Tuesday, September 30, 2008

Heart patients should be screened for depression

30 sept 2008--Heart patients should be regularly screened for signs of depression, the American Heart Association recommended Monday.
Depression is about three times more common in heart attack survivors and those hospitalized with heart problems than the general population, according to the recommendations published in the journal Circulation. The authors said only about half of heart doctors say they treat depression in their patients — and not all those diagnosed with depression are treated.
"I think we could reduce considerable suffering and improve outcomes," by screening, said Erika Froelicher, professor of nursing at the University of California, San Francisco. "I know we can do more."
While there's no direct evidence that heart patients who are screened fare better, depression can result in poorer outcomes and a poorer quality of life, the panel said. Depressed patients may skip their medications, not change their diet or exercise or take part in rehabilitation programs, they said.
Anyone from cardiologists to nurses to primary care doctors can and should be involved in determining whether a patient is depressed, said Froelicher, who was co-chair of the panel that wrote the recommendations.
The panel suggests that heart patients be screened by first asking two standard questions: In the past two weeks, have you had little interest or pleasure in doing things? Have you felt down, depressed or hopeless?
If the patient answers yes to one or both, a questionnaire is recommended to determine if the patient is depressed and the severity. If depression is indicated, the patient may need to see a professional qualified in treating depression, the panel said, adding that treatment options include antidepressants, seeing a psychotherapist and exercise.
"Some physicians are qualified to treat it — others may be more comfortable referring the problem to a qualified mental health professional," Froelicher said.
Psychiatrist Michelle Riba said the statement's emphasis on frequent screening is important.
"What you want to see in a particular patient is how they do over time," said Riba, past president of the American Psychiatric Association, which has endorsed the heart association's recommendations.
One doctor said screening isn't enough; patients need close monitoring to make sure they get help.
"A lot of patients with depression don't follow up on it," said Dr. Mary Whooley, a professor of medicine at the University of California, San Francisco, who was not on the panel.
Barbara Forman, 62, struggled with depression after her double bypass about five years ago. She said she spent most of her time at her Englewood, Ohio, home sitting in her chair, frequently crying for no reason. When she did get out, she was often winded, even from a walk up a sidewalk to deliver cupcakes to her grandchild's classroom.
"I'm thinking, is this the way it's going to be for the rest of my life? Since I've had a heart event, is my life over?" she said. "It also made me afraid to do things. I didn't know how a heart attack felt. I would think, 'Is this a heart attack?'"
A couple of months after she got home she called Mended Hearts, a group affiliated with the heart association that provides support to heart patients, and talked to someone who let her know depression was common in heart patients.
Her family doctor sent her to a psychologist, and after some initial reluctance, she started taking an antidepressant. That, along with starting a walking routine and volunteering with Mended Hearts and the heart association, improved her outlook.
"You can't sit in your house and just vegetate," she said. "Over the last 18 months to two years — It's really gotten better."
More older Americans screened for colon cancer

30 sept 2008--There has been a substantial increase in the number of colorectal cancer screening tests conducted in older Americans, a new study shows.
"Most cases of colorectal cancer are diagnosed in older adults," Dr. Mary C. White, of the Centers for Disease and Control and Prevention, Atlanta, and colleagues note in the Journal of the American Geriatric Society. "Two thirds of new cases of colorectal cancer involve people aged 65 or older and one quarter of diagnoses are made in those aged 80 and older."
They point out that "as the number of older Americans continues to increase, greater attention is being paid to cancer screening in this population."
The researchers reviewed responses from roughly 6,000 participants in the 2000 National Health Interview Survey and a similar number in the 2005 version. All of the subjects were at least 65 years old.
The questionnaire included self-reports of colorectal cancer screening by colonoscopy, sigmoidoscopy, or home fecal occult blood tests.
The proportion of respondents reporting up-to-date colorectal cancer testing increased significantly from 39.5 percent in 2000 to 47.1 percent in 2005.
People who had a family history of the disease and those who had some higher education made greatest use of colorectal cancer testing. The lowest use was by those who reported that they did not visit a particular physician office for usual preventive care, those with uncertain family history of the disease, and those without health insurance.
A lower proportion of women than men were screened for colorectal cancer across all age groups, and the proportion screened declined with older age.
"Since 2001, Medicare has provided reimbursement for use of colonoscopy as a screening tool at 10-year intervals," the investigators point out. "It appears that the change in Medicare coverage for screening colonoscopy was associated with an increase in colorectal cancer testing in older adults."
SOURCE: Journal of the American Geriatric Society, August 2008.
Pain, a Limp and Winkle Picker’s Disease

30 sept 2008--Doctors who treat themselves may have fools for patients, but they look like geniuses compared with a reporter who tried to diagnose herself via the Internet.
It seemed so simple. I Googled “foot pain,” and up came two sites with neat little pictures of feet, arrows pointing to various parts and instructions to “click where it hurts.” I clicked and, voila! both sites said my pain — on the top and side of the foot, around the big toe — was probably from a bunion or gout.
Gout? Hmmph. What came to mind was Henry VIII, the movie version, hugely fat and grotesque on his throne, bellowing about his toe. As for bunions, weren’t they from pointy shoes, high heels, a family history? I had none of those. This wasn’t quite adding up.
Onward I clicked. I took fleeting comfort from a slide slow of hideous foot diseases that I clearly didn’t have. Lists of other ailments didn’t match, either. I don’t have diabetes or flat feet and I hadn’t injured myself. One site mentioned leprosy, which had drama but seemed unlikely. I was baffled.
A podiatrist, recommended by a doctor friend, took about 37 seconds to figure out what was wrong. He shoved my big toe up and down, gave it a squeeze that made me shriek and said smugly, “We’ll take some X-rays, and I’ll show you what’s causing your pain.”
A few minutes later, there it was on his computer screen: a bone spur, sticking up like a tiny, evil spike where the big toe joins the rest of the foot. The cause was arthritis of the big toe, which sounds ridiculous even to me. But it’s real, a wearing out of the cartilage that normally protects the bones from rubbing against each other. I’ve always walked a fair amount — at least three miles a day, often twice that or more in recent years — and at 56, I guess it’s catching up with me. Without realizing it, I’ve been wearing out my feet.
The medical name for this condition is hallux limitus, which means “stiff toe.” It’s progressive, and can turn into hallux rigidus — a really stiff toe. It’s humbling to be hobbled by such a comical-sounding ailment.
The podiatrist recommended shoes with stiff, rounded soles called rocker bottoms, to minimize bending of the joint. I figured out that I also needed lots of room in the toe, to avoid pressure on the spur. He said a cortisone shot into the joint might help. (It didn’t.) He also suggested shoe inserts, orthotics, but I was skeptical because I’ve had knee surgery and I feared the inserts might throw my knees out of whack.
Finally, he said I would eventually need surgery to remove the spur and shorten a bone. He said he could perform it right there in his office, and the sooner the better. At that point, if I’d been able to run, I might have. Instead, I nodded politely and said I’d think about surgery. But it sounded drastic.
I retreated to the Internet. Self diagnosis had been a lost cause (I would have done better had I Googled “toe pain”), but at least it was noninvasive. And knowing the name of the ailment made a big difference. Among other things, the Web cheered me up by revealing that hallux limitus is also called winkle picker’s disease (winkles are snails, and in England, winkle pickers used to be a nickname for pointy shoes, if that makes any sense). Unfortunately, I also found out that it can sometimes be disabling. Three of the more useful links were Arthritis Practitioner (www.arthritispractitioner.com, search for hallux limitus), eMedicine (www.emedicine.com/orthoped, click on foot and ankle) and Foot Physicians (www.footphysicians.com, foot and ankle information).
Some of the information echoed the podiatrist’s advice about shoes, and through trial and error I did find one type that seems to minimize the pain — clogs with firm soles and soft uppers. They are far from stylish, but limping is worse.
Doctor No. 2 was an orthopedic surgeon, who also wanted to operate. When I hesitated, he smirked and said, “When it hurts enough, you’ll come back.” No I won’t! I wanted to snap, but didn’t. He left before I could even ask how many toes he had fixed or what his success rate was. I limped home, feeling like a wimp.
Doctor No. 3 offered to inject a joint-lubricating drug into my toe. It sounded promising, but I chickened out, in part because the drug was approved for knees and not toes and in part because it would cost $2,800, but mainly because the doctor’s nose ran constantly and he let it drip everywhere, including onto a consent form explaining the risk of infection from the treatment.
Back on the Web, I found plenty of fellow sufferers. The patient forums fascinated me, especially the ones where people compared notes about surgery (www.healthboards.com, search hallux limitus; and www.foot.com, click on foot cafe, then message boards, and search hallux limitus). Some had good results, but others wished they had never had the operation — enough to reinforce my ideas about postponing it. Graphic surgical photos put me off, too (www.mdmercy.com, search hallux rigidus). In addition, I have not been able to find a convincing report on success rates, which are hard to sort out because there are different types of hallux limitus and different operations.
So, I have been muddling along for about a year now, walking a bit less, biking a bit more, wearing frumpy shoes and hoping that even if my foot wasn’t getting better, at least maybe it wouldn’t get worse. Recently, at my internist’s urging, I saw doctor No. 4, a podiatrist who specializes in noninvasive treatments. He had some new ideas about shoes and padding to protect the spur, and he didn’t seem to think my foot was all that bad. I told him I had always imagined that one day I’d put on a backpack and walk across continents, but lately was starting to give up on the idea.
“You might still make it,” he said. “Just start with a small continent.”
Seniors in Poor Areas More Likely to Die After Surgery

30 sept 2008-- Elderly Americans who live in low-income ZIP codes are more likely to die after surgery than those who live in higher-income ZIP codes, according to new research.
The study analyzed death rates among more than one million older adults who had one of six common high-risk heart or cancer surgeries between 1999 and 2003.
The risk of death was between 17 percent and 39 percent higher for patients in low-income ZIP codes, mainly because the quality of care is lower at hospitals in lower socioeconomic areas, the study authors said.
In fact, all patients (regardless of income) who had surgery at hospitals in the poorest areas were more likely to die, while all patients who had surgery at hospitals in the richest areas were less likely to die.
"It may be that hospitals that treat patients of lower socioeconomic status have lower quality of care due to fewer resources, such as technologically advanced equipment or specialists," lead author Dr. Nancy Birkmeyer, an associate professor of surgery at the University of Michigan, said in a Center for the Advancement of Health news release.
The study was published in the September issue of the journal Medical Care.
"While some prior studies have demonstrated socioeconomic disparities in the outcomes of individual procedures, ours is the first to show that the relationship is consistent across a wide range of surgical procedures," Birkmeyer said.
While the study can improve understanding of patterns of care, it doesn't offer concrete answers for elderly patients who need surgery, said Dr. Harlan Krumholz, a professor of medicine, epidemiology and public health at Yale University.
"The study can only really raise questions about inequalities in outcomes, because the authors have limitations in their ability to know the socioeconomic status of any particular patient and the condition of the patient when they had the surgery," Krumholz said in the news release. "Nevertheless, it is time for us to look closely at whether people are getting the same care and outcomes regardless of their financial circumstances."
More information
The U.S. National Institute on Aging has more about seniors and surgery.
Scams and Shams That Prey on Cancer Patients

By Amanda Gardner
30 sept 2008-- Cancer patients often turn to the Internet as a source of information and hope. But all too often, those hopes are betrayed by purveyors of so-called cancer "cures" that are anything but, experts say.
Earlier this month, five companies were charged with making false and misleading claims for cancer cures, and settlements were reached with six other companies, the U.S. Federal Trade Commission announced. Products marketed by the companies included essiac teas and other herbal mixtures, laetrile, black salve (a corrosive ointment), and mushroom extracts.
"There is no credible scientific evidence that any of the products marketed by these companies can prevent, cure, or treat cancer of any kind," said Lydia Parnes, director of the FTC's bureau of consumer protection, the Associated Press reported.
In June, the U.S. Food and Drug Administration issued warning letters to two dozen companies peddling everything from cure-all teas to tablets and tonics. And earlier this year, more than 100 manufacturers of such products were issued similar letters.
According to the American Institute for Cancer Research, black salves are one of the most dangerous of these fake cures. The products, which supposedly "draw out" the disease from under the skin, can actually burn the skin and cause scarring.
Which is not to say that none of these compounds has potential as cancer fighters. But consumers need to be careful.
"Many of these compounds touted as having beneficial effects have lots of lab research, but it's more selling hope in a jar based on preliminary lab research," said Sarah Wally, a nutritionist with the American Institute for Cancer Research in Washington, D.C. "That's not fair to the consumer, particularly consumers with cancer who have a really strong motivation to try anything that might offer hope."
Many of these so-called cures or preventive treatments won't actually cause harm (except to your wallet), but some can interact with regular, supervised medical treatment, Wally said.
"Antioxidants can actually interfere with chemotherapy and radiation treatment," she said. "Some people think, 'I'm just drinking juice.' But they might be drinking two gallons of juice a day of super-antioxidant juice compound, not thinking to discuss it with their doctor."
And, some consumers may actually forego lifesaving conventional treatments in favor of shams.
Here's some advice from the experts: "If it sounds too good to be true, it probably is," said Dr. Ted Gansler, director of medical content for the American Cancer Society. Beware of claims that one treatment will cure all types of cancer or more than one type of disease. Also be leery of language such as "scientific breakthrough," "miraculous cure," "secret ingredient" and "ancient remedy," as well as claims that a product is "natural" and therefore safe. And take note of claims that the product has limited availability and that the company needs advance payment. Find out if the product has ever been tested in humans. Laboratory and animal research is fine, but only as a starting point, not as a basis for recommending the therapy in humans, Wally said. "Be careful about the credentials of the people promoting the treatment," Gansler said. "The possibility that someone with no medical or scientific treatment is going to come up with a cure for cancer or other diseases is not very likely." Reliable sources of information include the American Cancer Society, Memorial Sloan-Kettering Cancer Center in New York City, and the University of Texas M.D. Anderson Cancer Center. (All have Web sites.) "Watch out for evidence that is only testimonial," Gansler said. "In some of the most notorious alternative clinics, people will be diagnosed with cancer who don't even have cancer and, later on, they're 'cured.' " The "patient" may actually believe he or she was cured. Be on the lookout for obvious factual errors. If someone says their "Stage 7" cancer has been cured, be leery. There is no "Stage 7" cancer. Wally advised: "Before you wholeheartedly jump into these things, you need to really sit down and have a discussion with your physician." This is especially true in an age when alternative and complementary medicines are gaining acceptance. It can be tricky distinguishing between something bogus and something that may have a benefit, Wally added.
More information
The FDA has more on fake cancer cures to be avoided.

Monday, September 29, 2008

AAO-HNS: Cochlear Implants Found Worthwhile in the Elderly

By John Gever
CHICAGO, 29 sept 2008--Cochlear implants for older patients led to better hearing as well as improvements in quality of life, researchers said here. Among 31 patients ages 57 to 85 given cochlear implants, two-thirds reported good or excellent satisfaction with the devices, said Patrick Maiberger, M.D., of Virginia Commonwealth University in Richmond, at the American Academy of Otolaryngology -- Head and Neck Surgery meeting here. Patients also had positive scores on the social support and general subscales of the Glasgow Benefit Inventory, reflecting improvement in quality of life. Patients with multiple comorbidities were no less satisfied with the implants than those in better overall health, Dr. Maiberger added.
But the efficacy of cochlear implants in these patients was significantly less than in a control group of patients ages 36 to 49, he said.
Cochlear implantation is common in older patients. Nevertheless, there is debate about the actual benefits, which have not been well studied in controlled trials, Dr. Maiberger said.
He noted that implant performance in audiologic testing does not necessarily correlate with quality of life.
Dr. Maiberger and colleagues gave two surveys, the Glasgow inventory and a questionnaire specific for quality of life in older cochlear implant recipients, to patients at least 55 years old receiving implants at Virginia Commonwealth. Questionnaires were given at least six months after implantation.
Mean age of the sample was 69.5 (SD 6.6).
The researchers also gave the questionnaires to a control group of 11 younger patients (mean age 43.6, SD 4.2).
Patients with bilateral implants were excluded. Only English-speaking recipients with full electrode insertion were included.
On the overall satisfaction component of the cochlear implant quality-of-life instrument, four of the 31 participants reported excellent results, 16 said they were good, and 11 reported fair or poor satisfaction.
In contrast, all control participants reported good or excellent satisfaction (P=0.02).
The older patients were most pleased with the improvement in hearing in quiet places, with 22 reporting good or excellent satisfaction.
In noisy environments, good or excellent satisfaction was reported by only seven older participants, compared with all 11 of the younger patients (P<0.0001). href="http://www.medpagetoday.com/Geriatrics/Dementia/tb/10197" target="blank">Hearing Test May Measure Cognitive Decline)
The satisfaction results were about the same in 18 participants with one or zero comorbidities as in the 13 with two or more, Dr. Maiberger reported.
On the Glasgow survey, which was completed by 22 of the older participants, mean scores on the social support and general subscales in the older patients were 13.99 (SD 31.66) and 12.49 (SD 31.06), respectively.
Older participants showed negative scores on the physical health component (-7.55, SD 11.15). This component reflects participants' overall physical health and declines would be expected in an elderly sample, Dr. Maiberger said.
The control group had positive physical health scores and much higher scores than the older group on the social support and general subscales.
Dr. Maiberger said the small sample size and potential for selection bias were limitations to the study. On the other hand, he said, its use of objective and validated instruments for evaluating quality of life and strict inclusion and exclusion criteria were strengths.
Rick A. Friedman, M.D., Ph.D., an otolaryngologist at the House Ear Clinic in Los Angeles, said the results confirmed his own experience with older patients.
"Everybody would agree that elderly cochlear implant users probably don't fare as well as younger post-lingual recipients," said Dr. Friedman, who was not involved with the study.
"I think it's not surprising but it's reassuring to see it documented that the quality of life is improved in the elderly patients, even with other comorbid illnesses."
The authors noted that the study was limited by its small size and should be repeated in future studies with larger sample sizes able to identify other factors that may impact performance in elderly cochlear implant patients.
The study had no external funding.
Dr. Maiberger and colleagues reported no potential conflicts of interest.
Dr. Friedman has received a speaker's honorarium from Alcon.
Primary source: American Academy of Otolaryngology-Head and Neck SurgerySource reference:Georgolios A, et al "Performance and QOL after geriatric cochlear implantation" Otolaryngology -- Head and Neck Surgery 2008; 139: S109-10.
Soybean Compound Improves Vascular Function in Stroke Patients

By Todd Neale
HONG KONG, 29 sept 2008 -- Endothelial function in ischemic stroke patients can be significantly improved by supplementation with a compound found in soybeans, a randomized placebo-controlled trial showed.
After 12 weeks, patients who had been taking once-daily oral isoflavone had significantly greater flow-mediated dilation of the brachial artery compared with those who had been taking placebo (P=0.035), Hung-Fat Tse, M.D., Ph.D., of the University of Hong Kong's Queen Mary Hospital, and colleagues reported online in the European Heart Journal.
"These findings may have important implications for the use of isoflavone for secondary prevention in patients with cardiovascular disease, on top of conventional interventions," the researchers said.
However, Dr. Tse said, patients should not start supplementing their diets with the compound or eating more foods rich with isoflavone on the basis of the results.
"At this juncture," he said, "regular isoflavone supplementation might not be advocated since the benefits and side effects of long-term supplementation are still unknown."
In addition, the researchers said, the treatment effect was comparable to that achieved through endurance training or statin therapy.
Dr. Tse and colleagues previously showed improved vascular endothelial function with isoflavone supplementation in patients at high risk for cardiovascular disease, but it remained unknown whether patients with established cardiovascular disease would derive the same benefits.
So they randomized 50 patients who had suffered a first or recurrent ischemic stroke more than six months previously to 80 mg of isoflavone daily and 52 to placebo for 12 weeks.
Overall, the mean age of the patients was 66, and 66% were men. Nine percent had had a recurrent stroke, 10% had coronary artery disease, and 47% had diabetes.
Fasting brachial flow-mediated dilation was measured using ultrasound at baseline and at 12 weeks. The dilation was induced by inflating and releasing a pneumatic tourniquet on the patients' forearms.
A flow-mediated dilation value of 3.7% or lower was considered impaired. The vast majority of the patients (80%) had impaired function at baseline and there were no significant differences between the groups.
By the end of the study, flow-mediated dilation was 1% better in the treatment group than in the placebo group (P=0.035).
In addition, the prevalence of impaired flow-mediated dilation was significantly lower in the treatment group (58% versus 79%, P=0.023).
After adjusting for baseline flow-mediated dilation, isoflavone supplementation was associated with a 68% reduction in the prevalence of endothelial impairment (OR 0.32, 95% CI 0.13 to 0.80, P=0.014).
The effect was greatest in patients with more severe endothelial dysfunction at baseline (P<0.001).
"The findings suggest that isoflavone exerts a secondary vascular protective effect in patients with established atherosclerosis, despite a lack of effect on conventional cardiovascular risk factors including blood pressure, lipid profile, and blood glucose," the researchers said.
Isoflavone supplementation also caused a significant 1.7 mg/dL decrease in high-sensitivity C-reactive protein (P=0.033), which might partly explain the improvement in endothelial function, the researchers said.
Other possible mechanisms include direct action on vasorelaxation, modulation of platelet function, and antioxidant and hypocholesterolemic effects, although the results suggested the latter two explanations do not apply, they said.
In addition, they said, isoflavone is a type of phytoestrogen and its function as a partial estrogen agonist may explain the cardiovascular benefits.
The researchers noted that the treatment effect of isoflavone supplementation may have been underestimated because background isoflavone consumption is higher in Asian populations than in those consuming western diets.
The study was funded by CRCG small project funding from the University of Hong Kong, the Sun Chieh Yeh Heart Foundation, an Outstanding Young Investigator Award from the University of Hong Kong, and an unconditional research donation from Great Liaison Limited in Hong Kong.
The authors did not declare any conflicts of interest.
Primary source: European Heart JournalSource reference:Chan Y-H, et al "Reduction of C-reactive protein with isoflavone supplement reverses endothelial dysfunction in patients with ischemic stroke" Eur Heart J 2008; DOI: 10.1093/eurheartj/ehn409.
Candesartan Has Limited Effectiveness for Diabetic Retinopathy

29 sept 2008--Candesartan, an angiotensin II receptor blocker, modestly reduces the development of retinopathy in type 1 diabetes and encourages regression of the condition in type 2 diabetes, according to two Lancet reports released online.
In separate studies, industry-funded researchers randomized 3300 patients with type 1 diabetes and 1900 with type 2 diabetes to either daily candesartan or placebo, with follow-up for a median 4.7 years. (Type 1 diabetics were normotensive, and patients with type 2 disease could be either normotensive or receiving treatment for hypertension.)
Type 1 diabetics on candesartan had a modest reduction in the incidence of retinopathy, but there was no effect on progression among those who already had retinopathy.
Among type 2 diabetics with established retinopathy, candesartan lowered the risk for progression of the complication, although not significantly. The drug also prompted regression among those with early retinopathy.
Commentators conclude that candesartan has benefits, but "with some caveats" about their limit.
Lancet article on candesartan in type 1 diabetes (Free abstract; full text requires subscription)
Lancet article on candesartan in type 2 diabetes (Free abstract; full text requires subscription)
Lancet comment (Subscription required)
Study Suggests Optimal Wait Times for Surgery After Stenting

By Peggy Peck
ROCHESTER, Minn., 27 sept 2008-- Elective surgery should be delayed for 90 days following placement of a bare-metal coronary stent and for more than a year when a drug-eluting device is used, researchers here reported. Those findings emerged from a pair of studies, published in the October issue of Anesthesiology, that examined cardiac risks associated with noncardiac elective surgery for patients who had undergone percutaneous coronary interventions using stents. The studies confirmed that surgical risks are greatest when patients are receiving dual antiplatelet therapy (aspirin and clopidogrel [Plavix]), said study co-author Charanjit S. Rihal, M.D., of the Mayo Clinic in Rochester, Minn. Current American College of Cardiology/American Heart Association guidelines suggest one month of dual antiplatelet therapy and a six-week wait before noncardiac surgery following bare-metal stent placement and at least 12 months of clopidogrel and aspirin after a drug-eluting stent is used and before noncardiac surgery.
Data from 899 patients were included in the researchers' analysis of bare-metal stent outcomes. The drug-eluting stent study included outcomes data from 520 patients.
The bare-mental stent patients were treated from Jan. 1, 1990 through Jan. 1, 2005, and the drug-eluting stent patients were treated from April 22, 2003 through Dec. 31, 2006.
In each analysis the researchers examined the risk for complications among patients who underwent non-cardiac surgery following stent placement and calculated temporal relationships between adverse cardiac events associated with the surgery and stent placement.
Among the findings:
There was no significant association between the risk of a major acute coronary event following noncardiac surgery and the timing of drug-eluting stent placement, but the lowest event risk occurred for surgeries performed more than 12 months after stenting.
Among patients who received bare-metal stents, the complication rate was 10.5% for surgeries performed less than 30 days after PCI, 3.8% for surgeries between 31 and 90 days, and 2.8% after 90 days.
Among patients with bare-metal stents, multivariate analysis confirmed that time between stenting and surgery was a significant predictor of cardiac complications of surgery (OR 3.2, 95% CI 1.5 to 6.9, P=0.006)
Univariate analysis found that age, shock at time of PCI, use of dual antiplatelet therapy, and prior history of myocardial infarction were the significant predictors of cardiac complications of noncardiac surgery in patients with drug-eluting stents (all P<0.05), but the single greatest predictor was emergent surgery (P=0.006)
In an editorial that accompanied the papers, Charles W. Hogue, Jr., M.D. and Jeffrey J. Rade, M.D., of Johns Hopkins Medical Institutions, said the studies "add to a growing body of literature demonstrating that timing really is everything when considering the risks and management of strategy of noncardiac surgery in patients with coronary stents."
Drs. Hogue and Rade wrote that it was also reassuring that the data confirm "the current guidelines, which recommend delaying elective noncardiac surgery for at least six weeks after BMS implantations and one year after DES implantation, but caution that some risk does extend beyond those time frames."
Dr. Rihal and colleagues noted that their studies, while reassuring, were limited by their retrospective design and by the failure to capture data such as beta-blocker and statin use.
Another limitation noted by the authors and the editorialists was the lack of a control group who underwent coronary angiography, had documented coronary artery disease that was not treated with PCI or CABG, and then went on to have noncardiac surgery.
The studies were institutionally funded.
Dr. Rihal reported no financial disclosures.
Drs. Hogue and Rade reported funding from the National Institutes of Health and the American Heart Association. Dr. Rade also reported funding from BMS/Sanofi.
Primary source: AnesthesiologySource reference:Nuttall GA, et al "Time and Cardiac Risk of Surgery after Bare-metal Stent Percutaneous Coronary Intervention" Anesthesiology 2008; 109: 588-95. Additional source: AnesthesiologySource reference: Rabbitts JA, et al "Cardiac Risk of Noncardiac Surgery after Percutaneous Coronary Intervention with Drug-eluting Stents" Anesthesiology 2008; 109: 596-604. Additional source: AnesthesiologySource reference: Rade JJ, Hogue CW Jr "Noncardiac surgery for patients with coronary artery stents: Timing is everything" Anesthesiology 2008 109: 573-5.
NAMS: Estrogen Cream Eases Vaginitis with No Endometrial Safety Signals

By Charles Bankhead
ORLANDO, 29 septc 2008-- Moderate to severe atrophic vaginitis can be eased for postmenopausal women by either of two low doses of estrogen cream, with no endometrial safety signals, investigators reported here.
Both low-dose regimens of the conjugated estrogen cream led to significant improvement in vaginal maturation index, vaginal pH, and most bothersome symptoms compared with placebo, Gloria Bachmann, M.D., of Robert Wood Johnson Medical School in New Brunswick, N.J., said at the North American Menopause Society meeting.
The improvement was statistically significant at 12 weeks and persisted during follow-up for a year.
In a subgroup of patients who had endometrial biopsies, no cases of endometrial hyperplasia or carcinoma occurred with either estrogen cream regimen.
"Low-dose [vaginal estrogen cream] represents an important therapy for treating atrophic vaginitis without endometrial safety concerns over a one-year study period," Dr. Bachmann and colleagues concluded.
As many as 40% of postmenopausal women are affected by atrophic vaginitis. Vaginal application of topical low-dose estrogens is thought to reduce systemic exposure to estrogen and limit its stimulatory effects on the endometrium, the investigators said.
Both daily and twice-weekly vaginal administration of low-dose vaginal estrogen cream have demonstrated efficacy for reducing symptoms of atrophic vaginitis. Dr. Bachmann reported findings from a randomized clinical trial comparing the two regimens.
The study involved 423 postmenopausal women who were randomized and received at least one dose of assigned therapy. The patients had symptoms of moderate or severe atrophic vaginitis, including a baseline composite symptom score of 5 for vaginal dryness, itching, burning, and dispareunia; a total score of <15 on the General Health Clinical Evaluation.
The patients were randomized to four treatment groups: daily or twice-weekly vaginal estrogen cream (0.5 g) or a matching placebo group for each administration schedule. Patients assigned to daily treatment were on therapy for 21 days, followed by seven days off.
The primary efficacy assessment was the change from baseline to week 12 in vaginal maturation index, vaginal pH, and most bothersome self-reported symptom. Patients continued open-label treatment of assigned therapy for the remaining 40 weeks.
Both active-therapy regimens led to significantly greater improvement in all outcome measures at 12 weeks compared with placebo.
A total of 155 patients treated with either regimen of vaginal estrogen cream had evaluable endometrial biopsies. In the patients assigned to daily therapy, six of 85 had evidence of proliferative endometrium. Among 72 assigned to twice-weekly treatment, six had proliferative endometrium.
No patient in either group developed endometrial hyperplasia or carcinoma. Transvaginal ultrasound at the end of the study revealed endometrial thickness ≥5 mm in 18 patients assigned to daily vaginal estrogen cream and in 12 patients on the twice-weekly regimen.
In general, adverse events were similar in the active-treatment and placebo groups, Dr. Bachmann reported, and treatment-emergent adverse events were uncommon. Treatment-emergent vaginal bleeding occurred in no more than two patients in any randomized group during the double-blind and open-label phases of the study.
The study was supported by Wyeth Research.
Investigators in the study included Wyeth employees.
Primary source: North American Menopause Society meetingSource reference:Bachmann G, et al "Endometrial safety of two low-dose regimens of conjugated estrogens vaginal cream in postmenopausal women with atrophic vaginitis over one year of therapy" NAMS Meeting 2008.

Sunday, September 28, 2008

Study: Doctors show little empathy

By Rita Rubin, USA TODAY
28 sept 2008--Physicians might be superb at diagnosing and treating diseases, but they could use a lesson or two about how to care for their patients' psyches, a study suggests. It found that cancer specialists and surgeons rarely responded with empathy to patients' concerns.
Researchers assessed transcripts of 20 audio recordings of consultations between men with lung cancer and surgeons or oncologists at a Veterans Affairs hospital. The transcripts revealed 384 opportunities for the doctors to show empathy — patient comments such as "this is overwhelming" and "I'm fighting it" — but they missed all but 39, researchers write in Tuesday's Archives of Internal Medicine.
"They really responded more to the concrete patient concerns and not so much to their existential fears about living and dying," says lead author Diane Morse, assistant professor of psychiatry and of medicine at the University of Rochester in New York. "I think doctors themselves can feel vulnerable about the issue of death and dying. It is a scary subject, especially if it's someone who has cancer and is close to their own age."
Previous studies have shown that patients whose doctors show empathy are more satisfied with their medical encounters, which leads to a better understanding of their condition and lower anxiety, Morse and her co-authors write.
"All people go to medical school because they want to help people," Morse says. Sometimes, she says, a simple "I know that this is really scary" can go a long way in making patients feel better.
Hospital Bracelets Face Hurdles as They Fix Hazard

28 sept 2008--At hospitals, as at Tiffany’s, ruby-colored bracelets are far preferable to amethyst.
New York’s 11 public hospitals are at the forefront of a national movement to standardize color coding of hospital wristbands to designate patient conditions, in which purple — the color of amethyst — means “Do Not Resuscitate.” Red, or ruby, indicates allergies, while yellow — call it amber — marks someone at risk for falling.
The goal is to prevent potentially dangerous mistakes, like giving the wrong food to an allergic child, or allowing a patient with balance problems to walk unescorted down a freshly waxed hallway. The drive was spurred, in part, by a notorious 2005 Pennsylvania case in which a patient nearly died because a nurse used a yellow band thinking it meant “restricted extremity” (don’t draw blood from that arm), as it did at another hospital where the nurse sometimes worked, when at this hospital it meant D.N.R.
While the new color-coding has been quickly embraced by at least 20 states and endorsed by the American Hospital Association, the purple bands, typically embossed with the letters D.N.R. to reinforce the message, are meeting with some resistance.
The nation’s leading hospital-accreditation agency, known as the Joint Commission, has expressed caution about the new system, citing concerns about branding patients by their end-of-life choices, or inadvertently broadcasting those choices to family and friends who have not been consulted.
The commission also said that children who do not understand the system had been prone to trade the wristbands like baseball cards.
“You need to strike a balance between the need for patient safety and accuracy and the whole privacy concern and sensitivity and compassion for the patient,” said Roxanne G. Tena-Nelson, executive vice president of the Continuing Care Leadership Coalition, a group of long-term-care providers in New York.
In most places, the new bracelets replace colored ones that have been used for decades without uniformity: a survey by the Greater New York Hospital Association last year found nine different colors used to denote patients with D.N.R. orders, five to indicate allergies and nine to highlight risks of falling. There is still some variation. Ohio has adopted the red and yellow bands but has avoided the purple ones because they conflict with a state law requiring a clear wristband for D.N.R.’s.
In New York, the Roosevelt Hospital division of St. Luke’s-Roosevelt Hospital Center, near Columbus Circle, began using the yellow and red bracelets this month, but is still debating whether to add purple. In Arizona, one hospital embossed its purple bracelets with a white dove carrying an olive branch, rather than D.N.R., while another chose the initials A.N.D., for “allow natural death,” as a gentler alternative.
Kim Miyauchi, associate nursing director at Kingman Regional Medical Center, the Arizona hospital that uses the white dove, said officials there worried that wearing the initials D.N.R. on one’s wrist was “a little bit harsh,” and also failed to convey nuances best captured in a medical chart, as with a patient who wants medication for heart failure but not to be shocked by a defibrillator.
“Sometimes people want varying levels of treatment at the end of life,” she explained. “Sometimes it’s not so clean as just don’t do anything.”
Attuned to the sensitivities, hospitals have cautioned their staffs that wearing the color-coded bracelets is voluntary, and that patients are allowed to opt for some other method instead, like colored dots — or just old-fashioned notations — on medical charts.
Some hospitals have also had problems with colored bracelets that patients bring from home, like the ubiquitous yellow Lance Armstrong “Livestrong” bracelets. Most hospitals are asking patients to cut these off, but if they refuse, the popular bangle can be covered with tape instead.
Proponents of the new system argue that standardized colors are essential to patient safety, especially since nurses and doctors often move among several hospitals.
The specifics are based both on historic precedent and the sign language of colors. Yellow, for falls, is commonly understood as a symbol for caution, whether by janitors mopping floors or by traffic engineers. Red, for allergies, is associated with a command to stop and check for danger. In the past, some hospitals have used blue to signify D.N.R., but it was ruled out on a national level, Ms. Tena-Nelson said, because the phrase “Code Blue,” is often used to call for resuscitation, the opposite of what D.N.R. patients want.
The color-coded system could be seen in full flower the other day on Yau N. Wan Gong, 77, who was recovering from gallstone surgery at Roosevelt.
Mrs. Gong was taking her afternoon promenade in the post-surgical ward wearing hospital-issued yellow slipper-socks, to denote that she was at risk of falling, along with two plastic bracelets on her right arm, one yellow, like the socks, the other pink. Pink has been adopted by some hospitals to indicate that a limb is somehow compromised and should not be used for procedures like drawing blood or inserting an intravenous line. (Mrs. Gong recently had surgery on her right side, so that arm is weak.)
Roosevelt also uses green bracelets, to mean “no blood transfusions,” usually at the request of a patient with religious beliefs that conflict with transfusions. But in Minnesota and Colorado, as in New Jersey, green indicates a latex allergy.
In Mrs. Gong’s case, the hospital staff had allowed her to continue wearing a green jade bracelet, which her son, Peter Gong, who was accompanying her on her walk, said gives his mother comfort because in Chinese culture it is supposed to ward off arthritis pain. Mr. Gong said nurses had carefully explained the color-coding system and asked for his mother’s consent, and that he was all in favor of it, hoping that “people will have a little more patience, hopefully, and understand that she is not as quick as a younger person.”
The system has made some patients more aware of the possibility for simple yet potentially fatal errors in any hospital.
When nurses at Roosevelt pointed out the yellow fall-risk name tag on his hospital room door, Tom Pineault, 74, a former merchant seaman who had just emerged from surgery for an ulcerated foot, also checked the tag for his name. “I made sure that was me that was in there,” he said. “I didn’t want to end up with somebody else’s meal.”
At Metropolitan Hospital on the Upper East Side, officials handed out red, yellow and purple pens to drive home the new color-coding system to the staff, since the hospital had previously used red bands, now for allergies, to denote “no blood transfusions,” now green.
Meryl Weinberg, the hospital’s executive director, said some employees worried that psychiatric patients would become obsessed with fiddling with the bands, but that has not turned out to be a problem.
As for the purple bracelet, “We did have one patient refuse to wear it because of the family not knowing,” said Patricia Graham, deputy director of nursing at Metropolitan. But she said the hospital had found the privacy concern less pressing than anticipated, noting that many patients who choose not to be revived are deeply committed to their decision, even proud of it.
And, she noted, most D.N.R. patients are in such poor condition that they rarely walk the hallways for all to see. To illustrate, Ms. Graham took a visitor to a room where a comatose woman was lying in bed attached to a ventilator and intravenous feeding tube. On the woman’s wrist was a green band — no transfusions, please — and a purple one.
Publication of Clinical Trials Supporting Successful New Drug Applications: A Literature Analysis

by Kirby Lee
28 sept 2008--The United States (US) Food and Drug Administration (FDA) approves new drugs based on sponsor-submitted clinical trials. The publication status of these trials in the medical literature and factors associated with publication have not been evaluated. We sought to determine the proportion of trials submitted to the FDA in support of newly approved drugs that are published in biomedical journals that a typical clinician, consumer, or policy maker living in the US would reasonably search.

Methods and Findings
We conducted a cohort study of trials supporting new drugs approved between 1998 and 2000, as described in FDA medical and statistical review documents and the FDA approved drug label. We determined publication status and time from approval to full publication in the medical literature at 2 and 5 y by searching PubMed and other databases through 01 August 2006. We then evaluated trial characteristics associated with publication. We identified 909 trials supporting 90 approved drugs in the FDA reviews, of which 43% (394/909) were published. Among the subset of trials described in the FDA-approved drug label and classified as “pivotal trials” for our analysis, 76% (257/340) were published. In multivariable logistic regression for all trials 5 y postapproval, likelihood of publication correlated with statistically significant results (odds ratio [OR] 3.03, 95% confidence interval [CI] 1.78–5.17); larger sample sizes (OR 1.33 per 2-fold increase in sample size, 95% CI 1.17–1.52); and pivotal status (OR 5.31, 95% CI 3.30–8.55). In multivariable logistic regression for only the pivotal trials 5 y postapproval, likelihood of publication correlated with statistically significant results (OR 2.96, 95% CI 1.24–7.06) and larger sample sizes (OR 1.47 per 2-fold increase in sample size, 95% CI 1.15–1.88). Statistically significant results and larger sample sizes were also predictive of publication at 2 y postapproval and in multivariable Cox proportional models for all trials and the subset of pivotal trials.

Over half of all supporting trials for FDA-approved drugs remained unpublished 5 y after approval. Pivotal trials and trials with statistically significant results and larger sample sizes are more likely to be published. Selective reporting of trial results exists for commonly marketed drugs. Our data provide a baseline for evaluating publication bias as the new FDA Amendments Act comes into force mandating basic results reporting of clinical trials.

New Merck osteoporosis drug boosts bone density

28 sept 2008--A new type of osteoporosis drug being developed by Merck & Co. increased bone density over two years in postmenopausal women with mild osteoporosis, the company reported Tuesday.
The drug, known chemically as odanacatib, increased bone density in a midstage trial by about 5.5 percent in the lower spine, while a comparison group of women getting dummy pills on average had bone density decrease about 0.2 percent from its level at the start of the study.
Over the same two years, bone density in women getting the drug increased 3-4 percent at the hip and upper thigh bone, while those on dummy pills saw decreases of nearly 1 percent at both sites.
Art Santora, head of clinical research for musculoskeletal conditions at Merck, said existing treatments generally increase bone mass in the first year of treatment, then just maintain it, but odanacatib continued to increase bone mass in the second year.
The results were for the 50-milligram dose of odanacatib. Three lower doses also were tested, but women getting the lowest dose saw bone density decrease. About 400 women, aged 64 on average, got one of the four drug doses or a dummy pill weekly for two years in the study, plus calcium and vitamin D supplements.
Merck now is focusing on the 50-milligram dose and has begun an international, final-stage study of it that is to include about 17,000 women.
The new data were reported Tuesday at the American Society for Bone and Mineral Research conference in Montreal.
Slightly more than one-third of the women - in the group getting placebo as well as those getting odanacatib - had side effects including nausea, headache, muscle spasms and rash; about 8 percent getting the 50-milligram dose of the drug stopped taking it.
Santora said odanacatib works by inhibiting an enzyme called cathepsin K. The enzyme breaks down the collagen matrix that holds bone together, and the drug prevents the enzyme from breaking down calcium and protein deep in the bone, he said.
Osteoporosis drugs already on the market, which can reduce fracture risk by half, instead work by blocking the function of bone cells called osteoclasts that break down old bone, Santora said.
Merck's former blockbuster osteoporosis treatment, Fosamax, lost patent protection earlier this year, except for a version that includes high doses of vitamin D.
Breast self-exams: What should YOU do?

28 sept 2008--Even though her mammogram showed no sign of cancer, Sandra Litt knew she could feel a lump. She had a second mammogram. Nothing there, the radiologist assured her.
"Then one night, I found the 'nothing there' had grown bigger," Litt said. Her self-exam had proved accurate. Two years ago, Litt underwent a double mastectomy and months of chemotherapy to survive an aggressive breast cancer.
It defies common sense, she says, for scientists to conclude that breast self-exams do women more harm than good.
"It's a very important tool," the 67-year-old Portland woman says. "Why throw away an important tool?"
A scientific review, published in August by the Cochrane Library, highlighted the downside of doing breast self-exams: Women taught to perform the monthly ritual wind up having unnecessary biopsies. They are about twice as likely to undergo biopsies that won't find cancerous tumors, according to two studies tracking hundreds of thousands of women in China and Russia.
Conflicting news coverage has heightened the confusion. "Breast self-exam has no benefit," one headline proclaimed. "Breast self-exam key in catching what mammogram may miss," another said.
What is clear is that studies don't supply an answer that fits all women.
For more information
Breast Center at OHSUKomen for the Cure
Dr. Elizabeth Steiner, director of the breast health education program at Oregon Health & Science University, said each woman must decide for herself, with full knowledge of the pros and cons, whether to perform self-exams. And there's not a right or wrong answer.
Some may do the exams and accept the risk of unnecessary biopsies, she said. Others may decide that either they can't commit the time to do them right, or that the potential for false alarms and anxiety isn't worth it. "That's a very personal decision," Steiner said.
Unknown effectiveness When doctors began promoting breast self-exams in the 1950s, the benefits seemed obvious. Here was a simple, inexpensive do-it-yourself way for women to find tumors before it was too late.
During the women's health movement of the 1970s, the self-exam gained importance as a means for women to take charge and rely less on a paternalistic health system.
But researchers have learned that self-exams aren't at all simple. The technique is complicated and difficult to learn to do well. Guidelines on how to do them correctly have evolved, leaving many women and doctors with outdated ideas. Further, decades of research still have not produced good evidence that self-exams make any difference in breast cancer survival.
"Not only do the trials not find a benefit, the trials demonstrate harm in terms of increased physician visits and benign breast biopsies," said Dr. Nancy Baxter, a University of Toronto surgeon who reviewed the evidence on self-exams for the Canadian Task Force on Preventive Health Care. She said self-exams may not reveal tumors early enough to improve survival.
"By the time a breast cancer is large enough to be detected by self-exam, tumor biology is the most important predictor of outcome, not finding a tumor a few months before it would have become apparent," she said.
Given the lack of evidence, the American Cancer Society stopped advocating self-exams in 2003. The U.S. Preventive Services Task Force considers the exams unproven. And the Canadian Task Force on Preventive Health Care has recommended against routine teaching of breast self-exams since 2001.
Unnecessary biopsies may not be the only hidden cost.
"One danger of pushing breast self-exams on patients is that they may be falsely reassured by it and opt out of their mammograms," said Dr. Heidi Nelson, medical director of the Providence Women and Children's Program in Portland. She stopped routinely teaching self-exams to patients after the large trials in China and Russia showed no benefit.Technique important Some evidence does suggest that self-exams done properly could make a difference.
For instance, they provide a means to search for tumors in outer parts of the breast where mammography may not reach. About half of breast cancers develop in the upper-outer quadrant of the breast, which is largely inaccessible to mammography scanners.
A small study in Canada in 1997 found that self-exams seemed to improve survival among a subset of women using proper technique. The preferred method, known as the vertical strip, three-pressure test, has proved the most sensitive and least likely to produce false alarms, Steiner said.
In the largest and most influential study to date, involving 266,000 women in Shanghai, Steiner said researchers taught an inferior method of exams. She said that could partly explain why the Shanghai study failed to find improved survival.
Self-exams also appeal strongly to some younger women, whose main screening test is a manual exam done by a doctor or nurse. Mammography is considered inappropriate for women younger than 40, and many doctors don't recommend it until age 50.
If a woman decides to do self-exams, Steiner said, it's important to learn to do them right -- and do them every month without fail.
"Done haphazardly and irregularly, it is probably worse than no breast self-exam at all," Steiner said. She encourages women to schedule an appointment devoted to learning the technique, which should take at least a half-hour. A few minutes squeezed into a routine annual exam aren't enough, she said.
Steiner said not all doctors are up to speed on breast exam technique, which calls for lying down, not taking a few minutes standing in the shower -- the form pushed for years by physicians and even anti-breast cancer groups. "It's important to ask, 'Do you feel confident in your own technique and training me how to do it?'" she said.
Nelson cautions women not to skip their mammograms if they don't find lumps during self-exams. But finding a lump also is no reason to panic, given the limited accuracy of the self-test.
Litt, the breast cancer survivor, has another piece of advice: "Do not ignore your own judgment; and be assertive," she said. "You don't get a do-over."

Saturday, September 27, 2008

Taking Time for Empathy

27 sept 2008--I would like to believe that I am a compassionate doctor. But when I must convey bad news to a patient, one of the first things I worry about is time.
One of the most challenging, and potentially rewarding, aspects of being a doctor is responding and acknowledging patients’ fear, anger, frustration and sadness. But I have always believed that it takes more time to listen and answer empathetically — time that is hard to ignore when you know there are other patients who have been waiting a long time outside to see you.
A paper this week in a medical journal, though, has made me think a little differently about time and empathy. The study, in The Archives of Internal Medicine, found that physicians overwhelmingly miss opportunities to express empathy to their patients.
Listening to transcripts and recordings of 20 conversations between men with lung cancer and their doctors, Dr. Diane Morse of the University of Rochester School of Medicine and her colleagues identified 384 “empathic opportunities” in the discussions — moments when a doctor might respond with a few words to address patient concerns ranging from fear of illness and death, to mistrust about care and the health care system, to confusion about treatment.
They found that the physicians missed 90 percent of opportunities to respond empathetically to their patients.
One of the reasons for this staggering statistic, the investigators suggest, is lack of time. “In a busy clinic,” the authors wrote, “physicians may believe that there is no time for empathic responses.”
As I read the paper, I remembered one particular afternoon in clinic spent with a man in his late 50s who had liver cancer.
The man, wiry and stooped, had immigrated some 30 years earlier and had worked in restaurants in the Los Angeles area. Accompanying him was his daughter, a radiant 20-something graduate student who spoke comfortably, confidently, in the English that was her first language.
She had researched her father’s diagnosis on the Internet and had arranged to have him seen in our clinic. She wanted to know if we could take out her father’s tumor.
After examining her father, I stepped out of the room to join the other surgeons viewing his CAT scans. As we crowded around the pictures, the tumor emerged — a dark circle in the middle of the man’s liver. View after view, the circle seemed only to widen, an ominous black hole that threatened to swallow what little normal liver was left.
I wanted to scream for the man and his daughter. Instead, I whispered a series of expletives directed at the tumor, then stepped back into the examining room, bracing myself for what would be a hard and, I believed, long conversation. I had to tell this family that the tumor was inoperable.
I had had these kinds of conversations in the past and could only imagine how difficult it would be for this patient and his daughter. I wanted to be compassionate with them, to take the time to listen and to acknowledge their fears and concerns.
But I also did not want to open the floodgates of emotion on an afternoon when the waiting room was overflowing.
In the end, I decided to take the time to listen to the man and his daughter, to ignore for a few moments the clock on the wall.
What surprises me, reflecting back on that interaction, is that despite all the questions and moments of deep emotion that came up during our conversation, the entire visit did not take nearly as long as I had imagined it would. And clinic that afternoon did not run any later than usual.
It did not take more time to be open to the man and his daughter’s emotional needs and to acknowledge them with a few words.
The results of Dr. Morse’s study have already made their way onto the Internet. “For Some Doctors, Empathy Is in Short Supply,” the headlines read.
But the statistic about doctors’ missed empathic opportunities is not, I believe, what is so intriguing about her study.
What is most interesting — and, I believe, most important — about this study is that empathy, expressed throughout a patient-doctor encounter, may actually help to alleviate problems with time.
Or at least not exacerbate them to the extent that many doctors, including myself, fear.
Dr. Morse and her colleagues found that while patients brought up important emotional issues throughout a visit, their doctors tended to express the bulk of their empathy toward the end of that visit.
When doctors did not respond to initial opportunities to be empathetic, patients would try repeatedly, throughout the rest of the visit, to elicit that support in some way.
In other words, too little empathy, or empathy expressed too late in an encounter, may actually result in longer visits.
When the doctors did respond in a way that explicitly recognized patient emotions, patient responses were not long, as some of us might imagine. Instead, patients usually responded with one or two words, or a single sentence.
There is, then, no floodgate.
Not long after I spoke to that man with liver cancer in clinic, I received a note from his daughter:
I just wanted to say thank you deeply for all your assistance and care regarding my father. Finding out my father has cancer has consumed me and my family emotionally and physically. Meeting you and the entire team calmed my heart more than you can know.
We had finished our visit in time, and it was, I believe, worth every minute.
Researchers study how pistachios may improve heart health

27 sept 2008--Going green may be heart healthy if the green you choose is pistachio nuts, according to researchers at Penn State who conducted the first study to investigate the way pistachios lower cholesterol.
"We investigated mechanisms of action to explain the cholesterol-lowering effects of the pistachio diets," says Sarah K. Gebauer, recent Penn State Ph.D. recipient, currently a post-doctoral research associate, USDA Beltsville Human Nutrition Research Center.
The researchers conducted a randomized, crossover design, controlled feeding experiment to test the effects of pistachios added to a heart healthy moderate-fat diet on cardiovascular disease risk factors. Controlled feeding experiments provide all the food eaten by study subjects for the duration of the study segment.
The participants began the study by eating a typical American diet consisting of 35 percent total fat and 11 percent saturated fat for two weeks. They then tested three diets for four weeks each with about a two-week break between each diet. All three diets were variations on the Step I Diet, a cholesterol-lowering diet in general use. The diets included, as a control, a Step I Diet with no pistachios and about 25 percent total fat and 8 percent saturated fat. The pistachio enhanced diets were Step I Diets with 10 and 20 percent of the energy supplied by pistachio nuts, respectively. The 10 percent pistachio diet had 30 percent total fat and 8 percent saturated fat and the 20 percent pistachio diet had 34 percent total fat and 8 percent saturated fat.
The participants ate half their pistachios as a snack and the rest incorporated into meals.
The researchers report in the most recent issue of the American Journal of Clinical Nutrition that "Inclusion of pistachios in a healthy diet beneficially affects cardiovascular disease risk factors in a dose-dependent manner, which may reflect effects on Stearoyl CoA Desaturase (SCD). " The researchers used the ratio of two fatty acids, 16:1 and 16:0 in plasma as a marker for SCD, an enzyme that is involved in the body's synthesis of fatty acids.
"SCD is an important enzyme involved in cholesterol metabolism," says Gebauer.
They found the ratio of 16:1/16:0 was significantly lower, suggesting a decrease in SCD activity, after eating the 20 percent energy pistachio diet compared to the control diet which had no pistachios. Also, the change in the 16:1/16:0 ratio was correlated with the change in cholesterol, suggesting that SCD activity may contribute to the lipid-lowering effects of pistachios. That, accompanied by the dose-dependent effects of the pistachios, begins to unravel the way in which pistachios improve cardiovascular health.
Compared to the control diet, the 20 percent pistachio diet lowered LDL cholesterol -- bad cholesterol -- about 12 percent and the 10 percent energy pistachio diet lowered LDL cholesterol by 9 percent that suggests a 9 to 12 percent decrease in coronary heart disease risk. The relationships of total cholesterol to HDL cholesterol and LDL cholesterol to HDL cholesterol may be more powerful predictors of cardiovascular risk. The effects of the 10 and 20 percent energy diets showed a dose dependent effect on these ratios.
However, the researchers note that the reduction in LDL cholesterol observed was seven times greater than would be expected from only the fatty acid profile of pistachios. They suggest that the lipid lowering effects not only reflect the fatty acid profile of the diet, but also are the result of other bioactive substances in pistachios, perhaps phytosterols and fiber.
"Our study has shown that pistachios, eaten with a heart healthy diet, may decrease a person's CVD risk profile, says Penny Kris-Etherton, distinguished professor of nutrition and primary investigator of the study."
Researchers conducting the study included Gebauer; Kris-Etherton; Sheila G. West, associate professor of biobehavioral health; and Deborah Bagshaw, clinical coordinator, Penn State; Colin D. Kay, former Penn State post doctoral associate now at the University of East Anglia, UK; and P. Alaupovic, Oklahoma Medical Research Foundation, Oklahoma City.
U.S. pistachio growers supported this study. Partial support also came from the NIH- supported GCRC at Penn State.
Do 'light' cigarettes deliver less nicotine to the brain than regular cigarettes?

27 sept 2008--For decades now, cigarette makers have marketed so-called light cigarettes — which contain less nicotine than regular smokes — with the implication that they are less harmful to smokers' health. A new UCLA study shows, however, that they deliver nearly as much nicotine to the brain.
Reporting in the current online edition of the International Journal of Neuropsychopharmacology, UCLA psychiatry professor Dr. Arthur L. Brody and colleagues found that low-nicotine cigarettes act similarly to regular cigarettes, occupying a significant percentage of the brain's nicotine receptors.
Light cigarettes have nicotine levels of 0.6 to 1 milligrams, while regular cigarettes contain between 1.2 and 1.4 milligrams.
The researchers also looked at de-nicotinized cigarettes, which contain only a trace amount of nicotine (0.05 milligrams) and are currently being tested as an adjunct to standard smoking-cessation treatments. They found that even that low a nicotine level is enough to occupy a sizeable percentage of receptors.
"The two take-home messages are that very little nicotine is needed to occupy a substantial portion of brain nicotine receptors," Brody said, "and cigarettes with less nicotine than regular cigarettes, such as 'light' cigarettes, still occupy most brain nicotine receptors. Thus, low-nicotine cigarettes function almost the same as regular cigarettes in terms of brain nicotine-receptor occupancy.
"It also showed us that de-nicotinized cigarettes still deliver a considerable amount of nicotine to the brain. Researchers, clinicians and smokers themselves should consider that fact when trying to quit."
In the brain, nicotine binds to specific molecules on nerve cells called nicotinic acetylcholine receptors, or nAChRs. When nerve cells communicate, nerve impulses jump chemically across gaps between cells called synapses by means of neurotransmitters. The neurotransmitters then bind to the receptor sites on nerve cells — in the case acetylcholine resulting in the release of a pleasure-inducing chemical called dopamine. Nicotine mimics acetylcholine, but it lasts longer, releasing more dopamine.
"It can cause specific neurons to communicate and thus increases dopamine for an extended period of time," Brody said. "Most scientists believe that's one key reason why nicotine is so addictive."
In an earlier study, researchers determined that smoking a regular, non-light cigarette resulted in the occupancy of 88 percent of these nicotine receptors. However, that study did not determine whether inhaling nicotine or any of the thousands of other chemical found in cigarette smoke resulted in this receptor occupancy. The central goal of the present study was to determine if factors associated with smoking — other than nicotine — resulted in nAChR occupancy.
The authors reasoned that if nicotine is solely responsible for receptor occupancy, then smoking a de-nicotinized cigarette or a low-nicotine cigarette would result in the occupancy of roughly 23 percent and 78 percent of nicotine receptors, respectively, based on the cigarettes' nicotine content.
"That would still be substantial," Brody said.
Fifteen smokers participated in the study. Each was given positron emission tomography (PET) scans, a brain-imaging technique that uses minute amounts of radiation-emitting substances to tag specific molecules. In this case, the tracer was designed to bind to the nicotine receptors in the brain.
The researchers could then measure what percentage of the tracer was displaced by nicotine when the research subjects smoked. In total, 24 PET scans were taken of participants' brains before and after three different conditions: not smoking, smoking a de-nicotinized cigarette and smoking a low-nicotine cigarette.
The PET data showed that smoking a de-nicotinized cigarette and a low-nicotine cigarette occupied 26 percent and 79 percent of the receptors, respectively, which was very close to what the researchers had originally estimated.
"Given the consistency of findings between our previous study with regular cigarettes and the present study — that showed us that inhaling nicotine during smoking is solely responsible for occupancy of brain nicotine receptors," Brody said.
In addition to Brody, other authors of the study were Mark A. Mandelkern, Matthew R. Costello, Anna L. Abrams, David Scheibal, Judah Farahi, Edythe D. London, Richard E. Olmstead, Jed E. Rose and Alexey G. Mukhin. The researchers report no conflicts of interest. Rose, from the Duke University School of Medicine, has received research support for a study unrelated to the present paper from Vector Tobacco Inc., the manufacturer of Quest cigarettes.

Friday, September 26, 2008

Voice Problems in Seniors Undertreated

26 sept 2008 -- Voice and swallowing problems aren't a normal part of aging, but many seniors with these conditions don't receive treatment, even though they may suffer serious quality-of-life issues such as anxiety, depression and social withdrawal, say Duke University Medical Center researchers.
They surveyed 248 octogenarians and found that almost 20 percent had dysphonia (hoarseness, weakness or loss of voice), and 14 percent had dysphagia (difficulty swallowing). The Duke team also found that 77.6 percent of those with dysphonia and 79.4 percent of those with dysphagia had not sought treatment, even though 55.9 percent of them expressed interest in getting help.
Half of those surveyed weren't aware there are treatments for dysphonia and dysphagia.
The findings were presented at the annual meeting of the American Academy of Otolaryngology--Head and Neck Surgery, in Chicago.
"Voice and swallowing issues are serious concerns, and people who want medical care are not getting it," study author and otolaryngologist Dr. Seth Cohen said in a Duke news release.
"Is it because they have so many medical problems, and these issues are getting pushed aside or overlooked? We don't know. What we do know is these medical concerns have a huge impact on quality of life, and more people should be aware of treatments available and be able to obtain them," Cohen said.
Previous research has suggested that almost 25 percent of seniors believe voice and swallowing problems are a normal part of aging. This belief is even more common among seniors with voice and swallowing problems. This attitude may lead some elderly people to simply accept these conditions and not seek treatment, said the Duke researchers.
"Our results highlight the need for better education of the general public and primary-care providers," Cohen said. "Whether this effort leads to increased awareness and/or better outcomes for these patients is the basis of further study. But, for now, we know these problems have a significant negative impact on quality of life, and obtaining appropriate treatment can make a big difference."
More information
The American Academy of Otolaryngology--Head and Neck Surgery has more about voice and aging.
Surgery unnecessary for 95 percent of those with asymptomatic carotid stenosis

26 sept 2008--Research led by Dr. David Spence of Robarts Research Institute at The University of Western Ontario shows that with more intensive medical therapy, the risk of stroke has become so low that at least 95 per cent of patients with asymptomatic carotid stenosis (ACS) would be better off with medical therapy than with surgery or stenting. ACS is a narrowing in the carotid artery, which supplies blood to the brain, which has not yet resulted in a stroke or transient ischemic attack (TIA). In the United States, one-half to two-thirds of the patients being subjected to surgery for revascularization are asymptomatic.
Spence will present his findings September 25th at the 6th World Stroke Congress being held in Vienna, Austria. He is the Director of the Stroke Prevention & Atherosclerosis Research Centre, a professor of neurology and clinical pharmacology at Western's Schulich School of Medicine & Dentistry and the author of "How to Prevent Your Stroke".
Spence says the less than five per cent of ACS patients who could benefit from revascularization can be identified with a procedure called Transcranial Doppler Embolus Detection: a helmet is placed on the head to hold ultrasound probes in place, and the arteries inside the head are monitored for microemboli, small blood clots or chunks of plaque that break off from the narrowing in the carotid artery and go into the brain arteries.
The historical benefit of revascularization for ACS was based on less intensive medical therapy than is now prevalent. Spence and a team of researchers studied 471 ACS patients. Of those, 199 were seen before 2003 and 272 after January 1, 2003. Microemboli were present in 12.6 per cent of patients before 2003, but in only 3.7 per cent since 2003. The decline in microemboli was associated with better control of plasma lipids and slower progression of carotid plaque. Since 2003, there have been significantly fewer strokes and hear attacks.
"The 96 per cent of patients without microemboli have only a one per cent risk of stroke in the next year, whereas the ones with microemboli have a 14 per cent risk of stroke," says Spence. "Since the risk of surgery is four to five per cent, patients without microemboli are better off with medical therapy including medications and lifestyle modifications. Only the ones with microemboli would benefit from carotid endarterectomy or stenting."
Mayo Clinic discovery may help diabetic gastric problem

ROCHESTER, Minn., 26 sept 2008 -- Mayo Clinic researchers have found what may provide a solution to one of the more troubling complications of diabetes -- delayed gastric emptying or gastroparesis. The researchers showed in animal models that a red blood cell derivative increases production of a key molecule, normalizing the digestive process. The findings appear in the current online issue of the journal Gastroenterology (http://www.gastrojournal.org/).
Gastroparesis occurs when the stomach retains food for longer periods. When that food eventually passes into the small intestine, insulin is released. Because the passage of food out of the stomach becomes unpredictable, maintaining a proper blood glucose level -- critical for controlling diabetes -- also becomes difficult. Gastroparesis can cause pain, nausea, vomiting, stomach spasms and weight loss due to inadequate absorption of nutrients. The abnormally high blood glucose levels cause chemical changes in nerves and in pacemaker cells which regulate digestive processes in the gut, and damage blood vessels that carry oxygen and nutrients to cells.
"If these data are confirmed in humans, it may point toward a treatment for this difficult problem," says Gianrico Farrugia, M.D., Mayo Clinic gastroenterologist and senior author on the study. "Our goal is to normalize gastric emptying and therefore improve a patient's quality of life and glucose control."
Science Behind the Findings
Previous studies in animals and humans showed that two aspects of gastroparesis were: 1) loss of Kit, a marker for interstitial cells of Cajal (ICC), and 2) loss of expression of neuronal nitric oxide synthase (nNOS). ICC cells produce electrical signals that regulate muscle contraction in the digestive tract. nNOS generates nitric oxide, which transmits nerve impulses in the digestive tract. Both are important for normal functioning but can be depleted by oxidative stress (an imbalance in ionic charges at the molecular level), a problem common in diabetes that also can lead to heart and kidney damage.
The research team decided to test a molecule known to protect cells against oxidative injury -- heme oxygenase-1 (HO1). The team measured gastric emptying in a set of diabetic mice and then looked at expression of HO1. Results showed that production of HO1 was lost in all mice with gastroparesis and nNOS expression was decreased. When the team induced HO1 production by introducing hemin, a red blood derivative, gastric emptying returned to normal and Kit and nNOS expression were restored, despite the diabetes. The team says that future research should target the HO1 pathway as a means of reversing the affects of diabetic gastroparesis.
Others researchers were Kyoung Moo Choi, Ph.D.; Simon Gibbons, Ph.D.; Tien Hguyen; Gary Stoltz; Matthew Lurken; Tamas Ordog, M.D.; and Joseph Szurszewski, Ph.D., all of Mayo Clinic. The research was funded by the National Institutes of Health.
Personality can hamper a physician's assessment of depression

A physician's personality can affect practice behavior in inquiries about patient mood symptoms and the diagnosis of depression, according to a study led by University of Rochester Medical Center researchers.

26 sept 2008--"Some doctors, due to their personal preferences, traits or attitudes, are loathe to broach sensitive topics such as depression or suicide," said Paul R. Duberstein, Ph.D., professor of psychiatry at the Medical Center and lead author of an article on the study published online this month by the Journal of General Internal Medicine. "There is not one right way to do this. A physician does not have to undergo a personality change to ask patients about depression. But physicians should reflect on the possibility that their personal traits might have implications for their approach to the assessment of depression and perhaps other mental health concerns."
Some physicians, who are reluctant to inquire about depression and suicide or who are unnerved by the inquiry, could use a screening questionnaire, said Duberstein. Some practices should hire mental health specialists.
Treatment for depression often is sought initially from a primary care physician. But inquiries about depression and suicide could challenge a physician, emotionally and intellectually. Primary care physicians also have a limited time frame to collect information about many subjects, including sensitive issues such as depression.
"It is not surprising, therefore, that depression is frequently not diagnosed and physicians often do not inquire about suicidal thoughts," the article's authors state.
The researchers analyzed data, audiotapes and medical records from a study in which six actors, all of women were women, were trained to portray a patient with major depression or one with adjustment disorder with depressed mood. With prior physician consent and the cooperation of health plans, the actor-patients received insurance cards and other paperwork corresponding to their false identities. The meetings with the physicians were taped using concealed tape recorders. The physicians, who were not informed when an actor was a patient, were internal and family medicine specialists in Rochester. In all, 46 physicians with 88 patient visits were studied.
Physicians in the study were characterized along three dimensions: dutifulness, vulnerability and openness to feelings. Dutiful suggests conscientiousness, the tendency to follow through reliably, as in paying bills on time. Vulnerability means anxiousness, the tendency to feel unsettled, moody and under stress. Openness indicates empathy, the capacity to understand the feelings of others.
"Doctors high in dutifulness are more likely to document a depression diagnosis but ask fewer questions about depression. They are no more (or less) likely to ask about suicide than their less dutiful peers," the researchers report. "Concern with time-economy could explain why, despite their apparent level of vigilance, they ask fewer questions about depression and are not more likely to inquire about suicide, arguably the most important symptom of depression. Perhaps they believe that asking about suicide will extend the office visit."
Physicians high in vulnerability were also more likely to document a depression diagnosis.
The research is part of a series of studies of the physician-patient relationship. In one study, Duberstein and other researchers showed that primary care physicians with high levels of openness and average, as opposed to extremely high, levels of conscientiousness are more likely to be trusted by patients. An article published earlier this year reported that more dutiful physicians engaged in greater exploration of a patient's psychosocial and life circumstances, but involved the patient less in treatment discussions. Physicians with more anxious vulnerability also involved the patient less.
In addition to Duberstein, the authors of the Journal of General Internal Medicine article include: Benjamin P. Chapman, Ph.D., and Kelly R. McCollumn of the Laboratory of Personality and development at the Medical Center, Ronald M. Epstein, M.D., of the Rochester Center for the Improvement of Communication in Health Care and Richard L. Kravitz, M.D., of the Center for Healthcare Policy and Research at the University of California at Davis.
Is 'bone death' of the jaw the next health epidemic facing seniors?

New research released at world's largest ENT meeting

Chicago, IL, 26 sept 2008 – Despite little publicity surrounding the ailment, seniors may be facing an emerging epidemic in the form of bisphosphonate osteonecrosis ("bone death"), a debilitating ailment of the jawbone that patients are predisposed to, through common treatments for the more well-known ailment osteoporosis. Experts in the field of otolaryngology and dentistry will discuss this emerging problem and its diagnosis and treatment at the 2008 American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) Annual Meeting & OTO EXPO, in Chicago, IL.
With over half of Americans over the age of 50 being treated for low bone mass and osteoporosis (more than 44 million people), many are prescribed oral or intravenous bisphosphonates for treatment. However, these treatments predispose these patients to bisphosphonate osteonecrosis, an ailment first identified only five years ago, which can result in pain, swelling, or infection of the gums or jaw, gums that will not healing, loose teeth, numbness or a feeling of heaviness in the jaw, drainage, and exposed bone.
The discussion will also include perspective from the dental community, which has also expressed concern about the risk.
Title: The Emerging Epidemic? The Management of Bisphosphonate Osteonecrosis Presenters: D. Gregory Farwell, MD (moderator); John W. Hellstein, DDS; Derrick T. Lin, MD; Douglas B. Villaret, MD; Gerry F. Funk, MD Date: Wednesday, September 24, 2008, 9:30-10:20 am (all times CDT)

Thursday, September 25, 2008

Study: Extending time of stroke drug treatment OK


24 sept 2008--Stroke sufferers can still benefit from clot-busting medicine even if they receive it an hour or so beyond the current three-hour window after symptoms start, an important new study suggests.
The finding could potentially extend treatment to thousands more people each year and prevent many from being left disabled. However, it does not change long-standing advice that stroke victims seek immediate help if they feel sudden numbness or weakness in the face, arm or leg.
"Don't wait," said Dr. Larry Goldstein, director of Duke University's stroke center and a spokesman for the American Stroke Association. "If you think you are having symptoms, call 911."
The study by European doctors found that the clot dissolver could safely be given up to 4 1/2 hours after the start of symptoms. Results were published in Thursday's New England Journal of Medicine.
Stroke is the nation's No. 3 killer and the leading cause of disability such as paralysis or speech loss. More than 700,000 Americans suffer a new or recurrent stroke each year and more than 150,000 die. The most common strokes result from a blood clot blocking an artery supplying blood to the brain, starving brain cells of oxygen.
The best treatment is giving patients the drug TPA to break up the clot and open the artery. A large federal study in 1995 showed that people fared better when given the drug within three hours of the start of a stroke. Beyond that, studies have shown the drug can raise the risk of dangerous bleeding in the brain and may not be as effective.
However, only about a third of stroke victims seek help that fast, and fewer than 5 percent get TPA now. Some doctors have been trying to push the time limit, and the new study is the largest and most rigorous to test that approach.
Doctors randomly assigned 821 stroke patients in Europe who were not treated within three hours to receive an intravenous dose of TPA or a dummy drug up to 4 1/2 hours after symptoms started.
Doctors found those given TPA fared better — 52 percent survived without major disability compared with 45 percent of the others. The drug group had more cases of bleeding in the brain — 27 percent versus 18 percent. However, it was serious in only about 2 percent. The death rate was similar in both groups.
The study was funded by Boehringer Ingelheim Pharmaceuticals Inc., which markets TPA as Actilyse overseas. TPA is sold in North America by Genentech Inc. as Activase.
Last week, the same researchers reported similar results in a less rigorous observational study of 664 stroke patients also given TPA after three hours.
Dr. Lee Schwamm, director of Massachusetts General Hospital's acute stroke program, estimated that nearly 20,000 more patients a year could be treated under the time extension.
"I strongly believe it has the potential to have a major impact on practice" in the United States, said Schwamm, who had no role in the research.
Some experts worry that some patients and doctors may take their time treating strokes given the extra window.
"It is very clear that our focus must remain on the door-to-needle time. Every minute matters during a stroke," Dr. Patrick Lyden, head of the University of California, San Diego stroke center, wrote in an accompanying editorial.
Stroke neurologist Dr. Walter Koroshetz of the National Institutes of Health said treatment guidelines deserve a fresh look "to try to break this three-hour barrier."
Koroshetz said it's not clear which patients might benefit most from the extra time. Since the European study focused on mild stroke cases, it's unknown if severe stroke victims would also benefit, he said.
Dr. Kenneth Gaines, stroke director at New Orlean's Ochsner Medical Center, said he might be more willing to consider giving TPA in borderline cases. But he remained concerned about the bleeding side effects.
"The real solution is to move faster," Gaines said. "There is diminishing return the longer you delay treatment."