Sunday, September 30, 2007

Annual Physical Exam: Unneeded Expense?

(WebMD) An annual physical exam is a tradition for many U.S. adults, but it is not always necessary, according to a new study."I'm not advocating we should get rid of these visits," says researcher Ateev Mehrotra, MD, assistant professor of medicine at the University of Pittsburgh School of Medicine and a policy analyst at RAND Corp.Rather, the preventive services and tests ordered at these exams that are actually necessary often can be received at other visits and times, says Mehrotra. The study is published in the Sept. 24 issue of the Archives of Internal Medicine.Using two national surveys, Mehrotra and his colleagues analyzed 8,413 doctor visits for preventive health exams (annual physicals) and preventive gynecological exams, which women schedule to get Pap tests and pelvic exams. The doctor visits too place from Jan. 1, 2002, to Dec. 31, 2004.Among the findings:
About 44.4 million adults, or nearly 21 percent of the population, get a preventive physical exam annually.
About 19.4 million women, or about 18 percent of adult women, get a preventive gynecological exam annually.
Together, these account for 8 percent of all doctors' office visits. If every U.S. adult got an annual physical, the U.S. health care system would need to provide up to 145 million additional visits annually, the researchers estimate.
Most preventive care, about 80 percent, was received outside the preventive exams, when the patient saw the doctor for other reasons.
The cost of providing both types of routine exams was about $7.8 billion, almost the amount spent for breast cancer care in the United States in 2004.
More than a third of the annual physicals in the study included testing such as complete blood cell counts or urinalysis, which Mehrotra says are not proven to improve patient outcomes when performed routinely and so may be unneeded. Complete blood cell counts and urinalysis cost about $192 million a year in the study.
The annual physicals and preventive gynecological exams, however, were the most common avenue for getting certain crucial tests such as mammograms and Pap tests.
The number of adults getting the annual physicals varied by region, reflecting differing beliefs and practices. "Those in the Northeast have a 60 percent increased chance of getting a physical compared to those on the West Coast," Mehrotra tells WebMD. Annual Physical Exams: The Ongoing Debate The discussion about whether an adult needs an annual physical has been ongoing for nearly a century, Mehrotra tells WebMD. Currently, no major North American health-related organizations recommend the routine annual exams, he says.Still, many patients as well as many doctors believe the annual visits are a medical necessity. "The vast majority of people think they are being good patients if they go in to see their doctor every year," says Mehrotra. "Most doctors actually believe the same thing."Yet, the value of the exams has not been established in studies, he says."We need to figure it out," Mehrotra says. "Do people need to come in for a special visit? Can't we do a lot of these services at other times, without the need for a [special] visit?"The new study, he says, suggests that crucial preventive services can easily be received during other visits, and often are.Second Opinion The study provides some valuable information, says Douglas K. Owens, MD, a senior investigator at VA Palo Alto Healthcare System and professor of medicine at Stanford University. "The researchers are saying these [annual physicals] are common, often provide preventive services, but that many preventive services are provided at other visits""It is important to understand what these exams accomplish," he says, "and that there are other ways to accomplish the same thing that might be more efficient and cost-effective."Owens chairs a subcommittee of the American College of Physicians that develops guidelines about treatment and care but says he is giving his opinion, not that of the college. The ACP has no official guideline about the annual physical, he says.Some advocates of the annual physicals see the yearly exam, Owens points out, as a good way to build the patient-doctor relationship. Yet that relationship can be worked on, others say, in any doctor office visit, not just the traditional annual physical visit.Take-Home Points on Annual Physicals What's the message for patients? "The important thing for consumers is, there are preventive services important to get," Owens says. "If they are getting them as part of their routine care, that is great. If not, a periodic health exam may be a good avenue to get them.""Have a conversation [with your doctor]," Mehrotra suggests. "If your doctor tells you [that] you don't need to come in for an annual physical or don't need some of these tests, he's not [just] trying to save money. Patients should realize there is a lot of controversy about the value of physicals and they should have a conversation with their doctor about it."Patients should also realize, he says, that the preventive services they absolutely need can be received outside the traditional annual physical exam.
Who are the doctor bloggers and what do they want?

Rebecca Coombes, journalist, London

Medical blogs are sometimes seen as just rants about the state of health care, but they have also been credited with spreading public understanding of science and rooting out modern day quacks. Rebecca Coombes checks out the medical blogosphere
In "internet time" blogging has been around for almost an eternity. Now, with the possible exception of the odd intransigent high court judge, blogging has achieved household name status since catching the public's imagination nearly a decade ago.
The medical "blogosphere" is an especially crowded firmament. The opportunity to access raw, unfiltered material, to post instant comments, and to share information with a (often niche) community has become an addictive pastime for many doctors. The field has developed to the extent that devotees rely on their favourite blogs as their first port of call for topical opinion and debate. Taken as a group, the medical bloggers—the popular ones, at least—are overwhelmingly younger men, and many have a typically masculine geeky humour.
But the field is far from just a playground for the young. For example, David Colquhoun, professor of pharmacology at University College London, is 71 and now a celebrated . . . [Full text of this article]
U.S. Rejects Novartis Painkiller

By Hans Schoemaker and Jeanne Whalen

Novartis AG said the U.S. Food and Drug Administration rejected its painkiller Prexige in a decision that had been expected after the drug was withdrawn from the Australian market due to side effects.
1949 TV commercial: More Doctors Smoke Camels Than Any Other Cigarette

How times have changed... Click here to visit the web site :
100 Web Resources for Medical Professionals

If you are employed in the medical field or are currently studying medicine, then the Internet can be a valuable tool. From scientific research to professional networking, it often seems that you can be more productive online than you can in person. Doctors, nurses and others in the medical community are becoming reliant on convenient sites that offer useful information around the clock. The following 100 Web resources for medical professionals are not listed by importance, but rather alphabetized within their corresponding categories.
General Research Dentistry Nursing Obstetrics & Gynecology Oncology Pediatrics Psychiatry Dictionaries & Journals Directories Job Leads Social Networking Blogs
General Research
The sites below encompass a variety of topics and will be of interest to medical professionals, medical students and others who wish to learn more about health. From the latest news in medicine to reliable information regarding diagnosis and therapy, the following sites cover it all.
American Medical Association (AMA) — The official site of the AMA offers the latest medical news, as well as information on patient advocacy. The organization should be of interest to both physicians and medical students.
British Medical Association (BMA) — This UK organization welcomes both licensed physicians and medical students from Britain and overseas. Their official Web site offers breaking news on medicine, as well as professional and educational resources for the medical community.
Centers for Disease Control (CDC) — Healthcare providers will find the newest recommendations and guidelines from the CDC on this site. Where communicable diseases are concerned, physicians must stay abreast of the latest breakthroughs and research.
Doctor's Guide — The newest developments in medicine are posted to Doctor's Guide, with topics ranging from acne to viral infections. You will also find a multilingual medical dictionary on this site.
Food and Drug Administration (FDA) — The official site of the FDA lists many regulations that medical professionals should be familiar with. Also, breaking news that concerns the FDA will be posted to this site. — Featuring health news, a weekly newsletter and a wellness guide, this site is invaluable to both professionals and consumers. A drug interaction guide is also a handy tool for those who are prescribing or taking medication.
Health On the Net Foundation (HON) — HON offers a tool that searches hundreds of the most reliable medical sites for information. This site can be useful to anyone, not just medical professionals, and it is available in multiple languages.
MDLinx — MDLinx keeps healthcare professionals and consumers current on the latest in medical research. Also, the site features a job bank and targeted advertisements that may be of interest to medical staff and students.
Mayo Clinic — Mayo Clinic is one of the leading hospital systems in the United States, with multiple locations across the country. The official Mayo Clinic site offers reliable information for healthcare professionals and patients.
Medical / Health Science Libraries on the Web — Compiled by the University of Iowa, this convenient list offers links to every major college library on the Web that focuses on medicine or health sciences. — Offering medical news, medical definitions and an online database of common illnesses and conditions, this site is a great catch. All refresher course for any medical professional. Students will find the site to be great reference material, also.
MedlinePlus — From the National Library of Medicine, this massive site offers research material for both medical professionals and consumers. Video tutorials on this site are especially informative and entertaining.
National Institutes of Health (NIH) — NIH is "The Nation's Medical Research Agency", making their official site a favorite amongst healthcare workers. Various grants can be researched here, including professional research grants and college grants.
National Library of Medicine — Medical professionals should visit the official site of the NLM on a regular basis, as it offers the latest and most reliable news in medical research. Online medical journals, interactive tools and a library catalog are all available on this one informative site.
Ovid — Ovid is a favored site amongst those in the medical and science industries. Offering the latest news and resources in medical research, the reliable information found here should be useful to students and professionals alike.
WebMD — WebMD, though mainly frequented by consumers, can prove to be a quick reference tool for healthcare professionals and students.
World Health Organization (WHO) — The official site of the WHO offers news and research material on global healthcare issues.
Back to index
Dentists have a large online presence. Not only do many dentists and dental clinics have their own Web sites, there are plenty of reliable online sources of dental news and information. The following sites are some of the most popular dental sites.
American Dental Association (ADA) — The official site of the ADA includes specific areas for dental professionals and consumers, as well as exclusive content for ADA members.
American Dental Hygienists' Association (ADHA) — Dental professionals and students will find the latest news in dental hygiene on this site, as well as links to important dental health resources.
Dental Hygiene News — As the name suggests, this site is devoted to dental hygiene news. Other areas of the site include dental humor pages and an online dental hygiene store. — This aggregate site is updated constantly, keeping dental professionals and students abreast of the latest dental news. Dental News is also a print magazine and select articles are available for download on this site. — This is an online market for dental professionals, though the site also offers the latest related headlines and a forum for dental workers to discuss health.
WebDental — From dental supplies to dental schools, information on all things related to the industry can be found on this site. The self-proclaimed "World's Premier Dental Resource", WebDental should be of interest to everyone in the industry, including students.
Back to index
Nurses are often taken for granted in the medical community, though it isn't for lack of hard work. Nurses and students in nursing school will find the following sites to be both informative and welcoming. — This site doubles as a forum and news service, offering information and online support to both professional nurses and students.
American Academy of Nurse Practitioners (AANP) — The official site of the AANP offers the latest healthcare news, as well as information on legislation that affects nurse practitioners. Exclusive content is available for AANP members.
American Nurses Association (ANA) — The ANA Web site offers valuable news and resources for nurses, as well as areas specific to certain disciplines. A "Members Only" area contains exclusive content and products.
CyberNurse — CyberNurse is a site maintained by two nurses and offers countless online resources to those in the nursing profession. Nursing students will also find this site invaluable and the online store offers quality, related products.
National League for Nursing (NLN) — The NLN focuses on improving nursing education and welcomes both professionals and students into the organization. This site offers many resources for those in the nursing industry. — is a large, informative site on all things related to the nursing industry. From the latest medical headlines to education resources, all nursing professionals and students should frequent this site. — This online market for nursing supplies also offers a message board and job bank. An RSS feed containing the latest medical headlines is also featured on the homepage, making this a versatile resource for nursing professionals and students.
Back to index
Obstetrics & Gynecology
Obstetrics and gynecology cover many topics and there are plenty of sites dedicated to women's health. The following sites are most useful to women's health professionals, rather than just patients.
Association of Professors of Gynecology and Obstetrics (APGO) — A non-profit organization, the APGO is dedicated to improving women's healthcare. Those who wish to join will find an online application here, as well as more information on the organization's activities.
Contemporary OB/GYN — This is the official site of a monthly magazine of the same name. Key articles and resources can be found on this site, as well as the ability to subscribe to this cutting-edge publication.
International Breast Cancer Research Foundation (IBCRF) — This global foundation is dedicated to finding a cure for breast cancer and is conducting research that should be of interest to OB/GYNs, as well as medical students.
The National Women's Health Information Center — This government-sponsored site on women's health contains resources for OB/GYNs, medical students and consumers. Information regarding research funding can be found through this site, as well. — The leading resources for those involved in the women's healthcare industry can be found here. From news articles to educational tutorials, this site offers a lot of information. — News and information on perinatology should be of interest to both OB/GYNs and medical students. From clinical trials to the latest headlines, the leading resources can be found here.
Back to index
Cancer patients have countless sites devoted to them, but the sites below are mainly intended to assist professionals in the field of oncology.
American Society of Clinical Oncology (ASCO) — From online abstracts to news regarding medical legislation, all the latest information about oncology can be found on this site.
CancerNetwork — CancerNetwork offers the latest news in cancer research, as well as countless resources for oncology professionals and students.
National Cancer Institute (NCI) — This government institution is a leader in cancer research. The informative Web site offers news and publications on cancer research, as well as funding for oncologists and students.
OncoLink — Created by the Abramson Cancer Center, this site offers information and support to medical professionals, students and cancer patients. This is one of the largest sites focused on oncology and is updated daily.
Back to index
With so many online resources available on children's health, it is hard to choose the "top" sites. However, pediatricians and pediatric nurses will find the sites below to be most useful to them.
American Academy of Pediatrics (AAP) — The official site of the AAP offers reliable information and resources about pediatrics. There are areas devoted specifically to parents or professionals and members gain access to exclusive content.
American Board of Pediatrics (ABP) — The official site of this certifying board offers resources for those trying to become certified, as well as practicing pediatricians. — Dr. Greene is one of the most famous pediatricians in the world and was the first physician to start his own medical Web site. Healthcare professionals and students may benefit from Dr. Greene's advice, just as parents and caregivers have for years. — For healthcare providers and students who are curious about how the medical community feels about certain pediatric problems, this site may have the answers.
Back to index
From the latest research findings on mental health to online reference materials, the sites below will be useful to those working in the field of psychiatry.
American Academy of Child & Adolescent Psychiatry (AACAP) — The official site of the AACAP offers the latest news on child and adolescent psychiatry, as well as information on related legislation. Those wishing to join the academy can find out how to do so on this Web site.
American Board of Psychiatry and Neurology (ABPN) — The ABPN is a reputable certifying board that promotes excellence in the psychiatric industry. Their official site contains information on the latest in psychiatric research, as well as how to become certified.
American Psychiatric Association (APA) — Physicians can join the reputable APA through this site, as well as pay dues and catch up on the latest psychiatric research.
PsychNet - UK — This British site offers many resources to both medical professionals and consumers. Student lecture material can be found here, as well as leads on various mental health jobs around the UK. — Featuring the latest industry news and treatment guidelines, this site is a one-stop source of pertinent psychiatric information.
Back to index
Dictionaries & Journals
There are countless medical journals currently in publication, as well as many online glossaries and dictionaries. The following sites feature the most popular and/or extensive medical dictionaries and journals.
American Family Physician — This online journal is an exhaustive source of information about general practice, including the latest research and treatment standards.
American Medical News — This online publication offers academic essays and news articles that are free for 90 days. Paid members will have full access to the site's archives, however.
Free Medical Journals — As the name suggests, this site features free medical journals. There are currently over 400 journals on this site, most of them available in several different languages.
Glossary of Immunology — This handy online glossary features hundreds of medical terms. Using one's Web browser "Find" command will help find specific words on the list.
Health Affairs — Health Affairs focuses on medical policies. Although this journal is only available for a fee, select articles are posted online for no charge.
JAMA: The Journal of the American Medical Association — The AMA produces JAMA, one of the most popular medical journals in publication. Subscriptions are available through this site, though certain articles can be read online for free.
MedTerms Medical Dictionary — MedTerms is a popular resource for both healthcare professionals and students, as it offers definitions to over 16,000 medical terms.
The Merck Manuals — Merck produces some of the most exhaustive and reliable books about diagnosis and therapy. Many physicians have The Merck Manuals saved on their handheld devices, should they need to consult one of the site's online texts at work.
The New England Journal of Medicine (NEJM) — The NEJM is one of the most respected medical journals in publication. Key articles are available for free on this official site, as well as paid subscriptions to the full journal.
PubMed — This online database of MEDLINE records is available to registered physicians and is considered one of the most reliable online sources of medical information.
Back to index
The following online directories will assist both healthcare professionals and consumers with finding physicians, clinics and hospitals. Searches can be narrowed with certain specific fields, such as location, field of study, board certification or accepted insurances.
AMA DoctorFinder — Those looking for physicians who are recommended by the AMA can find them with this simple search tool.
American Hospital Directory — This hospital directory features major hospitals and clinics, in addition to detailed profiles of each result.
DocFinder — DocFinder was the first search tool of its kind and is still one of the best. Free of charge, one can search for doctors from a combined source of databases, including state licensing boards. — This online directory, which was created in 1996, can locate doctors according to specialty and location. Also, one can search for hospitals with this tool.
The Health Insurance Directory — This simple directory lists all major health insurances in the United States and connects users with the insurances' Web sites.
Hospital Directory — Featured on U.S. News & World Report's Web site, this hospital directory can help professionals and patients find specifically what they need. This is both a reliable and user-friendly tool.
WebMD Physician Directory — Already a useful site, WebMD features one of the most exhaustive search tools for locating a physician. Search criteria can get very specific with this directory, though it is quite easy to use.
Worldwide Hospitals Search — Not everyone needs to find a hospital in the United States, which is why this tool comes in so handy for many professionals. Featuring hospitals in over 60 countries, there are more than 12,000 current entries in this directory.
Back to index
Job Leads
Finishing a degree or certificate in healthcare may seem like hard work, but finding a desirable position is another feat that takes dedication. The sites below will assist those looking for a job in the medical industry, including doctors, nurses and administrators.
Candidate Direct — Candidate Direct is the most popular travel nurse agency on the Web. This company helps travel nurses find positions that suit them and the site's services are available 24 hours a day. — This is a popular classified ad site for jobs, though it isn't exclusive to medical professionals. However, its popularity may garner plenty of results for those seeking a career in the medical field.
Employment for Physicians — Like the title suggests, this site assists physicians who are looking for a new position. Doctors can search listings and post resumes on this site.
HealthCare Job Bank — Organized by state and occupation, there are many employers who post open positions on this site. These jobs encompass all health-related careers. — Those looking to work in a hospital may find a position through this site. From doctors to administrators, all positions within a hospital are included.
MEDJobScout — This simple search tool will help one to narrow his/her job search by location, profession and/or specialty.
Monster — The largest job site on the Internet, Monster features many open positions for medical professionals. One can also post his/her resume to this site, often garnering a large response.
Nurse Emp — Though the site's name suggests it is only for those seeking a job in nursing, employers will also post positions for other allied healthcare professionals. This is a popular resource for nurses and medical assistants.
Back to index
Social Networking
Online social networking can included Internet dating, meeting friends with similar interests and making professional connections that help one's career. Today, almost everyone uses some form of social networking tool. The following sites are popular amongst healthcare professionals. — Physicians who share advice and anecdotes and who make friends within their field of study primarily use this large system of message boards. — This site is a place to network with other physicians. Private, free and anonymous, doctors can share stories and advice without infringing upon anyone's privacy.
iMedExchange — One of the newest and most popular networking sites for physicians, iMedExchange is a very polished online hangout for doctors. Their online tutorial should entice most doctors to join.
LinkedIn — LinkedIn is a way to share your trusted contacts with others, thus creating a large group for you to network with. Unlike other social networking sites with a similar structure, LinkedIn is for professional networking only.
Medical Passions — This is one of the few online dating sites that is specifically dedicated to those within the medical industry. It is a great way to meet people with similar goals and interests (not to mention, erratic schedules).
MomMD — This popular online community is for women in the medical industry who want to meet friends and make business contacts. It is an empowering and welcoming community for female healthcare providers.
Nurse's Cafe — Nurse's Cafe is a place for nurses to discuss healthcare amongst colleagues or just meet other nurses who have similar interests and life experiences.
Nurse Linkup — A new community, Nurse Linkup offers forums, chat rooms, blogs and more to nurses who want to mingle online with colleagues.
Professional Nurse Network — Offering message boards, blogs and more, this site encourages nurses to start an online profile and meet other nurses.
Sermo — Sermo is the reigning champ among social networking sites for licensed doctors. It is considered a classy, intellectual environment for physicians to meet colleagues and make new friends.
Tiromed — Tiromed, another young site, enables both medical professionals and students to meet and greet. Mentoring is encouraged through this site, which can enrich a healthcare provider's career and life.
Back to index
about a nurse — This popular blog is written by May, an RN from California. Her musings about life in a medical-surgical ward has attracted many fans.
Addicted to Medblogs — This blog is written by someone who is a self-admitted medical blog addict. Here, roles are reversed and doctors often visit the site to leave comments.
code blog: tales of a nurse — Another popular nursing blog, code blog also posts stories that have been submitted by various healthcare professionals. It is an anonymous peek into a fascinating industry.
A Day In the Life of An Ambulance Driver — Driving an ambulance is never boring and neither is this blog. Popular for good reason, this author describes the ups and downs of emergency situations he has to endure every day.
Doctor Anonymous — This is a humorous blog written anonymously by a doctor. It covers medicine in relation to politics, life and beyond. Doctor Anonymous also has an online radio show, broadcast from this blog.
Emergiblog — This is one of the most popular medical blogs on the Web, expertly written by an ER nurse. There is never a dull moment in this nurse's life.
Family Medicine Notes — One of the longest-running medical blogs on the Internet, Family Medicine Notes has been maintained by a family physician since 1999.
FAST FOOD Pharmacy — This is an amusing, sometime poignant blog written by a pharmacist. As indicated by the blog's name, pharmacies are often observed as being like fast food drive-thrus.
GruntDoc — A former marine, this emergency doctor has many wild tales to tell from his home in Texas.
In the Pipeline — For more academic fare, this PhD maintains a very popular blog on Corante.
Kevin, M.D. — Kevin, M.D. is probably the most popular medical blog in the Internet. Written by primary care physician Dr. Kevin Pho and offers one doctor's opinion on the medical industry.
NHS Blog Doctor — This is a very popular blog written by a physician in the UK. His scathing look at problems within the British healthcare industry has many loyal readers.
Medpundit — Medpundit is another blog written by a doctor that provides an insider's view on the state of the medical industry.
The NJO Blog — This is a shared blog between several nurses, discussing the intricacies of nursing life.
Neurosurgeon shortage critical

By Jennifer CalhounStaff writer

As of Monday, Fayetteville will only have a neurosurgeon on emergency call three days a week. The rest of the time, patients who may need emergency brain surgery will be sent to UNC Hospitals at Chapel Hill.
Cape Fear Valley Health System previously had neurosurgeons on call 24 hours a day, seven days a week through an exclusive agreement with Carolina Neurosurgical Services, a group of four brain surgeons — the only ones in town.
Earlier this month, however, one of the group’s surgeons, Dr. Rene Kotzen, voluntarily gave up privileges at the hospital to lower his high malpractice insurance costs, said one of the group’s leaders, Dr. Carol Wadon.
As a result, the group told the health system it could no longer provide around-the-clock coverage of the emergency room.
“I think the problem is that the emergency room has become busier, and we have gotten older,” Wadon said. “And with malpractice going up, it’s almost impossible to keep the business going.”
Dr. Jim Hunter, Cape Fear Valley Health System’s chief medical officer, said head trauma patients in the region who need surgery on the days a neurosurgeon is not on call will be flown to UNC by helicopter or taken by ambulance.
“What I’d like the public to know is that they will get care,” Hunter said. “I don’t want to send a panic through this community that we can’t give care.”
The health system also could look into forming an alliance with other medical centers or teaching hospitals, said Joyce Korzen, the health system’s interim chief executive officer.
Southeastern Regional Medical Center in Lumberton has a similar agreement with Duke University Health System.
Beyond that, Korzen said she hopes to solve the problem by using a collaborative approach that would include recruiting neurosurgeons and working with Carolina Neurosurgical to find ways to deal with the shortage.
Hunter said the shortage of neurosurgeons is a problem that’s been going on across the country for years.
With only a hundred or so doctors in the specialty graduating every year, competition to recruit can be stiff.
In Fayetteville, it can be almost impossible, Wadon said.
“About one out of every 10 (neurosurgeons) I interview over the phone actually come here to interview,” she said.
Fayetteville’s reputation as a military town and long hours working as an on-call trauma physician at the emergency room don’t help recruitment efforts, she said.
In addition, the practice receives low reimbursement rates from Medicare, Medicaid and Tricare — the insurance plans held by about 70 percent of their patients.
But Wadon said she believes the biggest problem with recruiting neurosurgeons comes from the fact that North Carolina is one of 12 states that has not passed significant tort reform legislation. Passing reforms could reduce damages awarded to patients from medical malpractice lawsuits or cap them at $250,000. The reforms also could keep doctors’ insurance rates from rising.
With those reforms, Wadon said she believes it would offer a more hospitable environment for neurosurgeons, who pay some of the highest premiums for medical malpractice insurance.
Dick Taylor, CEO of the North Carolina Academy of Trial Lawyers, disagreed.
“We recognize that there really are issues with malpractice insurance rates, and that it is unregulated,” Taylor said. “But we also need to make medicine safer. To take away the incentive to make it safer is the wrong way to go.”
Tort reform, he said, would also bring an economic advantage to an already privileged class at the expense of people who have been catastrophically injured because of medical malpractice.
The “privileged” moniker is one that Wadon and her group members — Drs. Bruce Jauffmann and Kim Koo — take exception to.
“Every year, we wonder if we’re going to be able to stay open,” Jauffmann said Friday.
Wadon added: “People think we make millions of dollars, but that’s not true.”
With reimbursements low and malpractice insurance costs high, Jauffmann said they’ve been taking hits from all directions.
It was the combination of those hits that ultimately caused Kotzen to bow out of surgical work at the hospital, Jauffmann said.
Kotzen’s yearly malpractice insurance costs had reached the upper six figures, making it impossible for him to continue performing surgeries, Wadon said.
And while Kotzen will continue to see patients in his office, his current malpractice insurance will not cover him if he performs surgical procedures.
Wadon said Kotzen’s surgical malpractice insurance was high because of previous lawsuits in New York.
According to the New York State Physician Profile Web site, Kotzen was sued in at least three different medical malpractice cases in Kings County, N.Y., in the late 1990s and early 2000s.
One of the incidents involved Kotzen operating on the wrong side of a patient’s brain, according to a Feb. 26, 2001, article from The New York Times. Another neurosurgeon had prepped the wrong side of the brain, and Kotzen began the operation on the wrong side, the article said. He recognized his error and resumed the surgery on the correct side of the brain.
Wadon said some of Kotzen’s suits were the result of working in a state with very high rates of malpractice lawsuits where liability was spread to everyone involved with the surgeries.
With Kotzen out of the picture and no new neurosurgical recruits in sight, trauma patients in the region could be compromised, Wadon said.
And much of that comes down to whether the state passes tort reform, she said.
“We’re just the canaries in the coal mine,” she said. “This could happen with other specialties, too.”
How Defensive Medicine Changes the Practice of Medicine.

Emergency physicians are well known in the medical profession to be paranoid about litigation. And well they should be. Emergency medicine docs are among such litigation high risk specialties as obstetricians and neurosurgeons. There is every reason to believe (and some evidence) that this paranoia alters how these physicians practice medicine and not necessarily for the better.I was called by a local ER physician for a possible admission. The patient was elderly and by elderly I mean that she was entering her child bearing years when the US was entering World War I. She had been brought by her family to the ER because of chest pain which had since resolved. The ER physician revealed that the family and patient only wanted medical options (like pain relief) and did not want any invasive procedures. Both the ER physician and I agreed with this considering the patient’s advanced age, any invasive/intensive treatment attempts would likely cause more harm than good. The first rule is “Do no harm”. Right?The patient’s EKG was normal. Her first set of cardiac enzymes were all normal. She had no further chest pain or any other symptoms and she didn’t want to be resuscitated in the event that she had cardiopulmonary arrest (DNR). Satisfied, I didn’t seen anything more that we should do and I recommended discharging the patient home on nitrates, aspirin, clopidogrel, and pain medications, and have her follow up in the office within a few days. Then the ER physician threw me a curve ball.ER Doc: “I was going to admit her to telemetry for observation”.Me: “To observe for what? We aren’t going to do anything more than we are doing now.”ER Doc: “Well, to rule her out. Make sure she didn’t have a heart attack.”Me: “But even if she has had a heart attack it won’t change our treatment! We’re not going to do a cardiac catheterization or cardiac bypass on her. She won’t agree to it and her risk of dying from those procedures alone would be unacceptably high.”ER Doc: “What if she has more chest pain?”Me: “Then she can take her home medication or come back to the ER for treatment in the event that she has severe refractory pain. She might have more chest pain tonight. She might have severe chest pain 2 weeks from now. I can’t admit a patient just for convenience!”ER Doc: “But we’ve only gotten one set of cardiac enzymes on her. We need to get at least one more set to make sure that she didn’t have a heart attack.”Me: “Does she want to consider invasive testing or treatment if her enzyme levels are elevated?”ER Doc: “No, the family and the patient just want medical treatment regardless.”Me: “Is the family or the patient insisting on being admitted to the hospital?”ER Doc: “No, they are fine with whatever we recommend.”Me: *Banging my head on the table* “All right. It’s been several hours since her chest pain resolved and several since her first cardiac enzyme levels were drawn. You can get a second set now and if this set is normal then you can send her home.”The ER physician agreed to this, the second set of cardiac enzymes were normal, and the patient went home.The practice of emergency medicine (among other high risk specialties) has become so regimented and infused with defensive medicine tactics that many ER docs are not even aware of how this has changed the way they think. It seemed as if this ER physician could not fathom the concept that we would send home a patient who could easily have just had a heart attack despite the fact that we were going to do absolutely nothing different for her then if she went home. Even though the possibility of litigation in this case was remote it was the constant and overall threat of litigation that has fundamentally changed the thinking of physicians and how they practice medicine.This change in thinking has had significant consequences. Ever wonder why we spend so much on medical care? Part of the answer lies in this example. This ER doc was about to turn an $800 ER visit into a $4,000 hospital admission. Now imagine this happening all over the country in multiple variations and degrees of absurdity tens of thousands of times EVERY DAY.Medical malpractice attorneys are not directly at fault for this mess. But I don’t see this problem correcting itself as long as physicians feel that the current tort system is a disincentive to changing from a mostly CYA (Cover Your Ass) system to one which couples good medical care to proper resource utilization. However, tort lawyers tend to oppose every single reform attempt and so in my book, if they are not part of the solution, then they are part of the problem.

Written by Richard MacManus

We're well into the current era of the Web, commonly referred to as Web 2.0. Features of this phase of the Web include search, social networks, online media (music, video, etc), content aggregation and syndication (RSS), mashups (APIs), and much more. Currently the Web is still mostly accessed via a PC, but we're starting to see more Web excitement from mobile devices (e.g. iPhone) and television sets (e.g. XBox Live 360).
What then can we expect from the next 10 or so years on the Web? As NatC commented in this week's poll, the biggest impact of the Web in 10 years time won't necessarily be via a computer screen - "your online activity will be mixed with your presence, travels, objects you buy or act with." Also a lot of crossover will occur among the 10 trends below (and more) and there will be Web technologies that become enormously popular that we can't predict now.
Bearing all that in mind, here are 10 Web trends to look out for over the next 10 years...

1. Semantic Web
Sir Tim Berners-Lee's vision for a Semantic Web has been The Next Big Thing for a long time now. Indeed it's become almost mythical, like Moby Dick. In a nutshell, the Semantic Web is about machines talking to machines. It's about making the Web more 'intelligent', or as Berners-Lee himself described it: computers "analyzing all the data on the Web – the content, links, and transactions between people and computers." At other times, Berners-Lee has described it as "the application of weblike design to data" - for example designing for re-use of information.
As Alex Iskold wrote in The Road to the Semantic Web, the core idea of the Semantic Web is to create the meta data describing data, which will enable computers to process the meaning of things. Once computers are equipped with semantics, they will be capable of solving complex semantical optimization problems.
So when will the Semantic Web arrive? The building blocks are here already: RDF, OWL, microformats are a few of them. But as Alex noted in his post, it will take some time to annotate the world's information and then to capture personal information in the right way. Some companies, such as Hakia and Powerset and Alex's own AdaptiveBlue, are actively trying to implement the Semantic Web. So we are getting close, but we are probably a few years off still before the big promise of the Semantic Web is fulfilled.
Semantic Web pic by dullhunk

2. Artificial Intelligence
Possibly the ultimate Next Big Thing in the history of computing, AI has been the dream of computer scientists since 1950 - when Alan Turing introduced the Turing test to test a machine's capability to participate in human-like conversation. In the context of the Web, AI means making intelligent machines. In that sense, it has some things in common with the Semantic Web vision.
We've only begun to scratch the surface of AI on the Web. has attempted to introduce aspects of AI with Mechanical Turk, their task management service. It enables computer programs to co-ordinate the use of human intelligence to perform tasks which computers are unable to do. Since its launch on 2 November 2005, Mechanical Turk has gradually built up a following - there is a forum for "Turkers" called Turker Nation, which appears to have light-to-medium level patronage. However we reported in January that Mturk isn't being used as much as the initial hype period in Nov-Dec 05.
Nevertheless, AI has a lot of promise on the Web. AI techniques are being used in "search 2.0" companies like Hakia and Powerset. Numenta is an exciting new company by tech legend Jeff Hawkins, which is attempting to build a new, brain-like computing paradigm - with neural networks and cellular automata. In english this means that Numenta is trying to enable computers to tackle problems that come easy to us humans, like recognizing faces or seeing patterns in music. But since computers are much faster than humans when it comes to computation, we hope that new frontiers will be broken - enabling us to solve the problems that were unreachable before.

3. Virtual Worlds
Second Life gets a lot of mainstream media attention as a future Web system. But at a recent Supernova panel that Sean Ammirati attended, the discussion touched on many other virtual world opportunities. The following graphic summarizes it well:
Looking at Korea as an example, as the 'young generation' grows up and infrastructure is built out, virtual worlds will become a vibrant market all over the world over the next 10 years.
It's not just about digital life, but also making our real life more digital. As Alex Iskold explained, on one hand we have the rapid rise of Second Life and other virtual worlds. On the other we are beginning to annotate our planet with digital information, via technologies like Google Earth.

4. Mobile
Mobile Web is another Next Big Thing on slow boil. It's already big in parts of Asia and Europe, and it received a kick in the US market this year with the release of Apple's iPhone. This is just the beginning. In 10 years time there will be many more location-aware services available via mobile devices; such as getting personalized shopping offers as you walk through your local mall, or getting map directions while driving your car, or hooking up with your friends on a Friday night. Look for the big Internet companies like Yahoo and Google to become key mobile portals, alongside the mobile operators.
Companies like Nokia, Sony-Ericsson, Palm, Blackberry and Microsoft have been active in the Mobile Web for years now, but one of the main issues with Mobile Web has always been usability. The iPhone has a revolutionary UI that makes it easier for users to browse the Web, using zooming, pinching and other methods. Also, as Alex Iskold noted, the iPhone is a strategy that may expand Apple's sphere of influence, from web browsing to social networking and even possibly search.
So even despite the iPhone hype, in the US at least (and probably other countries when it arrives) the iPhone will probably be seen in 10 years time as the breakthrough Mobile Web device.

5. Attention Economy
The Attention Economy is a marketplace where consumers agree to receive services in exchange for their attention. Examples include personalized news, personalized search, alerts and recommendations to buy. The Attention Economy is about the consumer having choice - they get to choose where their attention is 'spent'. Another key ingredient in the attention game is relevancy. As long as the consumer sees relevant content, he/she is going to stick around - and that creates more opportunities to sell.
Expect to see this concept become more important to the Web's economy over the next decade. We're already seeing it with the likes of Amazon and Netflix, but there is a lot more opportunity yet to explore from startups.
Image from The Attention Economy: An Overview, by Alex Iskold

6. Web Sites as Web Services
Alex Iskold wrote in March that as more and more of the Web is becoming remixable, the entire system is turning into both a platform and the database. Major web sites are going to be transformed into web services - and will effectively expose their information to the world. Such transformations are never smooth - e.g. scalability is a big issue and legal aspects are never simple. But, said Alex, it is not a question of if web sites become web services, but when and how.
The transformation will happen in one of two ways. Some web sites will follow the example of Amazon, and Flickr and will offer their information via a REST API. Others will try to keep their information proprietary, but it will be opened via mashups created using services like Dapper, Teqlo and Yahoo! Pipes. The net effect will be that unstructured information will give way to structured information - paving the road to more intelligent computing.
Note that we can also see this trend play out currently with widgets and especially Facebook in 2007. Perhaps in 10 years time the web services landscape will be much more open, because the 'walled garden' problem is still with us in 2007.
Image from Web 3.0: When Web Sites Become Web Services, by Alex Iskold

7. Online Video / Internet TV
This is a trend that has already exploded on the Web - but you still get the sense there's a lot more to come yet. In October 2006 Google acquired the hottest online video property on the planet, YouTube. Later on that same month, news came out that the founders of Kazaa and Skype were building an Internet TV service, nicknamed The Venice Project (later named Joost). In 2007, YouTube continues to dominate. Meanwhile Internet TV services are slowly getting off the ground.
Our network blog last100 has an excellent overview of the current Internet TV landscape, with reviews of 8 Internet TV apps. Read/WriteWeb's Josh Catone also reviewed 3 of them - Joost, Babelgum, Zattoo.
It's fair to say that in 10 years time, Internet TV will be totally different to what it is today. Higher quality pictures, more powerful streaming, personalization, sharing, and much more - it's all coming over the next decade. Perhaps the big question is: how will the current mainstream TV networks (NBC, CNN, etc) adapt?
Zattoo, from Internet Killed The Television Star: Reviews of Joost, Babelgum, Zattoo, and More, by Josh Catone

8. Rich Internet Apps
As the current trend of hybrid web/desktop apps continues, expect to see RIA (rich internet apps) continue to increase in use and functionality. Adobe's AIR platform (Adobe Integrated Runtime) is one of the leaders, along with Microsoft with its Windows Presentation Foundation. Also in the mix is Laszlo with its open source OpenLaszlo platform and there are several other startups offering RIA platforms. Let's not forget also that Ajax is generally considered to be an RIA - it remains to be seen though how long Ajax lasts, or whether there will be a '2.0'.
As Ryan Stewart wrote for Read/WriteWeb back in April 2006 (well before he joined Adobe), "Rich Internet Apps allow sophisticated effects and transitions that are important in keeping the user engaged. This means developers will be able to take the amazing changes in the Web for granted and start focusing on a flawless experience for the users. It is going to be an exciting time for anyone involved in building the new Web, because the interfaces are finally catching up with the content."
The past year has proven Ryan right, with Adobe and Microsoft duking it out with RIA technologies. And there's a lot more innovation to happen yet, so in 10 years time I can't wait to see what the lay of the RIA land is!

9. International Web
As of 2007, the US is still the major market in the Web. But in 10 years time, things might be very different. China is often touted as a growth market, but other countries with big populations will also grow - India and African nations for example.
For most web 2.0 apps and websites (R/WW included), the US market makes up over 50% of their users. Indeed, comScore reported in November 2006 that 3/4 of traffic to top websites is international. comScore said that 14 of the top 25 US Web properties now attract more visitors from outside the US than from within. That includes the top 5 US properties - Yahoo! Sites, Time Warner Network, Microsoft, Google Sites, and eBay.
However, it is still early days and the revenues are not big in international markets at this point. In 10 years time, revenue will probably be flowing from the International Web.

10. Personalization
Personalization has been a strong theme in 2007, particularly with Google. Indeed Read/WriteWeb did a feature week on Personalizing Google. But you can see this trend play out among a lot of web 2.0 startups and companies - from to MyStrands to Yahoo homepage and more.
What can we expect over the next decade? Recently we asked Sep Kamvar, Lead Software Engineer for Personalization at Google, whether there will be a 'Personal PageRank' system in the future. He replied:
"We have various levels of personalization. For those who are signed up for Web History, we have the deepest personalization, but even for those who are not signed up for Web History, we personalize your results based on what country you are searching from. As we move forward, personalization will continue to be a gradient; the more you share with Google, the more tailored your results will be."
If nothing else, it'll be fascinating to track how Google uses personalization over the coming years - and how it deals with the privacy issues.

We've covered a lot of ground in this post, so tell us know what you think of our predictions. What other Web trends do you forsee over the next decade?
The impact of physical activity on weight-bearing knee joint

Exercise for cardiovascular health keeps knee cartilage healthy, too, suggests long-term, community-based study
The world’s most common joint disease, osteoarthritis (OA) is a major cause of disability among adults over the age of 50. Whether physical activity is beneficial or detrimental to weight-bearing joints, knees in particular, has been open to debate. Some studies implicate physical activity in provoking knee OA, while others suggest that physical activity may actually protect the knee joint from the disease. Confounding the matter is the fact that knee injury is a known risk factor for knee OA. Then, there’s the unclear role of osteophytes in knee OA progression, compounded by the limitations of radiographs for monitoring small yet significant changes in joint structure.
For a clearer picture of the impact of physical activity on the knee joint, a team of researchers in Australia turned to magnetic resonance imaging (MRI). This highly accurate high-tech tool makes it possible to directly visualize joint structures, detect early and pre-disease states of OA, and assess the influence of potential risk factors. Taking advantage of this novel methodology, the researchers studied the effect of physical activity, in various degrees of intensity, frequency, and duration, on knee structures in a total of 257 healthy adults between the ages of 50 and 79, with no history of knee injury or OA. Their findings, presented in the October 2007 issue of Arthritis Care & Research (, suggest that exercise that is good for the heart is also good for the knee.
Recruited from an established community-based research population, the Melbourne Collaborative Cohort Study, subjects all underwent MRI exams on the tibia bone and tibiofemoral joint of their dominant knee—the one on the leg they first step forward when walking. MRI was used to assess cartilage defects and bone marrow lesions, as well as measure cartilage volume, an indicator of cartilage health and strength. Loss of knee cartilage is linked to worsening knee symptoms in OA sufferers. Subjects also answered specific questions regarding their exercise and walking habits, as well as routine activity at home and at work, to determine their level of physical activity in both the 6 months and 7 days prior to the study. To create a baseline for each subject, past information on weight, height, body mass index, and physical activity, from questionnaires completed between 1990 and 1994, was obtained. Then, the team performed a series of analyses and comparisons.
Among the notable findings, both baseline and current vigorous physical activity— exercise that gets the heart pumping and the body sweating—were associated with an increase in tibial cartilage volume, free from cartilage defects. What’s more, tibial cartilage volume increased with frequency and duration of vigorous activity. Recent weight-bearing exercise was also linked to increased tibial cartilage volume and reduced cartilage defects. Finally, moderate physical activity, including regular walking, was associated with a lower incidence of bone marrow lesions.
“This is the first study to demonstrate a potentially beneficial effect of walking on the reduction in the risk of bone marrow lesions in the knee,” notes the study’s leading author, Dr. Flavia M. Cicuttini. “Bone marrow lesions have been associated with pain and radiograph-defined progression of osteoarthritis, type II collagen degradation, and loss of cartilage volume.”
Demonstrating a protective effect of past and current vigorous physical activity on knee cartilage in healthy adults, this study strongly supports the benefits of exercise for older individuals at risk for OA. Though both the intensity and duration of physical activity had a significant positive impact on cartilage, the ideal amount of physical activity for joint health remains unclear. “Our data suggest that at least 20 minutes once per week of activity sufficient to result in sweating or some shortness of breath might be adequate. This is similar to, if not somewhat less than, the recommendations for cardiovascular health,” Dr. Cicuttini observes.
Occupational Therapy After Stroke Helps Prevent Further Loss

GLASGOW, Scotland, Sept. 28 -- Putting stroke patients to work keeps them from deteriorating, found investigators in a meta-analysis.
Occupational therapy for stroke patients with problems managing every-day personal activities helped prevent a long downhill slide with a risk of serious deterioration and even death, according to a meta-analysis by research therapist Lynn Legg of the Glasgow Royal Infirmary University, and colleagues.
In addition, patients who received therapy to help with tasks, such as eating, dressing, grooming, and getting about, achieved a 5% improvement in handling these activities, they reported in BMJ OnLine First. Focused occupational therapy should be available to everyone who has had a stroke, they added.
"We believe that these finding should move the research agenda away from the questions surrounding whether occupational therapy as a package of interventions is effective to the identification of which specific interventions are effective for particular patients," the investigators concluded.
Previous reviews that have assessed the role of occupational therapy have not specifically focused on stroke, which is the leading cause of serious, long-term disability. Six months after a stroke approximately half of survivors are dependent on others to help them carry out everyday tasks, the researchers said.
They undertook a meta-analysis of nine randomized controlled trials with a total of 1,258 patients (mean age ranging from 55 to 87.5 years). The proportion of men ranged from 19% to 66%.
Most studies had parallel groups with occupational therapy by a qualified therapist focused on activities of daily living compared with usual care or no routine intervention.
Primary outcomes in the meta-analysis were independent of personal activities at the end of a scheduled follow-up. Secondary outcomes were death, institutionalization, extended activities necessary for maintaining a home (preparing meals, doing light housework, managing money), and quality of life for the patient and care-giver.
Occupational therapy delivered to patients after a stroke and targeted toward personal activities of daily living increased performance scores (standardized mean difference 0.18, 95% confidence interval 0.04 to 0.32, P=0.01). This amounted to a 5% difference in the Barthel index for personal activities for the group receiving occupational therapy.
However, Legg noted that the Barthel index had a ceiling effect so that once a patient reached a maximum score, there was no way to record further improvement.
Data on poor outcomes were available for 1,065 participants from seven trials and showed that for participants who received therapy the odds of a poor outcome were significantly lower.
Therapy reduced the risk of a poor outcome (death, institutionalization, deterioration, or increased dependency in managing everyday tasks) by 33% (odds ratio 0.67, confidence interval 0.51 to 0.87), the researchers reported.
The overall rate of a poor outcome for controls was 42%, which combined with an odds ratio of 0.67 for a poor outcome among treated individuals showed that for every 100 patients who received occupational therapy, 11 would be spared a poor outcome (95% CI, 7 to 30).
However, the researchers pointed out that this calculation is a relatively crude measure of outcome and does not capture potential benefits in other domains of health.
This figure also suggests that not all patients treated by an occupational therapist will benefit. Further work is required to define those individuals who are most likely to benefit, and economic studies are required to examine the cost-effectiveness of occupational therapy.
Additional analysis for death and deterioration included information on 407 participants from four trials and produced similar results (odds ratio of 0.60, CI, 0.39- 0.91, P=0.02), with no significant heterogeneity in the trials.
The study had limitations, the researcher wrote. First, the masking of therapies from patient and therapist was difficult, thus permitting the introduction of bias, particularly when the person providing the intervention was also the person doing the research, as was the case with many of these studies.
Secondly, while usual or standard care is recognized as an appropriate control, this may have included interventions that promoted activities that potentially reduced the estimate of the intervention effect.
Finally, intervention trials typically have lengthy follow-up periods with a risk of study dropout. This made doing a true intention-to-treat analysis with complex scores, such as the Barthel Index, problematic as it was difficult to score for missing participants.
Despite these potential concerns, however, the quality of the included trials was generally good, and the results were consistent among the trials, the researchers said.
No financial disclosures were reported. Staff time for this study was funded by The Big Lottery Fund and Chest Heart and Stroke Scotland.Additional source: BMJ Online FirstSource reference: Legg L, et al "Occupational therapy for patient with problems in personal activities of daily living after stroke: systematic review of randomized trials" BMJ 2007; doi:10.1136/bmj.39343.466863.55.

Saturday, September 29, 2007

CPAP Reverses Atherosclerotic Effects of Sleep Apnea

SAO PAULO, Brazil, Sept. 28 -- Treatment of obstructive sleep apnea with continuous positive airway pressure reverses early signs of atherosclerosis, researchers here found.
In a carefully controlled, randomized trial, CPAP therapy reduced carotid intima-media thickness 9% over four months and improved arterial stiffness 10% among men with severe sleep apnea reported in the first October issue of the American Journal of Respiratory and Critical Care Medicine.
These were "remarkable" changes as great as improvements seen in statin trials over six months to a year, said Luciano F. Drager, M.D., of the University of São Paulo here, and colleagues.
Furthermore, the findings provide the first solid evidence of the long-suspected causal link between sleep apnea atherosclerosis, commented T. Douglas Bradley, M.D., and Dai Yumino, M.D., both of the Center for Sleep Medicine and Circadian Biology at the University of Toronto, Canada, in an accompanying editorial.
"Because obstructive sleep apnea affects approximately 10% of the adult population," they wrote, "these results may have important public health implications for prevention of atherosclerotic diseases."
The link has been difficult to prove because the majority of sleep apnea patients have other risk factors for atherosclerosis, including obesity, hypertension, high cholesterol levels, insulin resistance, and hyperglycemia, they said.
Of the 400 consecutive men who had more than 30 apnea and hypopnea events per hour during a polysomnographic sleep test at the Brazilian center, the researchers excluded all but 24 for atherosclerosis risk factors.
The study included only treatment-naïve men 60 or younger with a body mass index no greater than 35 kg/m2 and no diabetes, hypertension, cerebrovascular or heart disease, renal failure, smoking history, or chronic use of any medication.
These participants were randomly assigned to CPAP or no treatment for four months.
On CPAP therapy, the average apnea-hypopnea index dropped to 4.5 events per hour and early vascular markers of atherosclerosis fell as well.
Carotid intima-media thickness improved significantly from baseline to four months in the CPAP group (707 versus 645 µm, P=0.04) whereas it got slightly worse in the control group (732 versus 740 µm). The overall difference between the groups was significant (P=0.02).
Arterial stiffness as measured by carotid-to-femoral artery pulse-wave velocity was unchanged in the control group (10.1 versus 10.3 m/s) but decreased significantly in all CPAP-treated patients (mean 10.4 versus 9.3 m/s, P<0.001). Again, the CPAP group improved significantly compared with controls (P<0.001).
The inflammatory marker C-reactive protein likewise improved only in the CPAP group (3.7 versus 2.0 mg/L, P=0.001, compared with 3.1 versus 3.3 mg/L for controls, P=NS) with a significant difference between groups in favor of CPAP (P<0.001).
The sympathetic activation marker catecholamine showed the same pattern of improvement in the CPAP group (365 versus 205 pg/mL, P<0.001) but not the control group (362 versus 357 pg/mL, P=NS) for an overall significant difference favoring CPAP (P<0.001).
No carotid plaque was observed in any participant, as expected because of the strict exclusion criteria. Carotid diameter did not change significantly with CPAP, likely because of the short study duration, the researchers said.
"These findings were all the more remarkable because there was no concurrent change in weight, lipid levels, or blood pressure," Drs. Bradley and Yumino said.
Early detection of atherosclerosis and subsequent therapeutic intervention can "significantly alter the natural course of cardiovascular disease," suggesting that the findings do have clinical implications, Dr. Drager and colleagues said.
However, the small sample size and highly selected patient population in the study may limit applicability of the findings, Drs. Bradley and Yumino said.
Before sleep apnea "can take its place with traditional atherogenic factors as a target for risk reduction, large-scale randomized trials that will determine whether treatment of obstructive sleep apnea prevents ischemic cardiovascular and cerebrovascular events should be undertaken," the editorialists wrote.
Therefore, it is premature to recommend apnea screening and CPAP treatment as a strategy to prevent atherosclerosis, the editorialists cautioned.
The study was supported by the Fundação de Amparo à Pesquisa do Estado de São Paulo, Conselho Nacional de Desenvolvimento Cientìfico e Tecnológico, and the E.J. Zerbini Foundation. All the CPAP machines were provided by Respironics, a manufacturer of CPAP devices.
The researchers and Dr. Bradley reported no conflicts of interest. Dr. Yumino reported receiving support from an unrestricted research fellowship from Respironics. Primary source: American Journal of Respiratory and Critical Care MedicineSource reference: Drager LF, et al "Effects of Continuous Positive Airway Pressure on Early Signs of Atherosclerosis in Obstructive Sleep Apnea" Am J Respir Crit Care Med 2007; 176: 706-712. Additional source: American Journal of Respiratory and Critical Care MedicineSource reference: Yumino D, Bradley TD "Pathogenesis of Atherosclerosis: Is Obstructive Sleep Apnea the New Kid on the Block?" Am J Respir Crit Care Med 2007; 176: 634-635.
This Time It's A Draw for Rosiglitazone (Avandia) and Pioglitazone (Actos)

BURLINGTON, Mass., Sept. 28 -- Pooled data from seven randomized trials of thiazolidinediones for type 2 diabetes confirmed a significant risk of congestive heart failure with either pioglitazone (Actos) or rosiglitazone (Avandia), but neither increased the risk of cardiovascular death.Compared with controls patients treated with either drug an a 72% increase in risk of congestive heart failure (RR 1.72, 95% CI 1.22-2.42, P=0.002), but the pooled risk for cardiovascular death was 0.91 (95% CI 0.63-1.32, P =0.063) with rosiglitazone and 1.01 (95% CI 0.51-2.01 P =0.98) with pioglitazone,
So found Rodrigo M. Lago, M.D., of the Lahey Clinic Medical Center here, and colleagues. They reported the data in the Sept. 29 issue of The Lancet.
"The pooled RR for development of congestive heart failure was 2.18 (95% CI 1.44 -3.32, P =0.0003) in the five trials of rosiglitazone, and 1.32 (1.04-1.68, P =0.02) in two studies with pioglitazone," they wrote.
The seven studies enrolled 20,191 patients who were followed for a mean of about 30 months. During that time 360 patients, including 214 who were given either rosiglitazone or pioglitazone, developed congestive heart failure. The congestive heart failure rate was 2.3% among patients treated with thiazolidinediones versus 1.4% for controls.
The estimated number-needed-to-harm for congestive heart failure was 107 across all seven studies but that number varied from 35 patients in one rosiglitazone trial to 491 to another rosiglitazone trial.
Absence of increased risk of cardiovascular mortality in the face of significant increase in the risk of congestive heart failure, suggests that thiazolidinedione-related fluid retention is more benign than other causes of heart failure, but the investigators said that hypothesis cannot be confirmed with a meta-analysis.
They noted that one trial initially found more heart failure and heart failure mortality for patients treated with pioglitazone, but subsequent analyses found that although more cases of heart failure were associated with pioglitazone than with controls, the number of primary and secondary events were similar in each group.
One interpretation of those data would be that pioglitazone-associated heart failure was indeed more benign that that caused by other factors, they wrote. But another, just as likely, interpretation was that "despite the potential for more adverse cardiovascular events associated with congestive heart failure, pioglitazone could have a cardioprotective effect compared with placebo."
The authors said their analysis was subject to all the limits of the meta-analysis methodology-reliance on aggregated data, varying definitions of heart failure, control groups that included both placebo and active treatments, and a lack of patient-specific outcome information.
Randomized trials of these two drugs is proving to be a mother-lode for data-mining researchers and this analyses is the latest in along line of meta-analyses, post-hoc analyses, and systemic reviews of the two drugs, most of which have been published in the four months since the New England Journal of Medicine published a meta-analysis of 42 trials by Cleveland Clinic investigators, which found a 43% increase in risk of myocardial infarction with rosiglitazone.
Earlier this month the Journal of the American Medical Association published a second rosiglitazone analysis that appeared to confirm the Cleveland Clinic paper along with a meta-analysis of pioglitazone studies that revealed an 18% reduction in cardiovascular mortality with pioglitazone.
A commentary and editorial in The Lancet offerred weary and wary advice about the interpreting the new paper by Dr. Lago and colleagues.
John G. F. Cleland, MD., and Stephen L. Atkin, M.D., of Castle Hill Hospital at the University of Hull in England, pointed out that although the analysis suggested that neither drug was associated with increased cardiovascular deaths "the confidence interval cannot exclude a 25% increase."
But the real problem-the elephant in the room-they wrote was that treatment should be "effective rather than merely innocuous." Both agents are most effective at improving glycemic control, but improved "glycemic control is not a surrogate for effective care of patients who have diabetes, which should be to reduce disability and increase lifespan."
The Lancet's editors pointed out shortcomings of meta-analyses. But they agreed that the reliance on surrogate markers-in this case hemoglobin A1C-"skirts the outcomes that matter most to patients-microvascular and macrovascular complications, quality of life, and survival."
The editors concluded with advice to the FDA and other regulatory agencies to demand better safety data or face the consequences, i.e. that "thiazolidinediones might simply become the latest in a series of preventable drug disasters."
Richard W. Nesto of the Lahey Clinic, senior author of the meta-analysis, disclosed financial support from GlaxoSmithKline and Takeda. No funding source was revealed for the study. Dr. Cleland disclosed support from the British Heart Foundation, GlaxoSmithKline, Roche, AstraZeneca, Pfizer, Sanofi, and Servier. Dr. Atkin disclosed support from GlaxoSmithKline, Takeda, and the British Heart Foundation. Primary source: The LancetSource reference: Lago RM "Congestive heart failure and cardiovascular death in patients with prediabetes and type 2 diabetes given thiazolidinediones: a meta-analysis of randomized clinical trials." The Lancet 2007;370:1129-36
Cleland JGF and Atkin SL "Thiazolidinediones, deadly sins, surrogates, and elephants" The Lancet 2007; 370: 1103-1104
Editorial: "Ensuring drug safety: lessons from the thiazolidinediones" The Lancet 2007; 370: 1101
Meditation therapy for rheumatoid arthritis patients

A revered contemplative practice for centuries, meditation has recently inspired research into its therapeutic value for everything from anxiety disorders to heart attack prevention. A painful, progressive autoimmune disease, rheumatoid arthritis (RA) is associated with a high risk of depression—double the risk of the healthy population, by conservative estimates—and various forms of psychological distress. Increasingly, RA patients are turning to alternative therapies like meditation to ease the toll of their disease.
Mindfulness-Based Stress Reduction (MBSR) is a meditation training program developed by Dr. Kabat-Zinn and colleagues at the University of Massachusetts Medical School. MBSR teaches participants to relate differently to thoughts and emotions, and continually focus the mind on the present moment to increase clarity and calmness. The program has been shown to improve psychological symptoms in patients with fibromyalgia, cancer, and multiple sclerosis, among other conditions. Researchers with the University of Maryland School of Medicine set out to assess the effect of this meditation therapy on depressive symptoms, psychological distress, general well-being, and disease activity among RA patients. Featured in the October 2007 issue of Arthritis Care & Research (, their study supports the potential benefits of prescribing a course in MBSR along with the conventional course of physical and pharmacological therapy.
Recruited through community health fairs and ads in Baltimore newspapers, 63 adult RA patients were selected to participate in this novel pilot study. Averaging 54 years in age, participants were mostly female, white, married, college educated, and comfortably middle-class. None had a history of psychiatric illness, alcohol or drug addiction, or other chronic pain disorders. All patients remained under their rheumatologist’s care and continued to take their routine medications throughout the study.
Through random assignment, 31 of the participants received intensive MBSR therapy, starting with an 8-week training course followed by a 4-month maintenance program. The remaining 32 participants were designated to a waitlist, agreeing to attend assessment sessions in exchange for free MBSR training after the study’s end. At baseline, and again at 2 months and 6 months into the study, both groups of participants underwent psychological and rheumatological examinations. To evaluate depressive symptoms and psychological distress, researchers used the Symptom Checklist-90-Revised, a self-report questionnaire widely recognized for its reliability and validity. Overall well-being was measured by the Psychological Well-Being Scales, comprised of questions designed to gauge positive outlook and approach to coping with difficulties. RA disease status was assessed by the Disease Activity Score in 28 joints (DAS-28).
Researchers compared scores of psychological and physical disease symptoms among MBSR participants with those among controls. Overwhelming, MBSR students embraced the program and kept up their mindfulness practice throughout the followup period. After 2 months, both groups showed improvements in depressive, psychological, and emotional symptoms, with no significant benefits attributed to MBSR. By 6 months, however, gains in the control group had largely disappeared, while MBSR participants maintained or improved further in psychological outcomes. By the culmination of the study, the MBSR group achieved a significant 35 percent reduction in psychological distress. Despite this dramatic improvement, the therapy had no impact on RA disease activity, measured by the DAS-28, which takes into account number of tender or swollen joints, a blood measure of inflammation, and the patient’s own report of disease status.
As the researchers acknowledge, the study had limitations, primarily its small sample size and its likely floor effect. On the strength of their backgrounds, participants might have been less vulnerable to psychological distress and depression than RA patients with fewer socioeconomic advantages, not to mention those with a history of mental illness or substance abuse. Yet, these limitations should not overshadow the positive findings and applications. “The study demonstrated that for patients with RA under routine medical supervision, an 8-week MBSR class plus a 4-month maintenance program had beneficial effects, and that it was safe and appealing to participants,” notes investigator Elizabeth Pradhan, PhD. “For doctors wishing to offer patients a complement to medical management, mindfulness meditation may offer hope for improving psychological distress and strengthening well-being in patients with RA.”
Antihypertensive Treatment May Help Maintain Memory

Caroline Cassels
September 27, 2007 — New research indicates antihypertensive treatment leads to increased, joint activation of brain areas responsible for memory performance — a finding that suggests such treatment may help patients maintain cognition and memory.
A study led by J. Richard Jennings, PhD, from the University of Pittsburgh, in Pennsylvania, and presented at the American Heart Association (AHA) 61st Annual Fall Conference of the Council for High Blood Pressure Research, showed patients had a 2-fold increase in the joint activation of these areas of the brain after a year of treatment with either the angiotensin-converting enzyme lisinopril or beta blocker atenolol.
While there is an established link between hypertension and mild cognitive deficits, the mechanism has not been clear. Previous research by Dr. Jennings's team used brain imaging to examine the correlation among the activation of the prefrontal areas, parietal areas, and amygdala/hippocampus in hypertensives compared with controls and found it was higher in individuals with high blood pressure.
Increased Correlation
"In the first study, we found that in hypertensive individuals the correlation between levels of activation of these areas of the brain was 0.61. Our next question was, If we successfully treated these individuals [for hypertension], would this finding be reversed and would their brain function look more like normotensives?" Dr. Jennings told Medscape Neurology & Neurosurgery.
"To our surprise, we found that rather than decreasing, the correlation increased to 0.90. Thus, these areas of the brain were nearly always activated at the same level, suggesting there was less specificity, which means that instead of each area doing its own specific job, they were all working at the same time to try to solve the [memory] task," he added.
The study included 28 never-medicated hypertensives, randomized to receive treatment with lisinopril or atenolol for 1 year. All patients underwent psychological and physiological tests, magnetic resonance structural imaging, and positron emission tomography.
Pretreatment correlation of parietal and prefrontal change was 0.61 vs 0.94 after treatment. According to the investigators, similar differences were observed for all areas, with an average pretreatment correlation of 0.66 vs an average posttreatment correlation of 0.91.
Mental Fatigue?
These findings, said Dr. Jennings, suggest hypertensive patients' brains adapt to maintain their intellectual function and that antihypertensive treatment appears to maintain or even augment this adjustment.
At this point, said Dr. Jennings, it is not clear whether there is a "cost" associated with the brain's adaptation to hypertension. "It could mean that [in patients with hypertension] the brain has to work harder, and this could result in mental fatigue, but at this point we just don't know," he said.
This question, he added, will be the focus of future research. In addition, he said, the investigators also want to look at different types of antihypertensive treatments to determine whether they have effects similar to the 2 agents studied in the current work.
According to AHA president Daniel Jones, MD, this study provides reassurance to individuals concerned about potential adverse cognitive effects of antihypertensive treatment. "Treating hypertension is beneficial not only for extending life, but also for improving quality of life," he said in a statement.
The study was funded by the National Heart, Lung, and Blood Institute of the National Institutes of Health.
American Heart Association 61st Annual Fall Conference of the Council for High Blood Pressure Research: Abstract P105. Presented September 27, 2007.