemia to the hospital, researchers report in the Nov. 13 issue of the Archives of Internal Medicine. About 11 percent of acute myocardial infarction patients without a previous history of heart disease see their primary care doctor, nurse practitioner or physician's assistant for angina-like pain or other symptoms in the month before hospitalization, but aren't sent to the hospital.

Thomas D. Sequist, M.D., M.P.H., of Harvard Medical School in Boston, and colleagues analyzed data from 966 acute myocardial infarction patients without a prior history of heart disease. They found that 27 percent (261 patients) had seen their doctor in the previous month for chest pain. More than half of these patients were sent directly to the hospital (155 patients) and 41 percent were not (106/261, or 11 percent of the total). These patients were matched with three control patients with similar symptoms who did not develop acute myocardial infarction.

The researchers found that such "missed opportunities" were associated with a 10 percent or higher Framingham risk score (FRS), for a 19.5 odds ratio, as well as with higher scores involving the Diamond and Forrester forecasting instrument. Pain medications and antacids were most often prescribed

"We identified low prescription rates for beta-blocker and aspirin therapy among these symptomatic outpatients with elevated risk scores, and recent guidelines suggest aspirin therapy for patients with an elevated FRS even in the absence of symptoms," the authors write. "More aggressive intervention…may have prevented their acute myocardial infarction."

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Red Meat Associated with Higher Risk of Breast Cancer

Risk increased only for hormone receptor-positive cancers

Increased red meat intake is associated with a higher risk of hormone receptor-positive breast cancer in relatively young, premenopausal women, according to a report in the Nov. 13 issue of the Archives of Internal Medicine.

Eunyoung Cho, Sc.D., from Harvard Medical School in Boston, and colleagues studied the risk of breast cancer in 90,659 premenopausal women aged 26 to 46 years based on red meat intake, which was assessed three times through a food-frequency questionnaire during 12 years of follow-up.

There were 1,021 cases of invasive breast carcinoma over the follow-up period. The risk of estrogen and progesterone receptor-positive cancers increased with increasing red meat intake, the researchers found. The relative risk ranged from 1.14 for three to five servings per week to 1.97 for more than 1.5 servings per day compared with three or fewer servings per week. There was no significant change in the risk of developing hormone receptor-negative cancers, according to the study.

"In conclusion, in this population of relatively young, premenopausal women, red meat intake was associated with a higher risk of hormone receptor-positive breast cancer but not with risk of hormone receptor-negative cancer," Cho and colleagues conclude. "Given that most of the risk factors for breast cancer are not easily modifiable, these findings have potential public health implications in preventing breast cancer and should be evaluated further."

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Occupational Therapy Benefits Dementia Patients

Community-based intervention also reduces burden on caregivers

Despite the fact that patients with dementia have limited learning ability, community-based occupational therapy improves their daily functioning and also has benefits for their caregivers, according to research published online Nov. 17 in BMJ.

Maud J.L. Graff, M.Sc., of the University Medical Center Nijmegen in the Netherlands, and colleagues conducted a randomized controlled trial of 135 community-based patients aged 65 and older with mild to moderate dementia and their caregivers. Those in the intervention group received 10 sessions of occupational therapy over a period of five weeks. The therapy comprised cognitive and behavioral interventions aimed at compensating for cognitive decline, while caregivers were given training in coping skills and supervision.

At six weeks, 84 percent of those who received occupational therapy showed improvements in motor skills while 78 percent needed less assistance in daily tasks and the benefits remained at 12 weeks' follow-up. Caregivers' sense of competence was measured using a questionnaire and those in the intervention group also showed sustained improvements.

"Because outcomes such as improvement in activities of daily living and sense of competence are associated with a decrease in need for assistance, we believe that, in the long term, occupational therapy will result in less dependence on social and health care resources and less need for institutionalization," the authors conclude.

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More People Could Benefit from Statins

Lifetime treatment of a wider population is cost-effective

A greater number of people could benefit from statins, and widening the pool of candidates for the drug would be cost-effective, according to the results of a study published online Nov. 10 in BMJ.

The study, conducted by the Heart Protection Study Collaborative Group of the University of Oxford in England, comprised 20,536 men and women aged 40 to 80 from 69 U.K. hospitals. The subjects were diagnosed with coronary disease, other occlusive arterial disease or diabetes. The cohort was randomized to receive 40 milligrams of simvastatin or placebo every day for an average of five years.

In most of the age and vascular disease groups covered by the study, lifetime treatment with simvastatin was cost-saving, even though these gains, as well as life-expectancy gains, decreased with increasing age and decreasing vascular disease risk. Those in the 40 to 49 age-group with a 42 percent five-year risk of major vascular events gained 2.49 years' life expectancy, but there were also gains for those with a much lower risk of major vascular events.

Based on current U.K. prices, the drug would be cost-saving or cost less than GBP2,500 per life-year gained for those with even a 1 percent risk of major vascular events. "Statin therapy should be considered routinely for people across a wider age range and at lower risk of vascular disease than is currently the case," the authors conclude.

The study was funded in part by Roche Vitamins Ltd. and Merck & Co., the maker of simvastatin.

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Consensus Achieved on Quality in Cardiovascular Imaging

Implementation of practical safety measures will take money and strong leadership

Guidelines on quality in cardiovascular imaging have now been developed, but their implementation will require a concerted commitment of effort and time, according to a report in the Nov. 14 issue of the Journal of the American College of Cardiology.

The report lays out guidelines that resulted from a meeting of the American College of Cardiology-Duke University Medical Center Think Tank on Quality in Cardiovascular Imaging held in Washington, D.C., in January 2006. Implementation of the guidelines should improve outcomes for patients and enhance their satisfaction with the treatment they receive and its costs, the report states.

"Imaging has transformed our ability to prevent, diagnose and manage cardiovascular disease," lead author Pamela Douglas, M.D., of Duke University Medical Center in Durham, N.C., explains in a statement. "Cardiovascular imaging has enjoyed both rapid technological advances and sustained growth, yet less attention has been focused on quality than in other areas of cardiovascular medicine."

The guidelines looked at four main areas: matching patients with the most suitable imaging technique, getting the best images, correctly interpreting images and communicating the results to patients' physicians. Choosing the most appropriate technique for each individual patient was key, according to Douglas. "Our goal is to identify which patients would benefit the most from each technique while minimizing inappropriate testing," she adds.

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High Cardiac Troponin T Linked to Reduced Survival

Elevated levels of cardiac troponin T found in nearly 20 percent of percutaneous coronary intervention patients

Elevated levels of cardiac troponin T following percutaneous coronary intervention is associated with reduced survival in patients with normal creatine kinase levels, according to the results of a study published in the Nov. 7 issue of the Journal of the American College of Cardiology.

Abhiram Prasad, M.D., and colleagues from the Mayo Clinic in Rochester, Minn., measured the post-procedure levels of cardiac troponin T -- a marker of myonecrosis -- in 1,949 patients who had undergone percutaneous coronary intervention and had normal pre- and post-procedure levels of creatine kinase-muscle-brain fraction.

The researchers found elevated levels of cardiac troponin T in 19.6 percent of patients, which was associated with significantly higher mortality and higher combined rates of death and myocardial infarction over the median follow-up of 26 months. Elevated cardiac troponin T levels decreased three-year survival from 93.2 percent to 86.9 percent, the investigators report.

"The present report should help refocus the stage light on post-procedural infarction," Neal S. Kleiman, M.D., from Methodist DeBakey Heart Center in Houston, writes in an accompanying editorial. "If we are to continue to reduce the long-term morbidity and mortality in patients who have had interventions, we will need to recognize that there are new markers of risk that merit our attention."

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PET Imaging of Carotid Plaques Detects Inflammation

Non-invasive method correlates with macrophage staining

Positron emission tomography (PET) imaging with fluorodeoxyglucose, whose uptake has been shown to be increased in carotid plaques, is an effective and non-invasive way to assess inflammation in patients with severe carotid stenoses, researchers report in the Nov. 7 issue of the Journal of the American College of Cardiology.

Ahmed Tawakol, M.D., of Massachusetts General Hospital in Boston, and colleagues examined the ability of 18F-fluorodeoxyglucose PET imaging to detect carotid plaque inflammation in 17 patients with severe carotid stenoses. Afterward, patients underwent carotid endarterectomy and carotid specimens were examined for macrophages.

There was a strong correlation between the imaging and inflammation as assessed by the PET signal in plaques and macrophage staining, as well as the mean uptake of fluorodeoxyglucose and mean inflammation. There was no correlation between plaque area or thickness, or extent of smooth muscle staining, according to the report.

"We established that fluorodeoxyglucose-PET imaging can be used to assess the severity of inflammation in carotid plaques in patients," the authors conclude. "If subsequent natural history studies link increased fluorodeoxyglucose-PET activity in carotid arteries with clinical events, this non-invasive measure could be used to identify a subset of patients with carotid atherosclerosis in need of intensified medical therapy or carotid artery intervention to prevent stroke."

The study was supported by grants from Pfizer and GlaxoSmithKline.

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AHA: Novel Anticoagulant Drug, Antidote Promising in Phase 1

RNA aptamer-based technology that targets factor IXa was tested in 85 patients

A novel anticoagulant system that relies on a shape-changing RNA aptamer and its fast-acting antidote has been tested for the first time in patients, according to a report presented at the American Heart Association's Scientific Sessions and simultaneously published in Circulation: Journal of the American Heart Association. The drug platform, known as REG1, could have applications for oncology, rheumatic disease or infections and seemed safe. However, one patient did experience transient encephalopathy that may or may not have been therapy-related, reported Richard Becker, M.D., of Duke University in Durham, N.C.

Christopher Dyke, M.D., Becker and colleagues randomized 85 healthy volunteers to receive an intravenous infusion of RB006, an oligonucleotide that binds to factor IXa, or a placebo. An escalating drug-dosage design was used, with 15, 30, 60 and 90 mg of the drug. The antidote, RB007, was administered at a 2:1 ratio three hours later.

Patients treated with 15 mg of the drug had a 1.1-fold increase in activated partial thromboplastin time (APTT) 15 minutes after administration, while those given higher doses had a more pronounced response (2.9-fold increase in mean relative APTT at 15 minutes with 90 mg dose). The antidote returned the APTT to baseline within one to five minutes.

"The drug-antidote system as we describe here could be used as a potential replacement for heparin," said Becker. Aptamers "are able to fold and they assume shapes that are directed against a target," he notes. While the current platform targets factor IXa, the use of other targets could make the drug-antidote system useful in oncology and other diseases, he said.

The study was funded by Regado Biosciences, Inc., of Durham, N.C.

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Retinoic Acid Does Not Benefit Emphysema Patients

Treatment does not improve pulmonary function or quality of life

Retinoic acid treatment does not improve pulmonary function or quality of life in patients with chronic obstructive pulmonary disease (COPD) and emphysema, according to the results of a study published in the November issue of Chest.

Michael D. Roth, M.D., from the University of California Los Angeles, and colleagues randomly assigned 148 patients with moderate-to-severe COPD and a primary component of emphysema to either low-dose all-trans retinoic acid (1 mg/kg/day), high-dose all-trans retinoic acid (2 mg/kg/day), or 13-cis retinoic acid (1 mg/kg/day), with a placebo control within each group. After six months, placebo patients were crossed over to drug and drug patients were crossed over to placebo within each group for three months.

After the initial six months, there were no improvements in pulmonary function, health-related quality of life, or CT density mask score with any of the treatments. However, in the high-dose all-trans retinoic acid group, the researchers found time-dependent changes in the diffusing capacity of the lung for carbon monoxide and the St. George Respiratory Questionnaire, and five of 25 patients had delayed improvements in their CT scores. The changes correlated with plasma drug levels, the report indicates.

"No definitive clinical benefits related to the administration of retinoids were observed in this feasibility study," Roth and colleagues conclude.

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Perceived Asthma Control Reduces Emergency Visits

Greater control also reduces risk of asthma hospitalization

Asthma patients who feel more in control of their asthma have better health and quality of life and are less likely to visit the emergency department or be hospitalized for asthma, according to study findings published in the November issue of Chest.

Mark D. Eisner, M.D., M.P.H., from the University of California San Francisco, and colleagues conducted telephone interviews with 865 patients who had been hospitalized for asthma. The interview included the Perceived Control of Asthma Questionnaire. They then assessed the number of emergency department visits and hospitalizations for asthma for a median of 1.9 years.

The researchers found that patients with greater perceived control were in better physical health, had less severe asthma, and had better asthma-related quality of life. Better perceived control was associated with a significantly lower risk of visiting the emergency department (hazard ratio, 0.92) and being hospitalized for asthma (HR, 0.84).

"Greater perceived control is associated with improved asthma-related health status as well as with a decreased prospective risk of severe asthma attacks resulting in emergency health care utilization," Eisner and colleagues conclude. "This difference does not appear to be mediated by changes in preventive care or asthma self-management practices."

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Greater Risk of COPD in HIV-Positive Men

Risk increased by 50 to 60 percent compared with HIV-negative men

HIV-positive men have a 50 percent to 60 percent higher risk of developing chronic obstructive pulmonary disease (COPD) than HIV-negative men, according to a study in the November issue of Chest.

Amy C. Justice, M.D., Ph.D., from the Veterans Affairs Connecticut Healthcare System in West Haven, and colleagues examined the prevalence of COPD in 1,014 HIV-positive and 713 HIV-negative men based on both patient self-report and by diagnostic codes from the International Classification of Diseases, ninth revision (ICD-9).

The researchers found that the prevalence of COPD was similar by the ICD-9 criteria (10 percent in HIV-positive versus 9 percent in HIV-negative men) but significantly different by self-report (15 percent versus 12 percent, respectively). However, after adjusting for demographic factors, smoking, alcohol abuse and injection drug use, they found that the risk of COPD was significantly higher in HIV-positive men by both the ICD-9 criteria (odds ratio 1.47) and self-report (OR, 1.58).

"Health care providers should be aware of the increased likelihood of COPD among their HIV-positive patients," Justice and colleagues conclude. "The possibility that HIV infection increases susceptibility to and/or accelerates COPD deserves further investigation and has implications regarding the pathogenesis of COPD."

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Botulism Outbreak in Four Receiving Unlicensed Botox

Suspended clinician injects self, three others with concentrated, research-only toxin

Four cases of botulism occurred when a suspended clinician used an unlicensed preparation of botulinum toxin A for cosmetic purposes, with some patients receiving doses more than 40 times the estimated lethal dose in humans, according to the Nov. 22/29 issue of Journal of the American Medical Association.

Daniel Chertow, M.D., M.P.H., of the U.S. Centers for Disease Control and Prevention in Atlanta, and colleagues studied the clinical aspects of four patients given unlicensed, "for research use only" botulinum toxin A in November 2004 by a suspended clinician. One of the patients was the clinician himself.

All patients reported clinical symptoms consistent with naturally occurring botulism, including progressive weakness and cranial neuropathies affecting facial movements and swallowing. Two of the patients reported shortness of breath and all required mechanical ventilation at some point. While pretreatment serum toxin levels ranged from 21 to 43 times the lethal dose, the investigators suspect some of the patients may have received doses up to 2,857 times the estimated lethal dose by injection.

"Physicians and patients must be aware of the hazards associated with illegitimate use of unlicensed botulinum toxin products," the authors write. "Only licensed products should be used clinically. Entities inappropriately marketing, selling, or using unlicensed botulinum toxin products should be sought and subjected to full criminal and civil penalties."

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Oral Rinse Cuts Nosocomial Infection After Cardiac Surgery

Decontamination of nasopharynx and oropharynx seems to decrease respiratory and surgical site infections

Cardiac surgery patients who undergo chlorhexidine gluconate decontamination of the nasopharynx and oropharynx have lower rates of post-surgery nosocomial infections, including lower respiratory tract and surgical site infections, according to the results of a study published in the Nov. 22/29 issue of the Journal of the American Medical Association.

Patrique Segers, M.D., of the University of Amsterdam in the Netherlands, and colleagues evaluated the incidence of nosocomial infection, the Staphylococcus aureus rate in the nasal carriage, as well as the length of hospitalization in 954 patients (485 chlorhexidine group, 469 controls) having open heart surgery between August 2003 and September 2005. Patients used an oral rinse and nose ointment four times daily from the time they entered the hospital to soon after the surgery.

In the chlorhexidine gluconate group, 96 patients (19.8 percent) had 116 nosocomial infections compared to 123 controls (26.2 percent) who had 164 infections. The lower respiratory tract infection rate was 9.3 percent in the treated group and 15.8 percent for controls, resulting in an absolute risk reduction of 6.5 percent. The rate of surgical site infection was not significantly different. However, nine treated patients (1.9 percent) had deep surgical site infections compared to 24 controls (5.1 percent), a 3.2 percent absolute risk reduction. Hospitalization was 9.5 days for the treated patients and 10.3 days for controls.

"This safe and inexpensive disinfectant is effective in decontaminating the nasopharynx and oropharynx…and should be considered in the preoperative preparation of a patient undergoing cardiac surgery," the authors conclude.

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Trial Questions Benefits of Herniated Disc Surgery

SPORT trial shows limited benefit of surgery compared with non-operative treatment

The benefits of surgery compared with non-operative treatment for lumbar disc herniation appear to be limited, or at least inconclusive, according to two reports in the Nov. 22/29 issue of the Journal of the American Medical Association.

James Weinstein, D.O., M.Sc., of Dartmouth Medical School in Hanover, N.H., and the Spine Patient Outcomes Research Trial (SPORT) investigators found that 472 patients with lumbar disc herniation randomized to either surgical or non-operative treatment had similar improvements in clinical outcome after two years. Adherence to treatment was limited and slight improvements from surgery were found to be statistically insignificant.

In a second observational study of SPORT that included 743 patients initially refusing randomization, surgery showed improvement in bodily pain, physical function and disability index at three months compared with usual care. The differences narrowed after two years, however, and the authors caution against interpretation of non-randomized self-reported outcomes.

"These findings suggest that in most cases there is no clear reason to advocate strongly for surgery apart from patient preference," writes Eugene Carragee, M.D., of Stanford University Medical Center in Stanford, Calif., in an accompanying editorial. "For the patient with emotional, family and economic resources to handle mild or moderate sciatica, surgery may have little to offer."

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Majority of Physicians Take on Public Roles

Community activities and collective advocacy viewed as very important by most

About two-thirds of physicians report being actively involved in public roles related to the community, including political involvement and collective advocacy, according to study findings published in the Nov. 22/29 issue of the Journal of the American Medical Association.

Russell Gruen, Ph.D., of the University of Melbourne in Victoria, Australia, and colleagues mailed surveys to 1,662 primary care and non-primary care specialist physicians in the United States to determine their views on the importance of community participation, political involvement and collective advocacy, how often they assumed a public role and what factors were related to these activities.

More than 90 percent of respondents rated public activities as important, with a majority rating community activity and collective advocacy as very important. Two-thirds of respondents reported participating in one of the three types of public roles within the last three years. Age, female sex and graduation from a non-U.S. or non-Canadian medical school were linked to assigning high importance to public participation.

"A variety of personal, professional and practice characteristics may influence physicians' civic mindedness and civic activity," the authors conclude. "Confirming and understanding these potential influences could provide important guidance to leaders and policy makers who want to enlist the positive energy of physicians in promoting public health at a societal level."

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Support Can Ease Stress for Ethnic Dementia Caregivers

Multifaceted interventions improve quality of life for Hispanic and white caregivers

Hispanics and whites, but not blacks, who care for relatives with dementia have significant quality-of-life improvements when supported by a multifaceted intervention that includes in-home and telephone discussions, researchers report in the Nov. 21 Annals of Internal Medicine.

Steven H. Belle, Ph.D., of the University of Pittsburgh Medical Center, and colleagues evaluated caregiver quality of life and clinical depression in a randomized, controlled trial of 212 Hispanic, 219 white and 211 black dementia caregivers. The six-month intervention included dealing with caregiver depression, self-care and social support using in-home and telephone discussions. Controls received two short telephone calls.

In the intervention group, Hispanic and white caregivers, but not blacks, had statistically significant increased quality of life improvement compared to controls. However, black spouse caregivers did report improved quality of life. Clinical depression was lower in the intervention group (12.6 percent) than in controls (22.7 percent).

"A structured multicomponent intervention adapted to individual risk profiles can increase the quality of life of ethnically diverse dementia caregivers," the authors conclude.

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Avian Flu Clusters Found in Turkey and Indonesia

Studies raise question about viral evolution toward consistent human-to-human transmission

Clusters of human H5N1 virus infection have been identified in Turkey and Indonesia, although the diagnoses in Turkey were at first difficult to make, according to two studies published in the Nov. 23 issue of the New England Journal of Medicine.

Ahmet Faik Oner, M.D., of Yuzuncu Yil University in Van, Turkey, and colleagues diagnosed eight patients aged 5 to 15 years with H5N1 virus infection who had a history of close contact with diseased or dead chickens. All had fever and seven had evidence of pneumonia, though initial influenza tests were negative, leading researchers to conclude that H5N1 can be difficult to diagnose. Four patients died.

I. Nyoman Kandun, M.D., M.P.H., of the Directorate General of Disease Control and Environmental Health in Jakarta, Indonesia, and colleagues investigated three clusters of H5N1 virus infection that affected eight patients (median age 8.5 years) and resulted in four deaths. In each cluster, the researchers found that infected patients were members of the same family, and most lived in the same home.

"The continuing evolution of H5N1 viruses and the clusters of human infections in Indonesia and Turkey raise important questions," state the authors of an accompanying editorial. "First, can the source of H5N1 be eliminated? And second, is the increasing number of clusters of human infection an indicator of evolution toward consistent human-to-human transmission?"

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Researchers Question Benefit of Fetal Oximetry

Clinician knowledge of fetal oxygen saturation has no effect on Caesarean rates or infant outcomes

Clinician awareness of fetal oxygen saturation does not lead to a reduced rate of Caesarean delivery or improvements in the condition of newborns, researchers report in the Nov. 23 issue of the New England Journal of Medicine.

Steven L. Bloom, M.D., of the University of Texas Southwestern Medical Center in Dallas, and colleagues randomly assigned 5,341 nulliparous women who were at term and in early labor to either "open" fetal pulse oximetry, in which fetal oxygen saturation values were displayed to the clinician, or "masked" fetal pulse oximetry, in which hidden values were recorded by a computer.

The researchers found similar rates of Caesarean delivery between the open and masked groups (26.3 percent and 27.5 percent, respectively) and no significant group differences in the condition of the infants at birth.

"Low oxygen saturation, although common in women with fetal heart-rate abnormalities, was also quite frequent in women with normal fetal heart-rate patterns," the authors write. "These results may explain our finding that fetal oximetry was of no benefit as an adjunct for the interpretation of electronic fetal heart-rate patterns."

"This case does offer the opportunity to discuss the appropriate role of the Food and Drug Administration in approving new medical devices," states the author of an accompanying editorial.

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Bivalirudin Monotherapy Benefits Cardiac Patients

Study supports use of bivalirudin as a substitute for heparin plus glycoprotein IIb/IIIa inhibitors

In patients with moderate- or high-risk acute coronary syndromes, treatment with bivalirudin alone is associated with similar rates of ischemia, significantly lower rates of bleeding and an improved net outcome compared to heparin plus glycoprotein IIb/IIIa inhibitors, according to a study in the Nov. 23 issue of the New England Journal of Medicine.

Gregg W. Stone, M.D., of the Columbia University Medical Center in New York City, and colleagues assigned 13,819 patients with acute coronary syndromes to one of three antithrombotic regimens: unfractionated heparin or enoxaparin plus a glycoprotein IIb/IIIa inhibitor, bivalirudin plus a glycoprotein IIb/IIIa inhibitor, or bivalirudin alone.

A nominal 7 percent decrease in bleeding events was seen with bivalirudin, plus a glycoprotein IIb/IIIa inhibitor offset the nominal 7 percent increase in ischemic events. A significant 47 percent reduction in bleeding with bivalirudin monotherapy offset the non-inferior 8 percent increase in ischemic events and produced a small but significant 14 percent reduction in net clinical outcomes at 30 days.

"The ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial provides strong support for the use of bivalirudin as a substitute for heparin plus glycoprotein IIb/IIIa inhibitors in patients with acute coronary syndromes who undergo early invasive management, in particular if they are pretreated with clopidogrel," states an accompanying editorial.

The study was supported by the Medicines Company and Nycomed.

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Switch to Anastrozole Helps Breast Cancer Survival

Benefit observed for postmenopausal women who switch to anastrozole after two to three years of tamoxifen

Women with breast cancer who switch to anastrozole after two to three years of treatment with tamoxifen have improved event-free and overall survival, possibly avoiding side-effects and drug resistance associated with tamoxifen, according to a report published online Nov. 17 in The Lancet Oncology.

Walter Jonat, M.D., from the University of Kiel in Germany, and colleagues performed a meta-analysis of three clinical trials including 4,006 postmenopausal women with hormone-sensitive early-stage breast cancer. The women had been treated with tamoxifen for two to three years and had either switched to anastrozole (1 mg/day) or had continued 20 to 30 mg/day of tamoxifen, for a total of five years.

The researchers found that switching to anastrozole significantly improved disease-free, event-free, distant recurrence-free, and overall survival (hazard ratios 0.59, 0.55, 0.61, and 0.71, respectively).

"These findings confirm that clinicians should consider switching postmenopausal women who have taken adjuvant tamoxifen for two to three years to anastrozole," Jonat and colleagues conclude.

The study was funded by AstraZeneca.

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