Saturday, May 31, 2008

Death of spouse ups odds of nursing home care

By Megan Rauscher

31 may 2008--An older person's likelihood of entering a nursing home or other long-term care facility is particularly high immediately after the death of a spouse, new research indicates.
There could be various reasons for this, Elina Nihtila, of the department of sociology at the University of Helsinki, Finland, who led the research, told Reuters Health.
"It may be related to the loss of social and instrumental support, in the form of care and help with daily activities such as help in cooking, cleaning, and shopping formerly shared with the deceased spouse," Nihtila said.
"Second, grief and spousal loss may cause various symptoms, such as depression and anxiety, loss of appetite, sleep disturbances, fatigue and loss of concentration that could increase the need for institutional care." She added. "Furthermore, grief may cause increased susceptibility to physical diseases."
The research team analyzed how the death of a spouse affects the likelihood of entering institutionalized care among nearly 141,000 Finnish adults aged 65 and older. All of them were living with a spouse at the beginning of the study and were followed for five years.
"The data were unique in that they covered a large number of persons bereaved during the follow-up and gave the dates of bereavement and of first admission into institutional care," Nihtila and colleagues explain in the American Journal of Public Health.
Results showed that the risk of entering long-term institutional care was higher among older adults who had lost their spouse than among those living with their spouse. "The excess risk of institutionalization was highest during the first month after the spouse's death -- more than three times higher among both men and women -- and decreased with time from bereavement, stabilizing at approximately 20% to 50% higher over 1 to 5 years," Nihtila noted.
The researcher thinks home help services "should be targeted to the bereaved immediately after a spouse's death to reduce the need for institutional care."
SOURCE: American Journal of Public Health, July 2008 (online May 29, 2008).
Airborne Fine Particulate Matter Linked to Stroke Risk

By Todd Neale
ANN ARBOR, Mich., 31 may 2008Even low levels of airborne fine particulate matter appear to be associated with an increased risk of cerebrovascular events, researchers found.Levels of particulate matter in a southeast Texas county were associated with "borderline significant" increases in the risk of ischemic stroke and transient ischemic attack, Lewis Morgenstern, M.D., of the University of Michigan, and colleagues reported online in the Annals of Neurology.When levels of fine particulate matter rose by 5.1 mg/m3 the risk of suffering one of the events increased by 3% that day (RR 1.03, 95% CI 0.99 to 1.07) and the day after (RR 1.03, 95% CI 1.00 to 1.07).
"Although the magnitude of increased risk for stroke/[transient ischemic attack] because of [particulate matter] exposure was relatively small," the researchers said, "most of the public is exposed to ambient air pollution at the levels observed in this community or greater every day, suggesting a potentially large public health impact."
The median particulate matter level was 7.0 mg/m3, less than half the standard set by the Environmental Protection Agency (15 mg/m3).
The results, therefore, "call into question current standards for fine particulate matter and whether these standards are sufficient to protect the public from stroke," the researchers said.
Past studies have found a link between air pollution and cardiovascular disease in general but data on the association with stroke have been more limited, the researchers said.
Fine particulate matter -- a diameter less than 2.5 mm -- can penetrate airways and alveoli and enter the circulation because of its smaller size and chemical activity, they said.
The particles may raise the risk for cerebrovascular events by inducing arterial vasoconstriction or acute increases in blood pressure and plasma viscosity, they said.
To explore the issue, Dr. Morgenstern and colleagues turned to the Brain Attack Surveillance in Corpus Christi Project, which is designed to capture all strokes in Nueces County, Tex. There are a large number of oil refineries, chemical plants, and other sources of particulate matter pollution in this area.
Nevertheless, the level of particulate matter during the study was low, most likely because of the prevailing winds and coastal location, they said.
Air pollution and meteorological data were obtained from the Texas Commission on Environmental Quality.
From Jan. 1, 2001 through Dec. 31, 2005, the researchers identified 2,350 ischemic strokes and 1,158 transient ischemic attacks in patients ages 45 and older (median age 72). Half of the patients were Mexican-American, 44% were white, and 5% were African American.
The increased risk of suffering a stroke or transient ischemic attack was independent of ozone levels after accounting for temperature, day of the week, and temporal trends in cerebrovascular events.
Season did not modify the association.
"These data contribute to the literature because there is currently a scarcity of data on the effect of environmental exposures on risk for stroke in the United States," the researchers said.
Future studies on the effects of particulate air pollution on the risk for subtypes of ischemic stroke could reveal the biological mechanisms at work, they said.
The authors acknowledged some limitations to the study, including the fact that, as an ecological study, it should be used primarily for generating hypotheses. The results should be replicated, they said, and future studies should take into account any unmeasured confounders.
In addition, measurement of particulate matter is subject to error. The values obtained in this study may not be generalizable over a wider geographic area, they said.
Finally, they said, residual confounding by other pollutants may have occurred.
The study was funded by a grant from the National Institute of Neurological Disorders and Stroke.
The authors made no disclosures.
Primary source: Annals of NeurologySource reference:Lisabeth L, et al "Ambient air pollution and risk for ischemic stroke and transient ischemic attack" Ann Neurol 2008; DOI: 10.1002/ana.21403.
Gene variant worsens chances for women with breast cancer

31 may 2008--European doctors said Friday they had identified a genetic characteristic that strongly worsens survival chances for women with breast cancer who are treated with a common form of chemotherapy.
The telltale sign is a variant of a gene called NQO1, which in its normal form produces an enzyme that protects cells against oxidative stress -- a key factor in the spread of cancer.
The variant of NQ01, called NQ01*2, stops production of this protective enzyme. It is present in between four and 20 percent of the world's population, with a preponderance in Asia, according to figures presented in the study.
The researchers -- led by Heli Nevanlinna of the University of Helsinki and Jiri Bartek, a Czech scientist with the Danish Cancer Society -- found that women who had a double copy of NQ01*2 in their genome had only a 17-percent survival rate when treated with an anthracyclin-based chemotherapy.
Those who had only a single copy of NQ01*2, or did not have the variant at all, had a survival rate of 75 percent.
The paper, published online by the specialised British journal Nature Genetics, is based on DNA data from more than 2,000 Finnish women treated for breast cancer.
SAEM: AHA Guidelines for Cardiac Arrest Treatment Increase Survival

By Todd Neale
WASHINGTON, 31 may 2008-- The rate of resuscitation after out-of-hospital cardiac arrests jumped nearly four-fold when new guidelines on CPR were fully implemented in a North Carolina county, according to researchers here.The 2005 American Heart Association guidelines outlined a protocol calling for simple, continuous chest compressions, controlled ventilation, and early use of induced hypothermia.When the guidelines were fully implemented in Wake County, which has urban and suburban areas and a population of about 815,000, cardiac arrest survival increased 3.99-fold (95% CI 2.19 to 7.27), Brent Myers, M.D., M.P.H., medical director of the Emergency Medical Services System in Raleigh, N.C., reported at the Society for Academic Emergency Medicine meeting here.
Overall survival increased from 2.4% using older guidelines to 6.7% after introduction of the full 2005 AHA protocol.
He said that "the neurologic improvement was at least as robust as the survival improvement."
The entire protocol was introduced for less than $200 per patient, he said.
"All of these changes are simple, they are inexpensive, and they are incredibly effective," he said. From January 2004 through October 2007, there were 2,594 out-of-hospital cardiac arrests in patients ages 15 and older (mean age 65; 58% male).
More than a third (36%) were witnessed and received CPR from a bystander before emergency medical services arrived and 26% had ventricular fibrillation/ventricular tachycardia rhythm.
From January 2004 through April 2005, the emergency medical services system followed the older AHA guidelines, which mandated a 15:2 compression-to-ventilation ratio without a focus on interruption of compressions and with an emphasis on intubation.
Survival rates during this period were 2.4% overall and 12.1% for patients with ventricular fibrillation-ventricular tachycardia rhythm.
In April 2005 the system started following the new recommendation for continuous cardiac compression with a 30:2 compression-to-ventilation ratio with minimal interruption. After 12 months, the survival rates had increased to 4% overall and 21.8% for patients with ventricular fibrillation-ventricular tachycardia rhythm.
In April 2006, use of an impedance threshold device, a ResQPod, was introduced to better control ventilation and avoid over-ventilation. The device also helps improve the effectiveness of chest compression by enhancing blood flow to the coronary arteries.
This change was associated with another rise in survival -- 4.5% overall and 28.5% for patients with ventricular fibrillation-ventricular tachycardia rhythm.
Six months later, the system began early induction of hypothermia, the final stage of the protocol. Ice packs and chilled IV fluids were applied within two to three minutes of receiving a pulse and after the patient was found to be unresponsive neurologically.
Survival rates after a year of following the entire protocol were 6.7% overall and 37.4% for patients with ventricular fibrillation-ventricular tachycardia rhythm.
The odds of overall survival increased three-fold (95% CI 1.7 to 5.0) and the odds of survival for patients with ventricular fibrillation-ventricular tachycardia rhythm rose 4.3-fold (95% CI 2.2 to 8.6) from the beginning of the study.
In a multivariate analysis, the odds ratios for survival for each phase of implementation were as follows:
New CPR protocol: 2.13 (95% CI 1.12 to 4.04)
Addition of impedance threshold device: 2.33 (95% CI 1.09 to 5.00)
Addition of early hypothermia: 3.99 (95% CI 2.19 to 7.27)
Patients who received CPR from a bystander were 1.79-fold (95% CI 1.18 to 2.72) more likely to survive.
Dr. Myers defended the decision not to conduct a randomized trial, saying it would be unethical to do so.
"We felt that at each stage the evidence was so compelling to do what we were doing that we shouldn't randomize," he said.
He concluded, "Our findings not only demonstrate beneficial outcomes for victims of cardiac arrest, but also suggest the possibility that such treatment plans can be implemented for other medical conditions."
Dr. Myers and one of his co-authors are on the speaker's bureau for Alsius.
Primary source: Society for Academic Emergency MedicineSource reference:Hinchey P, et al "Out-of-hospital cardiac arrest survival after the sequential implementation of 2005 AHA guidelines for compressions, ventilations, and induced hypothermia" SAEM Meeting 2008; Abstract 167.
Nonalcoholic Fatty Liver Linked to Kidney Disease in Diabetic Patients

By Judith Groch
VERONA, 31 may 2008-- For patients with type 2 diabetes, non-alcoholic fatty livers may lead to chronic kidney disease, an observational study found.
The risk for chronic kidney disease was 69% higher for diabetic patients with non-alcoholic fatty liver disease than for diabetic patients without the liver disorder, Giovanni Targher, M.D., of the University of Verona, and colleagues here and at the University of Colorado reported online in the Journal of the American Society of Nephrology.
Non-alcoholic fatty liver prevalence has been estimated to be in the 15% to 30% range in the general population in various countries and appears to be increasing, the researchers said. However, there has been little information about the association between the fatty liver disease and the risk of developing diabetic nephropathy.
Treating earlier stages of nephropathy in diabetic patients could slow the progression of the kidney disorder to end-stage renal disease. Thus, early detection of precursors and risk factors for chronic kidney disease is very important, Dr. Targher and colleagues wrote.
Their study included 1,760 outpatients with type 2 diabetes and normal or near-normal kidney function and without overt proteinuria.
Patients were followed for 6.5 years (through December 2006) for the occurrence of chronic kidney disease (overt proteinuria and/or estimated GFR< 60 ml/min per 1.73 m2).
The participants were recruited from the Valpolicella Heart Diabetes Study cohort, a prospective observational study to evaluate associations between diabetes and chronic vascular complications.
Patients with other common causes of fatty liver, such as alcohol abuse, chronic viral hepatitis, and use of potentially liver-toxic medications were excluded.
During follow-up, 547 participants developed incident chronic kidney disease, with a yearly risk of about 4.5%, the researchers said.
Nonalcoholic fatty liver disease, diagnosed by liver ultrasound and exclusion of other common causes of chronic liver disease, was associated with a moderately increased risk for the kidney disorder (hazard ratio 1.69, 95% confidence interval 1.3 to 2.6, P<0.001).
Adjustments for gender, age, BMI, waist circumference, blood pressure, smoking, diabetes duration, glycosylated hemoglobin, lipids, baseline estimated GFR, microalbuminuria, and medications (hypoglycemic, lipid-lowering, antihypertensive, or antiplatelet drugs) did not appreciably attenuate this association (HR 1.49, 95% CI 1.1 to 2.2, P < 0.01).
The annual cumulative incidence of 4.5% per year was comparable to that previously described in other Italian and European populations with diabetes and similar baseline characteristics.
The underlying biologic mechanisms by which fatty liver disease may increase the risk for chronic kidney disease in type 2 diabetes are poorly understood, the investigators said. The most obvious explanation is that the findings simply reflect the coexistence of underlying known risk factors.
However, they said, the findings were independent of numerous baseline risk factors, so that it is conceivable that nonalcoholic fatty liver may confer an excess risk beyond these known risk factors and that fatty liver itself in diabetic patients may be involved in the pathogenesis of chronic kidney disease.
The possible molecular mediators may include the release of some pathogenic factors from the liver, including elevated advanced glycosylated end products, increased reactive oxygen species, elevated C-reactive protein, TNF-α, TGF-β1, and other proinflammatory cytokines.
Importantly, several studies have shown that these potential mediators of vascular and/or renal injury are remarkably higher in diabetic or obese patients with fatty liver disease and are thought to be pathogenic factors for the progression of chronic kidney disease.
In addition, they said, the liver disease may worsen whole-body insulin resistance and hyperglycemia, which may in turn contribute to the progression of kidney disease. This was supported by the observation in this study that HbA1c was higher in patients with fatty liver than in those without it.
Study limitations included the use of an estimated GFR to define chronic kidney disease. Also, the fatty liver diagnosis was based on ultrasound diagnosis and exclusion of secondary causes of chronic liver disease but was not confirmed by biopsy. Whether these observations can be extended to nonwhite patients and other ethnic groups remains to be determined.
It is not known whether treating fatty liver disease will ultimately prevent progression to chronic kidney disease, the researchers said.
However, they wrote, it is notable that interventions effective in preventing or delaying the progression to chronic kidney disease in patients with diabetes, such as weight reduction or treatment with angiotensin receptor blockers or insulin-sensitizing agent, may also be effective for fatty liver disease.
Further prospective studies are required to confirm the reproducibility of these results and whether the findings can be extended to nonwhite ethnic groups, they concluded.
No financial conflicts were reported.
Primary source: Journal of the American Society of NephrologySource reference:Targher G, et al "Increased risk of CKD among type 2 diabetics with nonalcoholic fatty liver disease" J Am Soc Nephrol 2008; DOI: 10.1681/ASN.2007101155.

Friday, May 30, 2008

Brazil approves stem cell research

30 may 2008--Brazil's Supreme Court ruled Thursday that scientists can conduct embryonic stem cell research, which holds the promise of curing Parkinson's disease and diabetes but raises ethical concerns about the limits on human life.
Six of the court's 11 justices upheld a 2005 law allowing embryonic stem cell research and turned down a petition filed that same year by then-Attorney General Claudio Fontelles, who argued the law was unconstitutional because it violates the right to life.
The remaining five judges argued that while the 2005 law is constitutional, research should only be carried out "with restrictions" such as not allowing the embryo to be destroyed and submitting each case for the approval of an ethics commission.
The law opens the way for research with embryos resulting from in-vitro fertilization that have been frozen for at least three years.
Advocates have said that a favorable Supreme Court ruling could make Brazil Latin America's leader in stem cell research.
They praise Brazilian scientists for their work with adult stem cells for the treatment of cardiovascular diseases and Type 1 diabetes, and have said that similar breakthroughs could be achieved with embryonic stem cells.
But the court's decision drew immediate fire from the National Conference of Brazilian Bishops, which said it "regretted" the ruling, comparing it to a death sentence.
In a statement, the bishops' conference said its position "is not a matter of religion, but of the defense of human life, beginning with conception."
Church leaders in the world's largest Roman Catholic country have said they support adult stem cell research, which they describe as "ethically acceptable."
Adult stem cells, which are harvested without destroying an embryo, can be used to recuperate damaged tissue. But scientists say they are less flexible than embryonic stem cells, which can develop into different types of cells.
Socially Active Seniors Stay Sharp

By Crystal Phend
BOSTON, 30 may 2008-- Frequent interaction with family and friends, volunteering, and other social activities may delay age-related memory loss, researchers found.Memory declined twice as fast among adults 50 and older who were least socially active as it did among those with the most social contact, Lisa F. Berkman, Ph.D., of the Harvard School of Public Health, and colleagues reported in online in the American Journal of Public Health.These results of a large observational study "suggest that increasing social integration may be an important component of efforts to protect older Americans from memory decline," they wrote.
But it's not clear whether this effect reflects a lifetime of mentally-stimulating interaction rather than current contact, which could be boosted to potentially reduce memory loss, noted Karen A. Ertel, Sc.D., of the Harvard School of Public Health and a co-author on the paper.
Because previous studies have linked social ties to incidence of dementia and Alzheimer's disease, Dr. Berkman's group looked at the effect on memory among 16,638 men and women 50 and older who were followed longitudinally in the nationally representative Health and Retirement Study.
Biennial interviews in the study included immediate- and delayed-recall memory tests used to monitor memory loss over six years in the study.
About half of the participants reported current social interaction in three or more areas, including marriage, volunteer activity, and at least weekly contact with children, parents, or neighbors.
Memory scores at baseline in 1998 were similar between highly socially active participants and those with lower levels of social activity.
Thereafter, though, memory declined faster among those with low social scores. Memory scores declined 0.32 points per year on average with an additional 0.04-point-per-year decrease for each decrease in number of types of social interaction reported (P<0.01).
After adjustment for health status and other predictors of memory decline, older adults with the lowest levels of social interaction were predicted to average a 0.29-point decline in memory score per year compared with a 0.14-point per year decline for those with social contact in all five areas.
Each individual component of social integration showed the same significant pattern of slower memory decline for those with more social contact. Analysis by gender, education, and presence of a vascular disorder likewise showed a protective effect of socialization.
The effect of social integration "may be particularly important" for individuals with less than a high school education, who had "a particularly precipitous" decline in memory score of about one point every 3 years.
"These results suggest that low social integration puts people at risk of accelerated memory loss," the researchers said, "but it is also possible that our results were attributable to reverse causation (i.e., poor memory or memory decline causing social withdrawal)."
However, Dr. Berkman's group found no evidence of reverse causation. Exclusion of participants who may have already had some memory loss at baseline as indicated by a memory score below the 25th percentile yielded results similar to those of the overall cohort.
Likewise, memory scores among a subgroup of participants enrolled in the study in 1993 explained less than 1% of variability in social integration in 1998.
"Declines in cognitive function before baseline were unlikely to explain the observed longitudinal association," the researchers wrote.
Rather, the mechanisms may include an effect on physical health, particularly diabetes and other vascular conditions implicated in other studies in development of dementia, they speculated. "Social ties may create pressure, either through explicit reminders or implicit behavioral norms, to take care of oneself."
Other possible mechanisms might be presenting complex cognitive and memory challenges that enhance cognitive reserve and resilience or through direct neurohormonal benefits by providing a sense of purpose and emotional validation, the investigators said.
They cautioned, though, that the study was limited by its nonrandomized design, lack of inclusion of all possible types of social connections and information on quality of social contacts, and low level of data on health status.
The study was funded by the National Institute of Aging. The researchers reported no conflicts of interest.
Primary source: Journal of Public HealthSource reference:Ertel KA, et al "Effects of social integration on preserving memory function in a nationally representative US elderly population" J Public Health 2008; 98.
Mediterranean Diet May Protect Against Diabetes

By Judith Groch
PAMPLONA, Spain, 30 may 2008Strict adherence to a traditional Mediterranean diet yielded an 83% relative reduction in the risk of developing type 2 diabetes, a prospective study found.
Even moderate adherence was associated with a 59% relative reduction in diabetes risk, Miguel Martínez-González, M.D., Ph.D., of the University of Navarra here, and colleagues reported online in BMJ.
Many studies have shown that the Mediterranean diet has a protective role in cardiovascular disease, but little is known about its role in preventing diabetes in healthy people, the researchers said.
Typically, the diet is characterized by high intake of fiber and vegetable fat, low intake of trans-fatty acids and saturated fats, and a moderate intake of alcohol.
It also makes abundant use of olive oil for cooking, frying, spreading on bread, or in dressing salads, which leads to a high ratio of monounsaturated fatty acids to saturated fatty acids.
Fruits, nuts, grains, legumes, and fish are also featured, whereas consumption of meat and dairy products is relatively low.
In addition to having a long tradition of use without evidence of harm, a Mediterranean diet is highly palatable, and people are likely to comply with it, the researchers said.
Diets rich in monounsaturated fatty acids improve lipid profiles as well as insulin resistance and glycemic control in people with diabetes, they wrote. This suggested that following a Mediterranean diet might protect against developing diabetes.
To find out, the researchers conducted the SUN (Seguimiento Universidad de Navarra) prospective cohort study, which included 13,380 university graduates and registered nurses from Spanish provinces. None had diabetes at baseline. Participants were followed for a median 4.4 years.
Dietary habits were assessed at baseline with a validated 136-item food frequency questionnaire and were scored on a nine-point index.
New cases of diabetes were confirmed through medical reports and an additional detailed questionnaire posted to those who
reported a new diagnosis of diabetes by a doctor during follow-up. The main outcome was confirmed cases of type 2 diabetes.
Participants who adhered closely to a Mediterranean diet had a lower risk of diabetes, the researchers found.
The incidence rate ratio adjusted for sex and age was 0.41 (95% CI 0.19 to 0.87) for those with moderate adherence (score 3-6) compared with those with low adherence (score <3).
For those with the highest adherence, scoring 7 to 9, the rate ratio was 0.17 (95% CI 0.04 to 0.75).
In the fully adjusted analyses, the results were similar. A two-point increase in the score was associated with a 35% relative
reduction in the risk of diabetes (incidence rate ratio 0.65,
95% CI 0.44 to 0.95), with a significant inverse linear trend (P=0.04) in the multivariate analysis.
Interestingly, the researchers said, those with high adherence to the diet (score > 6) also had a higher baseline prevalence of most risk factors for diabetes. They were older, had a higher BMI, a higher total energy intake, were more likely to have high blood pressure or a family history of diabetes, and were more likely to be former smokers.
These individuals would have been expected to be at greater risk for diabetes, but actually their risk was lower. It is possible that the diet may have provided substantial protection, the researchers wrote.
Study limitations included a small number of cases of diabetes despite extended follow-up over four years. Also, diabetes might have been underreported despite participants' high educational level and easy access to medical care (half were health professionals).
Because the participants were university graduates the findings may not be generalizable to groups with less education, the researchers said. Another possible caveat might have been the quality of the food frequency questionnaires, which are known to have a certain degree of measurement error.
Finally, the investigators said, a potential limitation, inherent in every observational study, is the possibility of confounding by unmeasured or unrecorded factors.
The study suggests that substantial protection against diabetes can be achieved by following the traditional Mediterranean diet, they said.
However, the limited number of cases of diabetes and the possibility of underreporting require that further larger cohorts and trials are needed to confirm these findings, the investigators concluded.
The study was funded by the Spanish Ministry of Health and the Navarra Regional Government (Department of Health).
No competing interests were declared.
Primary source: BMJSource reference:Martínez-González MA, et al "Adherence to Mediterranean diet and risk of developing diabetes: A prospective cohort study" BMJ 2008: DOI:10.1136/bmj.39561.501007.BE.
Gender Gap for Obesity and Osteoarthritis-Caused Hip Replacement

By Judith Groch
LUND, Sweden, 30 may 2008-- A high body mass index increases the risk of osteoarthritis-caused hip arthroplasty for men but not for women, according to a case-control study here.
However, both men and women who were overweight were likelier to need knee-replacement surgery, and the heavier they were, the greater the risk, Jonas Franklin, M.D., of Lund University and colleagues reported on line in the Annals of Rheumatic Diseases.
Studies have shown that a high BMI precedes knee osteoarthritis, but the relationship between high BMI and hip osteoarthritis has been less well defined, the researchers said.
The investigators compared 1,473 Icelandic men and women who'd had hip or knee replacement before the end of 2002 with 1,103 individuals who did not have joint replacement.
First-degree relatives of participating patients served as controls, while a randomly selected sample, representative of the Icelandic population, was used as a secondary control group.
Among the 1,473 patients, 872 were women, while among 1,103 controls, 599 were women, all born from 1910 through 1939. Participants had answered a questionnaire that included height and weight.
Adjusted for age, occupation, and presence of hand osteoarthritis, the odds ratio (OR) for having a total hip replacement was 1.1 (95% CI 0.9 to 1.5) for overweight men (BMI 25-30) and 70% greater for obese men (BMI>30), (OR 1.7 CI 1.0 to 2.9).
However, women who were overweight (BMI 25-30) or obese (BMI>30) were no more likely to need a new hip than normal-weight women. The OR for having a total hip was 1.0 (CI 0.8 to 1.3) for overweight women and 1.0 (CI 0.6 to 1.5) for obese women.
Being overweight or obese were factors in requiring knee arthroplasty for both men and women, the researchers reported.
Overweight men were 70% more likely to need total knee replacement (OR 1.7, CI 1.1 to 2.6), while the risk for obese men was more than five times higher (OR 5.3, CI 2.8 to 10.1).
Overweight women were 60% more likely to need knee replacement (OR 1.6, 95% CI 1.1 to 2.2), while obese women were four times more likely to need a new knee joint (OR 4.0, 95% CI 2.6 to 6.1).
For the knee, this study corroborates conclusions from earlier studies, the investigators said. For the hip, they added, some studies have claimed a positive relationship; others say not so. This study suggests that both may be right with a risk for men but not for women.
There may be anatomical, mechanical, and biochemical reasons for the different effects of high BMI on hip and knee osteoarthritis, the investigators said.
For example, it has been proposed that the gender differences for the effect of weight on the knee are caused by a difference in anatomical structure. Joint alignment and BMI may interact as risk factors for the knee, whereas such interactions may not be present for the hip joint.
Study limitations included voluntary participation so that non-participants may have differed from the study group. Because high BMI correlates with higher mortality, the results may have been influenced toward the null. However, this was not so in women's hip osteoarthritis where BMI was similar to that of the controls.
In addition, height and weight were self-estimated and many high-risk obese patients may never have been offered joint replacement.
Although the BMI of the controls was more like that of the cases than would be expected, such a bias would have a similar effect on men and women, which does not explain the weaker association for women and hip replacement, the researchers said. The fact that primary controls were relatives of the patients and secondary controls were from the general population probably contributed to the correlation of BMI among patients and controls.
This study supports a positive association between high BMI and total knee replacement in both sexes, but the association for hip replacement and BMI seems to be weaker, and possibly negligible for women, the investigators concluded.
No competing interests were reported. This study was supported by the Scientific Foundation of Akureyri Central Hospital, The Swedish Research Council (medicine), Lund Medical Faculty and University Hospital, the King Gustaf V 80-year Fund, The Swedish Rheumatism Association, and the Kock Foundations.
Primary source: Annals of Rheumatic DiseasesSource reference:Franklin J, et al "Sex differences in the association between body mass index and total hip or knee joint replacement resulting from osteoarthritis" Ann Rheum Dis 2008; DOI: 10.1136/ard.2007.086868.
Coronary CT Angiograms Show Diagnostic Promise

By Michael Smith
WASHINGTON, 30 may 2008 -- In patients with potential acute coronary syndromes, a negative CT angiogram means they can be sent home safely, a researcher said here.That finding comes from a study of patients considered to be at low risk for heart attack who were treated in a hospital emergency department for chest pain, Anne Marie Chang, M.D., of the University of Pennsylvania, reported at the Society for Academic Emergency Medicine meeting.Dr. Chang and colleagues assigned the patients to either an immediate coronary computerized tomographic angiography or to CT angiography after a nine- to 12-hour observation period that included tests for coronary biomarkers, Dr. Chang said.
The bottom line, Dr. Chang said, is that patients whose coronary [CT angiography] is negative are not at risk for cardiovascular death or MI.
"We have shown in our clinical practice," she said, "that if they have a negative [CT angiogram], you should be able to safely send patients home."
The procedure has "excellent performance characteristics" when it's compared to standard coronary angiography, as well as to exercise or pharmacological stress tests.
But it remained unclear if doctors can use the method to stratify low-risk patients, Dr. Chang reported, where low-risk is defined as a Thrombolysis in Myocardial Infarction (TIMI) score of less than two.
To try to answer the question, she and colleagues conducted a prospective evaluation of 568 consecutive patients, with 285 in the immediate CT angiography arm and 283 in the observation-first arm.
Patients with negative tests were sent home. The main outcome was cardiovascular death or myocardial infarction within 30 days, Dr. Chang said.
All told, 476 patients (84%) had a negative coronary CT angiogram and were sent home.
During the 30-day follow-up period, none of them died of a cardiovascular event or had a nonfatal MI, she said, implying that the negative scan is sufficient to rule out any danger.
The study was one of two evaluating aspects of coronary CT angiography presented by Dr. Chang.
The other was a retrospective look at four strategies for evaluating low-risk patients after a doctor determined they should be admitted and tested to rule out acute coronary syndrome.
The four strategies were:
Immediate coronary CT angiography in the emergency room for 98 patients, without serial cardiac biomarkers.
Coronary CT angiography and clinical decision unit evaluation with serial cardiac biomarkers for 102 patients.
Clinical decision unit evaluation with serial cardiac biomarkers and stress testing, for 154 patients.
Usual care, defined as admission with serial cardiac biomarkers and hospitalist-directed evaluation, for 289 patients.
The outcomes were actual cost of care, length of stay, diagnosis of coronary disease, and cardiovascular death or MI within 30 days, Dr. Chang said.
Analysis found that the median cost for immediate CT angiography was $1,240 compared with $2,318 for clinical decision unit evaluation with CT angiography, $4,024 for clinical decision unit evaluation and stress testing, and $2, 913 for usual care. The differences were significant at P<0.01, Dr. Chang reported.
Length of stay was 8.1 hours for immediate CT angiography, compared with 20.9 hours for clinical decision unit evaluation with CT angiography, 26.2 for clinical decision unit evaluation and stress testing, and 30.2 for usual care. The differences were, again, significant at P<0.01.
The rate of diagnosis of coronary disease was similar in all four arms, ranging from 5.1% to 6.6%.
However, there were no cardiovascular deaths or MIs within 30 days in the immediate CT angiography arm, compared with 0% and 3.2% for clinical decision unit evaluation with CT angiography, 0.7% and 2.3% for clinical decision unit evaluation and stress testing, and 3.1% and 12.2% for usual care. The differences were significant at P=0.04 for cardiovascular death and P<0.01 for MI.
The cohorts for the two studies overlapped, Dr. Chang said, with some of the patients in the prospective analysis also used in the cost-benefit analysis.
The retrospective study had support from Siemens. There was no external support for the prospective study. Dr. Chang said she had no potential conflicts.
Primary source: Society for Academic Emergency Medicine meetingSource reference:Chang AM, et al "Coronary computerized tomography for rapid discharge of low risk patients with potential acute coronary syndromes" SAEM Meeting 2008; Abstract 11. Additional source: Society for Academic Emergency Medicine meetingSource reference: Chang AM, et al "Actual financial comparison of four strategies to evaluate patients with potential acute coronary syndromes" SAEM Meeting 2008; Abstract 12.

Thursday, May 29, 2008

Very elderly fare well after planned surgery

29 may 2008--Many very old people who have undergone planned surgery are doing well years later, but elderly individuals requiring unplanned surgery or intensive care unit (ICU) treatment for medical reasons are far less likely to survive, Dutch researchers report.
Elderly ICU patients may not be given life-saving therapy, due to concerns that such treatments are "overly burdensome and not necessarily beneficial," Dr. Sophia E. J. A. de Rooij and colleagues from Academic Medical Center in Amsterdam write. However, they add, such decisions should be made based on both the anticipated benefits and patients' preferences, not just their age.
To examine how well older patients actually do after spending time in an ICU after surgery or for medical reasons, de Rooij and her team looked at 204 surviving patients from a group of 578 who had been admitted to a medical-surgical ICU between 1997 and 2002.
The patients' average age upon admission was about 82. All were alive in December 2003, and they were followed up 3.7 years after they had been discharged.
Fifty-seven percent of those who had undergone planned surgery were still alive, while just 11 percent of those who had emergency surgery and 10 percent requiring medical ICU treatment had survived, the team reports in the Journal of the American Geriatrics Society.
Among the patients who lived at home when they were admitted to an ICU, 74.3 percent were still living independently at follow-up. Just 17 percent of all of the surviving patients had severe cognitive impairment, while 24 percent had severe functional impairment.
"These results do not suggest that all very elderly ICU patients have a good prognosis," the researchers write, noting that most patients admitted to the hospital for unplanned surgery or medical ICU treatment survive for just one month.
Nevertheless, they add, the long-term health-related quality of life for the patients who had planned surgery was virtually equal to that of an age-matched group from the general population.
SOURCE: Journal of the American Geriatrics Society, May 2008.
AUA: Studies Link Cholesterol to Prostate Cancer Recurrence

By Charles Bankhead
ORLANDO, 29 may 2008-- Controlling serum cholesterol may help reduce the risk of prostate cancer as well as heart disease, two studies reported here suggest.
Men with the highest cholesterol levels had more than a two-fold greater risk of biochemical relapse after radical prostatectomy compared with men who had the lowest cholesterol levels, Lionel L. Banez, M.D., of Duke University, reported at the American Urological Association meeting.
"These findings suggest that cholesterol may play a role in prostate cancer progression," said Dr. Banez. "Cholesterol-lowering drugs, such as statins, should be investigated for a possible role in the treatment of prostate cancer."
A second study, presented by Robert J. Hamilton, M.D., of the University of Toronto, showed a correlation between higher cholesterol levels and higher PSA values.
Those findings support previous evidence that men treated with statin drugs to lower their cholesterol levels also had reductions in PSA levels, Dr. Hamilton said.
Dr. Banez and colleagues analyzed data from 471 men who underwent radical prostatectomy from 1998 through 2007. Lipid profile and prior exposure to statin therapy was available for all of the participants. The multivariate analysis controlled for variations in prostate cancer features and history of statin therapy.
The researchers found that higher cholesterol levels and higher levels of LDL predicted an increased risk of biochemical relapse (P=0.001, P=0.007).
HDL was not associated with recurrence risk.
Men in the highest cholesterol quartile (≥217 mg/dL) had a 2.5 times greater risk of relapse compared with men in the lowest quartile (<167 mg/dL) with a hazard ratio of 2.49, 95% CI 1.28 to 4.86, P=0.007.
The intermediate quartiles were not associated with recurrence risk.
How cholesterol might influence prostate cancer risk is unclear, said Dr. Banez. However, he pointed out that cholesterol is a precursor to testosterone, which fuels prostate growth and function.
Another mechanistic explanation posits that cholesterol interferes with signal transduction associated with normal cell growth, he said.
Dr. Hamilton and colleagues did a longitudinal study involving 1,214 men prescribed a statin from 1990 through 2006. At baseline the men were free of prostate cancer, had not undergone prostate surgery or taken medications that alter androgen levels, and had PSA values of 0.1 to 10 ng/mL.
The primary outcome was the association among total cholesterol, LDL, HDL, and PSA levels in the two years before starting statin therapy.
After adjusting for age, ethnicity, and body mass index, investigators found that the pre-statin PSA level associated with pre-statin total cholesterol (P=0.02) and LDL (P=0.04) levels, but not HDL.
For each 10 mg/dL increase in total cholesterol or LDL, PSA levels increased by 0.02 ng/mL.
Among men who had baseline PSA values ≥3 ng/mL, each 10 mg/dL rise in total cholesterol or LDL corresponded to increased PSA levels of 0.7 and 0.08 ng/mL, respectively.
Dr. Banez disclosed that he has been an investigator for AstraZeneca. Dr. Hamilton had no disclosures.
Primary source: Journal of UrologySource reference:Banez LL, et al "Higher cholesterol increases the risk of biochemical failure after radical prostatectomy: Results from the SEARCH Database Group" J Urol 2008; 179(suppl): 68. Abstract 192. Additional source: Journal of UrologySource reference: Hamilton RJ, et al "The association between cholesterol and PSA" J Urol 2008; 179(suppl): 721. Abstract 2094.
AUA: Lithotripsy-Diabetes Link Remains Unresolved

By Charles Bankhead
ORLANDO, 29 may 2008-- Recent studies have suggested that extracorporeal shockwave lithotripsy increases the risk of diabetes, but new research presented here fails to clarify the issue.
One study reported at the American Urological Association meeting found no connection between lithotripsy and diabetes, another revealed a positive association, and a third showed that obesity and older age -- not the mode of stone removal -- were factors.
To examine the link, Antoine Makhlouf, M.D., of the University of Minnesota in Minneapolis, and colleagues used a mail survey to collect information on 1,942 patients treated between 1999 and 2002 with the same lithotripsy machine. For comparison the investigators used data from participants in the National Health and Nutrition Examination Survey (NHANES), matched for age, sex, and body mass index.
At the time of lithotripsy, 8.67% of the patients had a diabetes diagnosis, which increased to 13.9% by the 2007 follow-up survey. Over the same period the prevalence of diabetes in the NHANES control group increased from 8.34% to 14.1%.
From the similar rate of increase (5.2% in the lithotripsy group compared with 5.6% in the NHANES group, P=0.07), Dr. Makhlouf and colleagues concluded that lithotripsy does not increase the risk of diabetes.
In the second study, Canadian investigators examined the association between lithotripsy and diabetes in 152 patients who underwent the procedure at Vancouver General Hospital between 1985 and 1987. Diabetes status approximately 20 years later was assessed by means of a telephone survey. Mean age of patients at the time of the survey was 67.4 years.
The lithotripsy patients had more than twice the rate of diabetes compared with the general population, reported Ben Chew, M.D., of the University of British Columbia in Vancouver.
The overall diabetes prevalence in the lithotripsy patients was 26.3%, including 29.4% in men and 20% in women. That compared with a background prevalence of 10.1% in men and 9.1% in women in the general population of British Columbia.
Noting that the study lacked a proper control group, the researchers said. "It would be premature to conclude that this increased prevalence is due to [lithotripsy] alone. It may be attributable to the fact that diabetic patients are prone to developing stone disease and that diabetes does not manifest until later in life."
Despite the uncertainty surrounding the data, the study "supports that an association exists," the authors concluded.
Matthew C. Kincade, M.D., of the University of Tennessee at Memphis, and colleagues compared the prevalence of diabetes and hypertension in patients who had kidney stones treated with lithotripsy or ureteroscopy from 2002 to 2007. The study involved 712 patients who underwent lithotripsy and 146 who had stones removed ureteroscopically.
At baseline, 634 lithotripsy patients (89%) and 113 ureteroscopy patients (93%) were free of diabetes. Additionally, 408 (57%) lithotripsy patients and 69 (56%) ureteroscopy patients did not have pre-existing hypertension.
During follow-up, 9.1% of the group treated with lithotripsy and 7.4% of the ureteroscopy group developed new-onset diabetes.
New diagnoses of hypertension were documented in 21.1% of the lithotripsy group and 14.5% of patients who underwent ureteroscopy.
In a multivariate analysis, the type of treatment for stone disease did not influence the risk of diabetes or hypertension. Age 60 and older and BMI ≥30 were the only significant predictors of diabetes risk, and only BMI ≥30 predicted an increased risk of hypertension.
"ESWL is a safe option for the treatment of urinary stone disease when compared to ureteroscopy," Dr. Kincade and colleagues concluded. "Patients with increased BMI . . . are at increased risk for both de novo diabetes and de novo hypertension after treatment of stones with either ESWL or ureteroscopy. Patients 60 years of age or greater are at an increased risk of developing de novo diabetes after treatment of stone disease."
Dr. Makhlouf disclosed that he is a consultant/adviser for Timm Medical Technologies and American Medical Systems. Dr. Chew disclosed relationships with multiple commercial interests. Dr. Kincade had no disclosures.
Primary source: Journal of UrologySource reference:Makhlouf AE, et al "Extracorporeal shockwave lithotripsy does not increase the risk of diabetes" J Urol 2008; 179(suppl): 462. Abstract 1350.
Study IDs Gene for Late-Onset Alzheimer's

29 may 2008-- A gene that plays a role in Alzheimer's disease in two large families in which many siblings suffer from the neurodegenerative condition has been identified by U.S. researchers.
Identification of this gene -- TRPC4AP on chromosome 20 -- opens a new line of research that may help improve understanding of what causes Alzheimer's disease.
TRPC4AP is involved in calcium regulation. It's known that when calcium levels aren't carefully controlled, cells can die, leading to the onset of disease.
In this study, researchers at the Medical College of Georgia and the VA Medical Center in Augusta focused on two large families with a history of late-onset Alzheimer's disease who were enrolled in a DNA bank. Both families had 15 siblings, five of whom had Alzheimer's. Analysis of blood samples revealed that all the patients in both families had the same pattern of single nucleotide polymorphisms (SNPs), which are single base changes in gene structure found throughout DNA.
When they analyzed samples from other Alzheimer's patients in the DNA bank, the researchers found that 36 percent had the same pattern of SNPs as the patients in the two families.
The study was published in the current issue of the American Journal of Medical Genetics Part B: Neuropsychiatric Genetics.
"The use of extended pedigrees is vital for genetic studies. The next step will be to identify the exact mutation in this gene which is causing the disease. The DNA is currently being sequenced to find this mutation," study author Dr. Shirley Poduslo said in a prepared statement.
"The long-term significance will be to understand the mechanism of the disease so that more effective drugs can be designed to slow the progression of the disease, delay the onset, identify patients early in the disease course and, hopefully, someday to keep this dreadful disease from occurring," Poduslo said.
Gut superbug causing more illnesses, deaths

29 may 2008--The number of people hospitalized with a dangerous intestinal superbug has been growing by more than 10,000 cases a year, according to a new study.
The germ, resistant to some antibiotics, has become a regular menace in hospitals and nursing homes. The study found it played a role in nearly 300,000 hospitalizations in 2005, more than double the number in 2000.
The infection, Clostridium difficile, is found in the colon and can cause diarrhea and a more serious intestinal condition known as colitis. It is spread by spores in feces. But the spores are difficult to kill with most conventional household cleaners or antibacterial soap.
C-diff, as it's known, has grown resistant to certain antibiotics that work against other colon bacteria. The result: When patients take those antibiotics, competing bacteria die off and C-diff explodes.
This virulent strain of C-diff was rarely seen before 2000.
"The nature of this infection is changing. It's more severe," said Dr. L. Clifford McDonald, a Centers for Disease Control and Prevention expert who was not part of the study.
There are other factors that play into the rise of C-diff cases as well, including a larger of number of patients who are older and sicker. "And there may be some overuse and inappropriate use of antibiotics," said Dr. Marya Zilberberg, a University of Massachusetts researcher and lead author of the study.
The Zilberberg study was based on a sample of more than 36 million annual discharges from non-governmental U.S. hospitals. That data was used to generate the study's national estimates.
The research is being published in the June issue of Emerging Infectious Diseases, a CDC publication.
Using other scientists' estimates, the study concluded that 2.3 percent of the cases in 2004 were fatal — about 5,500 deaths. That was nearly double the percentage of C-diff-related cases that ended in death in 2000.
Many of the people who died had other health problems. The study did not try to determine if Clostridium difficile was the main cause of death in each case, Zilberberg said.
But earlier research concluded the infection is the underlying cause of thousands of deaths annually, and the problem is getting worse.
C-diff has become an acute health concern in Canada, where it was blamed for 260 deaths at seven Ontario hospitals recently, and 2,000 deaths in Quebec since 2002.
The Association for Professionals in Infection Control and Epidemiology is currently working with U.S. hospitals to study prevalence of the infection and what infection control measures seem to work best.
"This is not a time for alarm, but more a time for educating health professionals to understand this particular pathogen," said Kathy Warye, chief executive of the Washington, D.C.-based association.

Wednesday, May 28, 2008

Head Positional Maneuvers Endorsed for Benign Vertigo

By Judith Groch

PHOENIX, Ariz., 28 may 2008-- Almost like wet dogs shaking their heads, patients with benign paroxysmal positional vertigo are resolving dizziness by a series of directed movements to remove loose calcium crystals from semicircular canals in the ear.
The quick head-positioning treatment was effective for relieving vertigo especially in patients with loose calcium crystals (otoliths) in the posterior-canal, a common form of the disorder, Terry D. Fife, M.D., of the University of Arizona, and colleagues reported in treatment guidelines in the May 27 issue of Neurology.
The most common form of vertigo occurs when a patient looks up or bends over so that otoliths from the macula of the utricle fall into a semicircular canal. Now referred to as canaliths, they move in the semicircular canal eventually deflecting the cupula, resulting in a burst of vertigo and nystagmus.
All of the repositioning maneuvers move these ectopic canaliths from the semicircular canal into the vestibule of the ear where they are absorbed.
There are a number of repositioning maneuvers in use, said Dr. Fife and colleagues, but they lack standardization, the guidelines authors wrote.
So they reviewed all relevant articles from 1996 to June 2006. These included, for example, treatment for posterior-canal disorder and horizontal-canal and anterior-canal disorder.
Among various maneuvers reviewed, the investigators found that for the common posterior-canal disorder, the canalith repositioning maneuver (also called the Epley maneuver) is safe and effective and should be offered to patients of all ages with this form of benign positional vertigo.
The Semont maneuver is "possibly effective," they said, but received only a low recommendation on the basis of a single study.
The relapse rate and second occurrence rate are not fully established, the guideline writers said. Short-term relapse rates range from 7% to nearly 23% within a year of treatment, but long-term recurrences may approach 50%, depending on the age of the patients.
As an example of the positional treatment, the canalith maneuver for right-sided disorder begins with the patient sitting up on a bed or table.
Then, while lying down, the patient's head is held by the therapist in the right head-hanging position for 20 to 30 seconds (steps one and two). In step three, the therapist turns the head 90 degrees toward the unaffected side.
The head is held this way for 20 to 30 seconds before being turned another 90 degrees so that it is nearly in the face-down position (step four).
After 29 to 30 seconds the patient is brought to the sitting up position (step five).
Although the therapist guides the patient through these steps, the patient's head position is key to successful treatment, the investigators said.
The guidelines also evaluated whether activity restriction is needed following treatment and concluded that five of six studies showed no added benefit for post-treatment activity or position restriction, such as sleeping upright and wearing a cervical collar.
For patients treating themselves, home exercises seemed to pose little risk, but evidence was insufficient to show that it is as effective as maneuvers done by a physician or other therapist.
Turning to the efficacy of medication treatment, the investigators said that in the absence of randomized controlled trials, there is no evidence to support a recommendation of any medication in the routine treatment of this form of benign vertigo.
Lack of evidence precluded recommendations for surgical treatment for refractory disorder, they added.
Future studies, they concluded, are needed to clarify the best treatments for the horizontal-canal form of the disorder, they concluded.
Dr. Fife reported that he has received research support from GlaxoSmithKline and estimates that 6% of his time is spent on canalith repositioning. Other authors have received honoraria or research support from BiogenIdec, Pfizer, GlaxoSmithKline, and Boehringer Ingelheim, and Ortho-McNeil.
Additional source: NeurologySource reference: Fife TD, et al "Practice Parameter: Therapies for benign paroxysmal positional vertigo (an evidence based review): Report of the quality standards subcommittee of the American Academy of Neurology"
Evidence 'Equivocal' for Antioxidants in Cancer Treatment

By Michael Smith
SAN DIEGO, 28 may 2008-- The evidence for supplementing cancer radiation or chemotherapy with antioxidants is "equivocal at best" in the face of serious concerns about potential harm, researchers here said.While some studies have shown antioxidants can reduce the occurrence of clinically significant side effects, there is also evidence they can lead to lower tumor control, according to Brian Lawenda, M.D., of the Naval Medical Center San Diego, and colleagues.Until the safety issue is sorted out, oncologists and patients should be leery of the combination of radiation or chemotherapy with antioxidants, Dr. Lawenda and colleagues wrote online in a commentary in the Journal of the National Cancer Institute.
"Without strong safety data, it should be discouraged," Dr. Lawenda said, adding he and his colleagues have urged more research on the question.
The difficulty is that radiation therapy and some forms of chemotherapy -- anthracyclines and platinum-based agents, for example -- act by creating free radical damage in tumor cells. Antioxidants prevent or reduce such damage.
But the extent and effect of the possible interactions of various drugs, radiation regimens, and antioxidants has not been clearly established, they said.
Dr. Lawenda and colleagues studied published randomized clinical trials in which antioxidants were used with either form of cancer treatment.
Generally, they said, the trials were small but a few of those testing radiation therapy plus antioxidants had several hundred patients and one had 1,451.
That study, reported in 2006, was a meta-analysis of 14 randomized controlled trials that tested the antioxidant amifostine (Ethyol) in patients with various forms of cancer.
The analysis showed significant reductions (P<0.001) in a range of side effects, including a 63% reduction in the risk of developing mucositis and an 85% reduction in the risk of acute pneumonia.
At the same time, there was no difference in control rates, Dr. Lawenda and colleagues said.
On the other hand, a 2005 study randomized 540 radiation patients with head and neck cancer to get placebo or the antioxidant alpha-tocopherol, with or without the antioxidant beta-carotene.
Those who received both antioxidants had a 38% reduction in severe, acute side effects, which was significant at P<0.05, the researchers said. But the benefit was coupled with reductions of 29% and 56% in local tumor control rates for alpha-tocopherol and alpha-tocopherol plus beta-carotene, respectively.
All told, the researchers found nine studies testing radiation with and without antioxidants, and found data from a limited number of them that suggests antioxidants during radiotherapy decreases tumor control and shortens survival.
The researchers found 16 trials of antioxidants with chemotherapy, the largest of which had 250 patients. But because most of the studies were small, it was difficult to draw definitive conclusions either way, the researchers said.
The key clinical message, Dr. Lawenda said, is that doctors and their patients need to communicate about the use of antioxidants, especially because many such compounds are readily available and are widely publicized as having cancer-fighting benefits.
"We're saying to patients to be very careful about information coming out of the lay press," he said. And doctors, for their part, should be careful to ask patients about their antioxidant use and counsel them about the state of the science.
The study had no external support. Dr. Lawenda did not report any conflicts.
Primary source: Journal of the National Cancer InstituteSource reference:Lawenda BD, et al "Should supplemental antioxidant administration be avoided during chemotherapy and radiation therapy?" J Natl Cancer Inst 2008; 100: 773-783.
Study suggests antidepressants for stroke victims

28 may 2008--Doctors may want to give stroke victims antidepressants right away instead of waiting until they develop depression, a common complication, new research suggests.
The findings may lead to an expanded use for antidepressants. Someday high-risk people like stroke patients might take the drugs before suffering depression — just as people now take cholesterol drugs to prevent heart attacks, the lead author said.
The researchers gave low doses of the antidepressant Lexapro to stroke patients. The patients on the drug were 4.5 times less likely to develop depression than patients taking a dummy pill.
More than 700,000 Americans suffer strokes each year and more than one-third will develop depression in the next two years. Stroke patients with depression recover more slowly and are more likely to die, according to previous research.
"We showed you could in fact prevent the development of depression after stroke," said Dr. Robert Robinson of the University of Iowa who led the study. "I hope I don't have a stroke, but if I do, I would certainly want to be placed on an antidepressant."
Experts say strokes may damage parts of the brain affecting mood. Add to that the stress of relearning simple tasks and adjusting to stroke-caused impairments and you've got a recipe for depression.
Lexapro may work by making the chemical serotonin more available in the brain and by promoting brain repair, said Dr. George Bartzokis of the University of California, Los Angeles, who was not involved in the new study.
"Treating the depression may actually help treat the stroke and vice versa," Bartzokis said.
The study, appearing in Wednesday's Journal of the American Medical Association, was based on an analysis of 176 stroke patients, ranging in age from 50 to 90.
At the start, none suffered from depression. One-third were randomly assigned to take Lexapro. One-third took matching dummy pills. And one-third were assigned to receive talk therapy focusing on problem-solving skills.
After one year, about 9 percent of the Lexapro group had developed depression. That compared to 22 percent of the placebo-takers and 12 percent of the people who got problem-solving therapy.
Side effects such as dry mouth, dizziness, rapid heart rate and sexual problems were reported by all three groups at about the same rates.
Lexapro costs about $80 per month. A generic version of a similar drug costs about $40 per month and might be as effective, Robinson said.
Dr. Charles Reynolds, a geriatric psychiatrist at the University of Pittsburgh Medical Center, said he hopes doctors will start prescribing preventive antidepressants to stroke patients.
"Depression in the wake of a stroke amplifies the suffering and disability such patients experience," Reynolds said. "Dr. Robinson's work supports a novel way of preventing such suffering and disability."
But with prevention, some patients take pills who never would have needed them, putting them at risk for unnecessary side effects. Seven stroke patients would have to be treated with antidepressants to prevent one depression, the researchers found.
Robinson said that's acceptable, especially when compared to the current standards in heart attack prevention. He cited a study showing it takes 40 male patients taking cholesterol-lowering statins over five years to prevent just one heart attack.
The researchers excluded from the study patients who had cancer, other life-threatening conditions or severe verbal impairments, so the findings may not apply to all stroke patients.
AUA: New Therapies Show Promise for BPH

By Charles Bankhead
ORLANDO, 28 may 2008 -- Two new therapeutic strategies for benign prostatic hyperplasia (BPH) -- one oral, one injectable -- showed promise in clinical trials, investigators said here.
The vitamin D agonist elocalcitol significantly slowed prostate growth and improved urinary flow in a placebo-controlled dose-finding study reported at the American Urological Association meeting.
A second study found that a single intraprostatic injection of a PSA-activated protoxin significantly reduced prostate symptoms and volume in a small phase 1 clinical evaluation.
Elocalcitol is a nonhypercalcemic vitamin D agonist that demonstrated anti-inflammatory and antiproliferative activity in preclinical studies, said Francesco Montorsi, M.D., of the Universita Vita Salute San Raffaele in Milan, Italy. Preliminary clinical studies showed that elocalcitol arrests prostate growth and improves bladder function.
Clinical investigation continued in a dose-finding study involving 540 men with symptomatic BPH.
The patients were randomized to placebo or to one of three active therapies: elocalcitol 75 or 150 mcg or elocalcitol 150 mcg plus the alpha blocker tamsulosin (Flomax) at a dose of 0.4 mg.
Treatment continued for six months, and the primary endpoint was the percentage change in total prostate volume from baseline.
All three active-therapy groups did significantly better compared with placebo, which had a mean increase in prostate volume of 3.52%.
Prostate volume increased by 1.52% with the 75 mcg dose of elocalcitol (P<0.0135), 0.54% with 150 mcg of elocalcitol (PP=0.0059).
"The rate of prostate growth in the placebo group was in line with published literature," Dr. Montorsi said. "The reduced rate of growth with elocalcitol shows that the drug can arrest prostate growth."
Prostate symptoms improved by five to six points on the International Prostate Symptom Scale and did not differ between groups. Similarly, maximum urinary flow (Qmax) improved by about 1 to 2 mL/sec in all four groups.
"The results seem to be comparable to those historically obtained with the 'gold standard' alpha-blockers," said Dr. Montorsi.
In a subgroup analysis of men with IPSS scores ≥12 and at least three urgency episodes daily at baseline, the 150 mcg dose of elocalcitol led to significant improvement (P<0.01) compared with placebo, as did combination therapy (P<0.04).
Adverse events occurred less frequently with elocalcitol monotherapy compared with placebo and slightly more often with the combination, but the differences were not significant.
In particular, elocalcitol did not adversely affect sexual function compared with placebo.
Explaining the second strategy, investigators in Canada and at Johns Hopkins presented data from 15 patients treated with PRX302, a modified bacterial protoxin injected into the prostate.
The modified protoxin (proaerolysin) is activated by PSA, resulting in the release of C-terminal inhibitory peptide and generation of active toxin, said Peter J. Pommerville, M.D., of Can-Med Clinical Research in Victoria, British Columbia.
"We believe the activated toxin bores small holes into cell membranes, allowing the cell contents to leak out and promoting apoptosis," Dr. Pommerville said in an interview. "The end result is a reduction in prostate volume."
In the phase I study, three patients each received one of five doses of PRX302. Using transrectal ultrasound guidance, investigators injected the protoxin transperineally into both prostatic lobes. Additionally, three or four deposits per injection were made in the transition zone along the urethra.
The baseline prostate volume averaged 45.3 cm3 and decreased to 37.7 cm3 at 90 days (P<0.01).
IPSS score decreased from a baseline mean of 19.1 to 9.4 at 90 days (P=0.015).
Quality-of-life score improved from a mean of 4.3 at baseline to 1.8 at 90 days (P<0.01).
"We hypothesize that the reduction in prostate mass reduces the pressure on the urethra, leading to a reduction in prostate symptoms," said Dr. Pommerville.
The protoxin was well tolerated; no grade 3-4 adverse events occurred during the study, he added. The most common adverse event was urinary frequency.
Dr. Montorsi disclosed relationships with GlaxoSmithKline, Pfizer, Bayer, Eli Lilly, Pierre Fabre, and AMS. Dr. Pommerville disclosed that he is an investigator for Protox Therapeutics.
Primary source: Journal of UrologySource reference:Montorsi F, et al "Elocalcitol in the treatment of BPH: a multicenter, randomized, placebo-controlled phase IIb clinical trial" J Urol 2008; 179(suppl): 700; Abstract 2035. Additional source: Journal of UrologySource reference: Pommerville PJ, et al "A PSA-activated protoxin (PRX302) administered transperineally to men with symptomatic benign prostatic hyperplasia is well tolerated and exhibits signs of activity" J Urol 2008; 179(suppl): 673; Abstract 1961.
AUA: Autologous Cell Transplants Show Promise for Stress Urinary Incontinence

By Charles Bankhead
ORLANDO, 28 may 2008-- For stress urinary incontinence, the use of transplanted autologous muscle-derived cells has led to significant and durable symptom improvement, investigators reported here.
Of 177 patients followed for up to two years, fewer than 10% of women and 30% of men required absorbent pads, Hannes Strasser, M.D., of the Medical University of Innsbruck in Austria, said at the American Urological Association meeting.
"The procedure is safe and minimally invasive," said Dr. Strasser. "Ultrasonography-guided injection of autologous cells has been very effective and also very precise, which is of utmost importance."
Since April 2004, Dr. Strasser and colleagues have used cell transplantation to treat 65 men and 112 women, starting with removal of a small amount of muscle from the patient's upper arm. Myoblasts and fibroblasts are grown in culture for six to eight weeks. The fibroblasts are mixed with a small amount of collagen, which serves as a carrier and prevents cell migration.
Guided by transurethral ultrasound, the fibroblasts are injected into the urethral submucosa to treat atrophy, and the myoblasts are injected into the rhabdosphincter to effect reconstruction.
Follow-up examinations revealed thickening of the urethra and rhabdosphincter and increased contractility of the rhabdosphincter.
At baseline the women used an average of six pads daily, which decreased to one pad at two years. Dr. Strasser reported that 62.5% of the women required no pads, 28.4% used a single pad daily for precautionary reasons, and 9.1% still required multiple pads because of persistent urinary incontinence.
Most of the men had urinary incontinence secondary to treatment of prostate cancer. On average the men required about five pads daily before treatment, decreasing to 1.59 at two years. Dr. Strasser said 27.9% of the men had regained complete continence, 43.6% used a single pad daily as a precaution, and 28.5% had persistent urinary incontinence.
There were no severe treatment side effects or complications. One patient who had undergone multiple surgical procedures and radiation therapy had a bladder perforation. No patient had signs of obstruction, scars or strictures, or bulking of injected cells.
Longer follow-up is needed to confirm the safety and efficacy of the procedure, Dr. Strasser said, and a multicenter trial is needed to demonstrate replicability.
"This is not a wonder therapy that works in every incontinent patient," Dr. Strasser cautioned. "It cannot be used in patients with hypermobility or in patients with prolapse. It works very well in patients with intrinsic sphincter insufficiency."
Dr. Strasser disclosed that he has an ownership stake in Innovacell Biotechnologie GmbH.
Primary source: Journal of UrologySource reference:Strasser H, et al "Transurethral ultrasound guided injection oif autologous myo- and fibroblasts in treatment of incontinence in men: 2 year data" J Urol 2008; 179(suppl):483. Abstract 1413. Additional source: Journal of UrologySource reference: Strasser H, et al "Transsurethral ultrasound guided application of autologous myo- and fibroblasts in treatment of incontinence in women: 2 year data" J Urol 2008; 179(suppl):534. Abstract 1561.

Tuesday, May 27, 2008

Antipsychotics Dangerous for Elderly With Dementia

By Amanda Gardner
27 may 2008-- Elderly people with dementia who are given antipsychotics, even for a very short period of time, are more likely to end up in the hospital or even die, new research shows.
However, the problems underlying the need for such medications, behavioral problems such as aggression and agitation, are very real, and the alternatives to antipsychotics are limited, the researchers added.
"A misreading of the findings would be we don't need to do something for these nursing home residents," said study author Dr. Gary J. Kennedy, head of geriatric psychiatry for Montefiore Medical Center in New York City.
Many experts feel behavioral interventions should be tried first and antipsychotics used as a last resort, "when the behavior or the psychiatric symptoms are really out of control and causing complete distress not only for the person suffering from Alzheimer's, but for caregivers all around them," said Maria Carrillo, director of medical and scientific affairs at the Alzheimer's Association in Chicago. "It's important to work these things out with the physician and, of course, do follow-up very closely together, so you can make sure these antipsychotics are having the effect you want and, if not, discontinue them immediately."
The findings were published in the May 26 issue of the Archives of Internal Medicine.
Antipsychotic drugs are commonly used to treat some of the behavioral complications of dementia, including delirium.
Newer antipsychotic medications such as Zyprexa (olanzapine) and Risperdal (risperidone) have been available for about a decade and have largely replaced their older counterparts.
Researchers from the Institute for Clinical Evaluative Sciences in Ontario, Canada, compared 20,682 older adults with dementia living in the community with 20,559 older adults with dementia living in a nursing home between April 1, 1997, and March 31, 2004.
Each group was divided into three subgroups: those not receiving any antipsychotics, those taking newer antipsychotics, and those taking older antipsychotics such as Haldol (haloperidol).
According to information gleaned from medical records, community-dwelling adults who had recently received a prescription for a newer antipsychotic medication were 3.2 times more likely than individuals who had received no antipsychotic therapy to be hospitalized or to die during 30 days of follow-up.
Those who received older antipsychotic therapy were 3.8 times more likely to have such an event, relative to their peers who had received no antipsychotic therapy.
A similar pattern, albeit less dramatic, emerged in the nursing home group. Individuals taking older antipsychotics were 2.4 times more likely to be hospitalized or die, while those taking newer drugs were 1.9 times more likely to die or be hospitalized during the 30 days of follow-up.
The study does, however, have its limitations. "It's a carefully done study," Kennedy said. "One flaw is that the [participants] weren't randomly administered antipsychotics. There was some reason they were given an antipsychotic, such as aggression or agitation. It may have been done if they were recently admitted to the nursing home as part of the adjustment process.
Indeed, the authors acknowledged that about 17 percent of patients entering nursing homes start taking an antipsychotic within 100 days.
"For any of us, moving is like being sick. It takes a while to recover," Kennedy said. "We need other sets of interventions besides medications. What that implies is more staffing and better training for staff, and that may not be a whole lot more expensive than medicines."
Scientists test brain pacemakers for depression

27 may 2008--It's a new frontier for psychiatric illness: Brain pacemakers that promise to act as antidepressants by changing how patients' nerve circuitry fires.
Scientists already know the power of these devices to block the tremors of Parkinson's disease and related illnesses; more than 40,000 such patients worldwide have the implants.
But psychiatric illnesses are much more complex and the new experiments with so-called deep brain stimulation, or DBS, are in their infancy. Only a few dozen patients with severe depression or obsessive-compulsive disorder so far have been treated in closely monitored studies.
Still, the early results are promising. Dramatic video shows one patient visibly brightening as doctors turn on her brain pacemaker and she says in surprise: "I'm starting to smile." And new reports this month show that some worst-case patients — whose depression wasn't relieved by medication, psychotherapy, even controversial shock treatment — are finding lasting relief.
Six of 17 severely depressed patients were in remission a year after undergoing DBS and four more markedly improved, and more than half of 26 obsessive-compulsive patients showed substantial improvement over three years, say studies from a team at the Cleveland Clinic, Brown University, and Belgium's University of Leuven.
"Not all patients get better, but when patients respond, it's significant," says Dr. Helen Mayberg of Emory University, who has implanted about 50 depression patients. Her first remains in remission after five years; she estimates that four of every six show enough improvement to be classified "responders."
"We're rewiring the brain in many ways," says Dr. Ali Rezai, chief of the Cleveland Clinic's Center for Neurologic Restoration.
There's a need for innovative therapies. Up to 20 percent of depression patients and 10 percent of those with obsessive-compulsive disorder are treatment-resistent — several million people in the U.S. alone.
The rationale behind DBS is credible, says Dr. Wayne Goodman of the National Institute for Mental Health: Surgery sometimes helps worst-case patients by destroying misfiring patches of brain tissue. The electrodes are placed into similar spots, but don't destroy tissue — the electrical signals can be adjusted and turned off.
But it's not yet ready for prime-time, Goodman cautions. He worries that because the electrodes already are widely available, centers without proper training will start offering the $40,000 implant surgeries to psychiatric patients before science proves if they're really valuable.
"It is an invasive, experimental procedure," he warns, with risks including bleeding in the brain and infections. He calls DBS "the last resort for stringently selected patients."
Earlier this month, federal health officials and the Cleveland Clinic brought together the field's leading researchers to highlight progress so far and debate if it's time for much larger studies — even whether DBS might be tweaked to help people with traumatic brain injuries, such as Iraq war veterans.
"There's not enough awareness of what the potential is of this kind of stimulation," says meeting co-chair Dr. Margaret Giannini, who heads the government's Office on Disability.
In deep brain stimulation for Parkinson's, a wire is implanted within a walnut-sized area known as the thalamus, a hub of sensory information. That electrode is connected by a cable running through the neck to a pulse generated under the collarbone. Tiny electrical zaps disable overactive nerve cells, blocking tremors.
Scientists don't have nearly as much understanding of what goes awry to cause depression or other psychiatric illnesses — but they do know the thalamus isn't the right spot for those patients. They're focusing instead on two regions with names only a neurologist could love — the ventral capsule/ventral striatum and so-called Brodmann Area 25. Ignore the names; the point is that these are regions where brain circuitry involved in mood and anxiety intersect.
It's not yet clear who should have DBS in which spot, or if there are still other target areas. Much of the research to date has been funded by electrode manufacturers, with some paid for by the government — and consists of measuring patients' disability before and after DBS, not more rigorous studies that randomly assign patients to treatment.
Still, Diane Hire of Cleveland, the patient whose first smile was recorded, illustrates the hope.
The 12-year Navy veteran was medically discharged for depression and spent a decade on disability, unable to function. "I basically felt like a dead person walking. I had no feelings, no emotions," she told the scientists' meeting.
Her DBS was switched on in January 2007, and "my whole world changed," says Hire, 54. She's not back to work yet: "It is a real challenge to learn how to live as a healthy person again," she adds, saying she doesn't handle stress or multitasking well. But, "I wake up every day looking forward to what's ahead."
Dutch claim first sequencing of female DNA

27 may2008--Dutch scientists claim they have completed the first sequencing of an individual woman's DNA.
The researchers at Leiden University Medical Center say they have sequenced the DNA of one their researchers, geneticist Marjolein Kriek. They plan to publish it after review. No other scientists have verified their data.
The first sequencing of a composite human genome was announced in 2001, followed by the first individual DNA sequencing in 2007. Four individual male genomes have been sequenced.
Lead researcher Gert-Jan van Ommen said Monday that "it was time, after sequencing four males, to balance the genders a bit."
Laser Therapy a New Option for Vocal-Cord Cancers

27 may 2008-- A new laser treatment for early vocal-cord cancer targets tumor blood vessels while preserving and restoring patients' voices, according to Massachusetts General Hospital researchers, who noted that radiotherapy or surgery can permanently damage vocal quality.
Details about this new pulsed Potassium-Titanyl-Phosphate (KTP) laser treatment, which has been used in more than 25 patients, were presented at the recent annual meeting of the American Broncho-Esophagological Association and were expected to be published as a supplement in an upcoming issue of the journal Annals of Otology, Rhinology, & Laryngology.
"We had previously adapted lasers that target blood vessels to treat precancerous vocal-cord dysplasia and a variety of benign vascular lesions. We have now applied that experience to treat vocal-cord cancer, which is diagnosed in several thousand American patients each year," Dr. Steven Zeitels, director of the MGH Voice Center, said in a prepared statement.
The first 22 patients who received pulsed-KTP for vocal-cord cancer are cancer-free up to five years after treatment, without removal of vocal-cord tissue or loss of voice quality.
Some of the patients have required second or third laser treatments to remove residual cancer, but another benefit of this therapy is that it doesn't rule out future treatment options, Zeitels said.
The treatment has become a standard management approach at MGH and may soon be used by other institutions in the United States and other countries, said Zeitels, who estimated that about 90 percent of patients with early vocal-cord cancer would be candidates for pulsed-KTP laser treatment.
In Central Europe, Better Health Care Comes With a Cost

PRAGUE, 27 may 2008 — In the Czech Republic, you can now see a doctor for about $1.85. A day in the hospital can verge on $4. This is not cause for celebration.
For Czechs, who visit their doctors more often than anyone in Europe, it has led to great outrage. In fact, the idea of charging anything at all for health care can generate significant controversy, not to mention abrupt about-faces in policy, here and in other Central European countries.
In Hungary, health care fees were resoundingly defeated in a nationwide referendum in March, which resulted in the firing of the health minister. Here in the Czech Republic, which began imposing the modest fees at the start of the year, the prime minister himself was forced before the constitutional court in Brno to testify as the court weighs overturning them. It is scheduled to rule on Wednesday.
Countries rich and poor struggle with how best to provide affordable health care to their citizens without breaking the bank. In places like the Czech Republic, there is a sense of betrayal, because the state long took care of them, but also a justified fear for those left behind in the recent years of growth and change. Even in Prague, known as the golden city, new wealth for some — and their rising expectations for top-notch care — has meant only higher prices for those trapped with low salaries or fixed pensions.
“I have to save so I have money for food,” said Kveta Lachoutova, 78, a widow who is a retired statistician. In an interview in the waiting room at her doctor’s office here, she said that she was trying to live on a monthly pension of about $600, while spending close to $400 on rent and utilities. “I don’t buy anything else.”
For healthy people with jobs, the fees are quite literally pocket change, usually paid with the same 10 and 20 crown coins as streetcar tickets in Prague ($1 is worth around 16 crowns). Affluent Czechs will admit privately that they spend far more on veterinary care for their cats and dogs than their own medical care, even with co-payments for some medications.
But many Czechs see it as a matter of principle that health care should be free — though the system is financed in part through payroll deductions — along with a strong sense of solidarity for the poor. “The only analogy I can think of in our political culture is primary schools,” said Marc J. Roberts, a professor of political economy at the Harvard School of Public Health who has worked in Central Europe. “Most people in the United States believe that primary education should be free and open to all and that it shouldn’t be subject to market principles.”
The region has been a laboratory of health care reform in recent years. The effort has been led by free-market advocates from booming Slovakia, which sports a flat tax and scorching economic growth, at a rate of over 10 percent last year.
Slovakia introduced modest payments for doctors’ visits and hospital stays in 2003. But, as would later happen in Hungary, the fees did not last. The left-wing government that came to power in 2006 rolled them back later that year, within just a few months of taking office.
“What we want to achieve in the health system is a higher individual responsibility, making the consumers more responsible for what they consume,” said Peter Pazitny, executive director and one of the founding partners at the Health Policy Institute in Bratislava, and formerly the principal adviser to the Slovakian minister of health.
The need for reform in the region, Mr. Pazitny said, is obvious. Statistics from the Organization for Economic Cooperation and Development show that the Czech, Slovak and Hungarian health care systems rank at or near the bottom of all member countries in life expectancy, as well as mortality rates for strokes, heart disease and cancer.
The Czech government was receptive to the Health Policy Institute’s input and even employs another of Mr. Pazitny’s partners in Prague. But the members of the opposition would prefer that their former countrymen left them — and their health care system — alone.
“I would understand if these Slovak boys would do it as a paper for their seminar at university, but here they are introducing it into real life,” said Michal Hasek, leader of the Social Democratic caucus, the largest opposition party in Parliament.
The Czech Constitution says that “citizens have on the basis of public insurance the right to free medical care and free medical aids under the conditions defined by the law.” The new payments were not only unconstitutional, according to Mr. Hasek, but also causing real pain in some segments of the population. Opponents and the local tabloid news media have made premature babies in incubators, whose parents must pay the hospital fees, into symbols of the new system.
Experts disagree on whether upfront fees to discourage doctors’ visits are a good idea from a public health perspective, and even question whether they create much in the way of savings for the overall health care system. “Most expensive, unnecessary services are not asked for by patients, but suggested by the physicians just to generate more revenue and more income for them,” said Peter Gaal, professor of health policy at Semmelweis University in Budapest.
The fees here, $1.85 for a prescription as well as a doctor’s visit, and twice that for a day in the hospital, are clearly having an effect on Czech behavior. The Health Ministry said the number of prescriptions fell 40 percent in the first quarter, though some of that may have been a result of stockpiling at the end of last year. The government estimated that public insurers had saved more than $100 million in the first quarter compared with the previous year, while providers collected $62 million in fees.
“We try to take out some of the costs that people can pay for themselves from the health care system,” said Tomas Julinek, the Czech health minister, in an interview in his office last week. But there is a cap on payments, set at just over $300 for the year, which Mr. Julinek said would also protect the seriously ill.
Several chronically ill patients said that they were not sure how the cap would work, or exactly which costs would be included. “So far, I see the negatives and I experience the negatives,” said Lenka Vondrackova, a multiple sclerosis patient struggling to get by with her husband and two teenage sons on about $1,200 a month, a combination of his salary and her disability benefits.
They live crammed into a tiny apartment in a Communist-era apartment building in Cerny Most, a neighborhood in the far eastern part of Prague. Her regimen of medications requires five pills in the morning, a nasal spray once a day and three more pills in the evening, along with a shot administered by her husband or one of her sons. Before the reforms, they were able to save a little each month. “Now everything that’s left is taken up by the fees,” said her husband, Pavel.
“I believe that in the future it will become evident that there will be more money for better equipment and medication,” she said, wishing in particular for pills that could take the place of the painful injection she dreaded each night. “If it works out,” she added, looking away, torn between skepticism and hope.