Pancreatic Chemo Comparison Finds No Survival Boost

Search for more successful treatments for the deadly cancer continues, expert says

Pancreatic cancer patients undergoing chemotherapy after surgery don't see improved long-term survival with the drug gemcitabine, compared with patients receiving a chemotherapy regimen consisting of fluorouracil and folinic acid, new research suggests.
The finding, reported in the Sept. 8 issue of the Journal of the American Medical Association, stems from work conducted by Dr. John P. Neoptolemos, of the Cancer Research U.K. Liverpool Cancer Trials Unit at the University of Liverpool in England, and colleagues.
The study authors noted that, currently, the prognosis for pancreatic cancer is very poor, with a five-year survival rate of less than 5 percent. Surgery to remove cancerous tissue can boost the odds to as much as 10 percent, however, and there is active search underway to improve a patient's chances even more by adding in additional chemotherapy following surgery.
The pool of nearly 1,100 patients that the researchers focused on were part of the large European Study Group for Pancreatic Cancer trial that took place across 159 pancreatic cancer centers located in Europe, Canada, Australasia and Japan.
Between 2000 and 2007, the participants were divided into one of two six-month chemotherapy groups: one receiving fluorouracil and folinic acid post-surgery and the other receiving gemcitabine.
After nearly three years of treatment, the researchers found almost no difference between survival rates in the two groups.
Those who received fluorouracil and folinic acid chemotherapy had lived an average of 23 months. At the one- and two-year markers, survival rates for that group was approximately 78.5 and 48 percent, respectively.
At the three-year mark, patients on the gemcitabine regimen achieved an average survival rate of 23.6 months. One- and two-year survival rates were 80 and 49 percent, respectively, the investigators found.
"In conclusion, gemcitabine did not result in improved overall survival compared with fluorouracil plus folinic acid in patients with [surgically removed] pancreatic cancer," the authors concluded in their report.
However, the team did observe one appreciable difference: patients on gemcitabine were less likely to experience serious side effects as a result of their chemotherapy treatment than those on the fluorouracil/folinic acid treatment (7.5 percent versus 14 percent).
Dr. Michael Choti, a professor of surgery and oncology at the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University in Baltimore, described the study as "important," but he does not believe it will alter the current approach to post-surgical chemotherapy.
"Really in the scope of things following major surgery, both are fairly tolerable regimens, and this study doesn't necessarily change the pattern of use in terms of choosing post-operative therapy," Choti said.
"But the point is that pancreatic cancer is a terrible disease, and really just a minority of patients are candidates for surgery. And even for those, unfortunately 75 to 80 percent of those will go on to recur even after the surgery appears to be successful. So, indeed, there has been a strong interest in giving the best additional therapy possible," Choti added.
"So this is not a revolutionary finding, but it's part of an effort to look at what we have and even to find newer regimens with more combinations of drugs," he noted. "And that's exactly what's already underway, as we search for more aggressive and more successful treatments."

H1N1 Pandemic Flu Even Milder Than Seasonal Strains

Though youngest were most vulnerable, fewer serious complications seen, study finds

The H1N1 pandemic flu, which swept across the United States last year, was actually no more serious than most seasonal strains, a new study confirms.
According to the U.S. Centers for Disease Control and Prevention, there were 43 million to 89 million cases of the H1N1 pandemic flu in the United States from April 2009 through April 10, 2010. Of these, an estimated 274,000 were hospitalized and 12,470 died.
"We found that the pandemic H1N1 virus disproportionately affected children and young adults, but the symptoms and risk of most complications were similar to those of seasonal influenza viruses," said lead researcher Dr. Edward A. Belongia, from the Marshfield Clinic Research Foundation in Marshfield, Wisc.
In fact, children, young adults, pregnant women and people with underlying chronic medical conditions had a higher risk of hospital admission and serious complications when infected with the pandemic virus, the researchers noted.
However, whether the pandemic flu was deadlier or caused more critical illness than the simultaneously circulating seasonal strains has not been studied until now, Belongia noted.
"One implication is that the higher incidence of death or serious illness from the pandemic H1N1 infection in other studies may have been due to the high level of transmission in susceptible children and young adults rather than greater virulence of the pandemic virus," he said.
However, this study did not address specific high-risk populations such as pregnant women, Belongia said.
The report is published in the Sept. 8 issue of the Journal of the American Medical Association.
For the study, Belongia's group compared the H1N1 pandemic flu with the seasonal H1N1 flu, as well as the H3N2 seasonal flu.
Out of 6,874 people who agreed to take part in the study, the researchers found 545 patients with pandemic H1N1 flu, 221 with seasonal H1N1 and 632 patients with H3N2 flu. Ages of these patients ranged from 10 to 25.
A review of hospital records revealed that, among children, H1N1 pandemic flu was not linked to hospitalization or pneumonia compared with either H1N1 seasonal flu or H3N2 seasonal flu.
Among children with H1N1 pandemic flu, 1.5 percent were hospitalized, as were 3.7 percent with H1N1 seasonal flu and 3.1 percent of those with H3N2 flu, the researchers found.
Among adults, 4 percent of those with H1N1 pandemic flu were hospitalized, as were 2.3 percent with H1N1 seasonal flu and 4.5 percent with H3N2 flu, they added.
As for pneumonia, 4 percent of adults with H1N1 pandemic flu came down with the condition, compared with 2.3 percent of those with H1N1 seasonal flu and 1.1 percent of those with H3N2 flu, Belongia's team found.
Among children, 2.5 percent of those with H1N1 pandemic flu developed pneumonia, as did 1.5 percent with H1N1 seasonal flu and 2 percent of those with H3N2 flu.
Influenza expert Dr. Marc Siegel, an associate professor of medicine at New York University in New York City, said that "this confirms what we were noticing from the beginning with H1N1, which is that, structurally, it was a mild virus."
As a mild virus it wasn't any more deadly, Siegel said. It had a predilection for the young and it was expected there would be more serious complications, but there weren't, he added.
Siegel said the virus attacked young people because they didn't have any immunity to it, which is typical with pandemic flu strains.
"Even though it was a mild virus, we didn't have immunity, so that made it somewhat unpredictable," Siegel said. "This study shows that despite our lack of immunity the complications were no greater than the yearly flu. That's a new finding."
This year, it is doubtful H1N1 pandemic flu will be noticed, Siegel said. In the first place, this year's flu vaccine contains this flu strain and in the second place most people are now immune to this strain, because it spread so far and wide, he said.
"I do not expect there to be a problem this year," Siegel said.

Decline in Adult Smoking Stalls, Alarming Experts

And more than half of U.S. kids exposed to secondhand smoke, CDC report finds

Although the hazards of smoking are well known, 20 percent of Americans still light up, U.S. health officials said Tuesday.
The number of adult smokers dropped between 2000 and 2005, but the decline has leveled out, according to a new report from the U.S. Centers for Disease Control and Prevention (CDC).
"The 40-year decline in tobacco in the United States has stalled," CDC director Dr. Thomas R. Frieden said during an early afternoon press conference.
"Between 2005 and 2009 there was no further reduction in tobacco use," he said. And despite progress nearly 90 million American non-smokers are exposed to toxic chemicals in tobacco smoke."
Frieden laid the blame for the stalled smoking decline on the doorstep of the tobacco industry.
"The industry has gotten even better at sidestepping laws designed to get people to stop smoking," he said. "They ensure that every cigarette the sell is designed to deliver nicotine quickly and efficiently to keep people addicted."
In addition, the industry uses marketing techniques to get children to start smoking. And they create new products that get around laws to attract new smokers, Frieden said.
More men (24 percent) than women (18 percent) were smoking in 2009, says the report, which also found that people with less education and lower incomes were more likely than others to smoke.
Thirty-one percent of smokers live below the poverty level, and 25 percent never graduated from high school compared with 6 percent of those with graduate degrees, the report says.
Moreover, secondhand smoke remains a serious problem for 88 million nonsmokers. For example, 54 percent of children aged 3 to 11 are exposed to secondhand smoke, and 98 percent of kids living with a smoker have measurable levels of toxic chemicals from cigarette smoke, the report says.
Black nonsmokers are twice as likely as Mexican-American non-smokers and 33 percent more likely than white non-smokers to have measurable exposure to tobacco, the researchers say.
Dr. David L. Katz, director of the Prevention Research Center at Yale University School of Medicine, said a five-year stall in smoking rates suggests both "that those who now smoke may be diehards and tough to convert, and that perhaps we got a bit too complacent way too soon."
"Our goal should be nothing less than the elimination of tobacco use," Katz said. "This report tells us of the need to rededicate ourselves to this cause, and allocate the requisite resources."
Smoking and secondhand smoke exposure led to 443,000 deaths in 2009, making smoking the leading cause of preventable illness and death in the United States, the CDC said.
"These results underscore the need for every state and community to enact comprehensive smoke-free laws that apply to all workplaces and public places, including restaurants and bars," Matthew L. Myers, president of the Campaign for Tobacco-Free Kids, said in a statement Tuesday.
Twenty-eight states, Washington, D.C., Puerto Rico and more than 550 cities have laws requiring smoke-free restaurants and bars, Myers said.
"The high level of child exposure to secondhand smoke also underscores the need for parents to take additional steps to protect children, such as ensuring that homes, cars and other places frequented by children are smoke-free," he added. "For parents who smoke, the best step to protect children is to quit smoking."
Smoking rates vary by region and state. One problem is that states are cutting back on the money they devote to tobacco control programs, Frieden said. "If all states funded tobacco control at the CDC recommended level there would be an estimated 5 million fewer smokers in this country, and that would prevent at least 1 million deaths," he said.
Last year, Utah and California had the fewest smokers. California's comprehensive tobacco control program has resulted in a decline in lung cancer at a rate four times faster than in the rest of the country, the CDC noted.
The good news, Frieden said, is that tobacco use can be reduced. "Tobacco control measures work. Places that implement tobacco control programs get dramatic results," he said.
In Washington state the smoking rates is less than 15 percent, in California it's less than 13 percent and in Rhode Island and Massachusetts it's less than 15 percent, Frieden said.
In addition, those who smoke may be smoking less. "Cigarette sales have declined significantly, especially in 2009 when the federal cigarette tax increased by 61 cents per pack," said Myers.
"This decline in cigarette consumption could be a precursor to declines in the smoking rate, especially if proven tobacco control measures are implemented more aggressively," he added.

Men Seem More Susceptible to Memory Problems Than Women

Among elderly, rate of mild impairment was 1.5 times higher in males, study finds

Elderly men are more likely to suffer memory problems than women, new research shows.
The study included 2,050 people, aged 70 to 89, in Olmsted County, Minn., who were interviewed about their memory and medical history, and who underwent testing of their memory and thinking skills.
Overall, nearly 14 percent of the participants had mild cognitive impairment (MCI), but the rate was 1.5 times higher in men (19 percent) than in women (14 percent). People with MCI have memory or thinking problems that are more serious than what's associated with normal aging. Although not everyone who has MCI develops Alzheimer's disease, people with the impairment do often go on to develop it, according to the Alzheimer's Association.
The study, published in the Sept. 7 issue of the journal Neurology, also found that about 10 percent of the participants had dementia, and 76 percent had normal memory and thinking skills.
"This is the first study conducted among community-dwelling persons to find a higher prevalence of MCI in men," study author Dr. Ronald Petersen, of the Mayo Clinic in Rochester, Minn., said in an American Academy of Neurology news release.
"If these results are confirmed in other studies, it may suggest that factors related to gender play a role in the disease. For example, men may experience cognitive decline earlier in life but more gradually, whereas women may transition from normal memory directly to dementia at a later age but more quickly," he added.
The study, funded by the U.S. National Institute on Aging and a Mayo Clinic Alzheimer's disease research program, also found that MCI was more common among people who had a lower level of education or who were never married.

Immune System Genes Show Links to Type 1 Diabetes

Finding is starting point for work on the disease's origins, possible treatment, experts say

The exact cause of type 1 diabetes is still unknown, but international researchers have found a link between the blood sugar disorder and a network of immune system genes.
Using a genome-wide association study, the researchers found that a certain group of genes that react in response to viral infections were present in both rats and humans, and that those same genes were also associated with a susceptibility to type 1 diabetes.
"Diseases arise as a result of many genetic and environmental factors through gene networks that cause tissue damage," explained study senior author Dr. Stuart Cook, the group head of molecular and cellular cardiology at the Medical Research Council Clinical Sciences Centre, and a professor of clinical and molecular cardiology at Imperial College in London.
"We used an approach to identify the major control points' central command of an inflammatory gene network. This led us to uncover hundreds of new genes that might cause diabetes and one major control gene that controls the whole network," said Cook.
He added that one of the genes belongs to a class of genes that might make a good target for drug therapy in the future.
Results of the study are published in the Sept. 9 issue of Nature.
Each year, more than 30,000 people are diagnosed with type 1 diabetes, formerly known as juvenile diabetes, according to the Juvenile Diabetes Research Foundation (JDRF). People with type 1 diabetes no longer produce enough of the hormone insulin to effectively use the sugars found in carbohydrate-containing foods. To survive, people with type 1 diabetes must take insulin injections or use an insulin pump for the rest of their lives.
Experts believe the disease is an autoimmune disease, which means that the body's immune system mistakenly turns against healthy cells, such as the insulin-producing cells in the pancreas, and destroys them. People who develop type 1 diabetes are believed to have a genetic susceptibility to the disease that's then triggered by something in the environment, possibly a virus.
In the current study, the researchers didn't initially set out to look for type 1 diabetes genes. They started out by looking at a certain group of genes in rats, in this case a network of genes controlled by a gene called interferon regulatory factor 7 (IRF7). IRF7 is like a master switch that controls the genes in its network. The entire network of genes controlled by IRF7 is called the IRF7-driven inflammatory network (IDIN).
The researchers discovered that when there were differences in IRF7, there were also differences in the way other genes expressed themselves.
Cook and his colleagues then searched for a network of genes in humans that might behave the same way. They found an area on chromosome 13q32 that is controlled by a gene called the "Epstein-Barr virus induced gene 2" (Ebi2). This gene appeared to be the human equivalent of the IRF7 gene in rats.
Within this human version of the IDIN, research found a gene called IFIH1, which has been found in other research to be associated with the development of type 1 diabetes.
"Usually, research starts from the genetics and goes to function. Here, they started with a function -- [an immune system reaction] -- and were looking for a gene," explained Marie Nierras, director of research and scientific affairs for the JDRF.
"The value of such a result is that if you can get to the same place using more than one pathway, it tends to support the hypothesis," she said.
In this case, the hypothesis supported is the idea that type 1 diabetes may be triggered by an immune system response to a virus. However, Nierras stressed that this study doesn't conclusively prove that a virus is the trigger for type 1 diabetes.
"We know better today that this network of genes is involved, and with a network, you have many targets you can test. This research invites us to plan experiments going forward, and opens up many more questions, like 'If I disrupt this branch of the network, do I disrupt diabetes?' Or, 'If you look back at previous research knowing this study's results, does that help to better explain previous results?'" said Nierras.
Cook said this type of genome-wide association study can be used for other diseases as well, and that his team is hoping to eventually develop a new drug based on the genetic target they discovered.

Pediatrics Group Urges Flu Shots for All Health-Care Workers

AAP calls mandatory shots 'ethically justified, necessary, and long overdue to ensure patient safety'

A group representing America's pediatricians is urging that flu shots be mandatory for all U.S. health-care workers in order to protect patients.
While many organizations have used voluntary programs in an effort to improve coverage, flu vaccination rates among health-care workers remain unacceptably low, said the members of the Committee on Infectious Diseases at the American Academy of Pediatrics.
"Mandatory influenza immunization for all health-care personnel is ethically justified, necessary, and long overdue to ensure patient safety," they wrote in the AAP policy statement, which will appear in the October issue of the journal Pediatrics.
Immunization rates of 80 percent or higher are needed to achieve the "herd immunity" required to have a major impact of flu transmission by health-care workers, but current rates of flu vaccination for this group remain near 40 percent, the authors said.
They noted that mandatory immunization for health-care workers is not unusual. For example, many medical facilities require specific vaccines and a tuberculin skin test as conditions of employment or to be allowed to work in specific areas of an institution.
Medical and religious exemptions to mandatory flu vaccination can be granted on an individual basis, the statement authors suggested.
They offered a number of examples of the effectiveness of mandatory flu vaccination policies. The Virginia Mason Medical Center in Seattle achieved a 99 percent compliance rate after it made influenza vaccination mandatory in 2005. The compliance rate was 100 percent after the U.S. National Institutes of Health Clinical Center made flu vaccination mandatory for employees who had contact with patients.
Flu outbreaks are a common and serious public health problem. Each year in the United States, influenza causes more than 36,000 deaths and 200,000 hospitalizations and costs the country $87 billion, according to the AAP statement.

2 Genes Have Possible Link to Deadly Ovarian Cancer

Scientists say findings may lead to new therapies for ovarian clear cell carcinoma

Mutations in two genes may be associated with one of the most deadly types of ovarian cancer, U.S. researchers have found.
In the study, researchers at the Johns Hopkins Kimmel Cancer Center looked for mutations in 18,000 protein-encoding genes in ovarian clear cell tumors from eight patients. The investigators found 268 mutations in 253 genes, with an average of 20 mutations per tumor.
Further investigation revealed that two genes -- ARID1A and PPP2R1A -- were more commonly mutated than other genes. ARID1A mutations were present in 57 percent of tumors while PPP2R1A mutations were present in 7.1 percent of tumors, according to the report published in the Sept. 8 online edition of Science Express.
ARID1A is a gene whose product normally suppresses tumors. PPP2R1A is a gene that, when altered, helps turn normal cells into tumor cells. The genes had not previously been linked to ovarian cancer, the researchers explained in a news release from the Johns Hopkins Kimmel Cancer Center.
The findings "may provide opportunities for developing new biomarkers and therapies that target those genes," Nickolas Papadopoulos, associate professor of oncology and director of Translational Genetics at the Ludwig Center for Cancer Genetics & Therapeutics at the cancer center, said in the news release.
Ovarian clear cell carcinoma, which accounts for about 10 percent of cancers that start in cells on the surface of the ovaries, mainly affects women aged 40 to 80 and is resistant to chemotherapy, according to background information in the news release.

Kids Playing With Laser Pointers May Be Aiming for Eye Trouble
Teen boy damages retina with Internet-purchased 'toy,' doctors say
 

A 15-year-old Swiss boy attempted to create his own laser show using a laser pointer he bought on the Internet and a mirror. Instead, he inadvertently beamed the laser into his eyes, creating permanent damage to his vision.

"These high-power laser products are very dangerous," said Dr. Martin Schmid, head of the retina unit in the department of ophthalmology at Lucerne Cantonal Hospital in Switzerland. Schmid is also one of the authors of the case report detailing the young boy's eye damage in a letter in the Sept. 9 issue of the New England Journal of Medicine.

Schmid said that part of the problem is that not all laser pointers are labeled properly, so it's not always easy to know if you have a pointer that could create serious damage. One sure way to know if you have a potentially dangerous laser pointer is if the laser can burn through paper, explained Schmid.

"Every laser pointer which is capable of burning holes into paper or of lighting matches or of popping balloons is highly dangerous for the eye and must not be used by non-professionals," he cautioned.

Those are exactly some of the uses the Swiss youngster was planning for his laser pointer. He told doctors that he purchased the laser pointer so that he could pop balloons from a distance, burn holes in paper cards and burn holes in his sister's sneakers.

While he was attempting his "laser light show," the teen said that the laser beam hit his eyes several times. Although he immediately noticed that his vision was blurry, he was afraid to tell his parents what had happened. He waited two weeks before letting them know that he was still experiencing blurred vision.

The vision in his left eye was so damaged that he couldn't count how many fingers a doctor was holding up until they were just three feet away. His visual acuity in his right eye was 20/50.

Schmid said the boy wasn't sure if the laser was dangerous, and he definitely didn't know it could cause immediate eye injury.

When the teenager's eyes were examined, doctors discovered that there had been significant internal bleeding in the left eye and that there were several small scars in the right eye. Even with treatment, there's still a scar that diminished the boy's vision in his left eye. However, his visual acuity has returned to near normal, according to the report.

The laser used by the boy produced an output of 150 milliwatts (mW), far above the maximal output of 5 mW that's expected from a laser pointer sold to the public. The authors point out that it's possible to purchase laser pointers as strong as 700 mW, although such a device may not look any different than a lower-powered device.

Additionally, Schmid said there are instructions available over the Internet for turning low-power devices into high-powered ones.

And, the authors pointed out, high-powered laser pointers can produce immediate and severe retinal injury -- so severe that even blindness can occur.

Dr. Roy Chuck, chair of ophthalmology and visual sciences at Montefiore Medical Center and the Albert Einstein College of Medicine in New York City, said, "We've seen lots of cases of laser burns, usually from researchers giving presentations, but now we're seeing more cases of people ordering these products over the Internet, though eye injuries in lay people are still pretty rare."

Chuck said that children shouldn't have access to laser pointers. "They're not giving presentations, so why would they need to have them?" He said that when it comes to laser toys -- like those used for laser tag -- buying a well-known name brand may be helpful in this case. "When you're buying off the Internet, it's not as regulated and you just can't tell what the strength of the laser is," noted Chuck.

Schmid added that lasers used in toys will generally be labeled as Class 1, although he said that products aren't always labeled properly.

And, even if you've purchased a "safe" laser toy, it's possible that creative children may turn to the Internet and figure out ways to boost the power of the laser. "By searching YouTube for 'burning laser pointers,' you will find a huge amount of videos showing such dangerous experiments. Moreover, there is an increasing number of homepages and videos demonstrating how to turn legal low-power lasers into burning, high-power lasers," said Schmid.

Dementia Warning Signs Identified in Type 2 Diabetics: Study

High blood pressure, slow gait, self-reported bad health might signal decline, researchers say

Three factors linked to cognitive deficits in older adults with type 2 diabetes have been identified in a new study.
Canadian researchers looked at 41 adults, ageds 55 to 81, with type 2 diabetes and found that those who had high blood pressure, walked slowly or had balance problems, or believed they were in bad health were much more likely to have poorer memory and slower, more rigid cognitive processing than those without these three problems.
The study appears in the September issue of the journal Neuropsychology.
While these factors may not actually cause cognitive deficits, their presence could alert doctors that such problems may exist or soon develop, the researchers said.
"Awareness of the link between diabetes and cognition could help people realize how important it is to manage this disease -- and to motivate them to do so," study co-author Roger Dixon, of the University of Alberta, said in an American Psychological Association news release.
Previous research has shown that type 2 diabetes nearly doubles the risk of dementia and Alzheimer's disease. Increasing rates of diabetes among older people in Western nations could lead to a dramatic increase in the number of people with dementia, Dixon noted.
In the United States, 23 percent of people older than 60 have diabetes, according to the National Institute of Diabetes and Digestive and Kidney Diseases.

Statins May Guard Against Rheumatoid Arthritis
Study showed only an association between the two, expert notes

Statins, lauded for their ability to lower cholesterol and prevent heart attacks and strokes, may also reduce the risk of developing rheumatoid arthritis, Israeli researchers report.

"We found that statin users who purchased their medication persistently were less likely to develop rheumatoid arthritis over a long follow-up period," said lead researcher Gabriel Chodick, from Maccabi Healthcare Services in Tel Aviv.

For example, compared with patients who took statins less than 20 percent of the time, patients who took statins for 40 percent to 59 percent of the time had a 23 percent lower risk of developing rheumatoid arthritis, he said.

"Patients who were covered for more than 80 percent of the time, had a 40 percent lower risk of developing rheumatoid arthritis," Chodick said. "The effect was stronger in younger patients and in patients using more effective statins."

The report was published online Sept. 7 in PLoS Medicine.

For the study, Chodick's team collected data on 1.8 million patients who got their health care through the Maccabi Healthcare Services, an HMO in Israel.

The researchers looked for connections between statin use and the development of both rheumatoid arthritis and osteoarthritis, a degenerative joint disease that is unlikely to be affected by statins, the researchers noted.

Over nine years of follow-up, 2,578 people developed rheumatoid arthritis and 17,878 developed osteoarthritis.

When Chodick's group looked at statin use, they found that those not taking statins had a 51 percent higher risk of developing rheumatoid arthritis over about 80 percent of the follow-up period.

After looking for other possibilities, those who took statins regularly had a 41 percent lower risk of developing rheumatoid arthritis compared with people who were not taking statins regularly.

Among those taking statins, there was only a small, short-term reduction in risk of development of osteoarthritis.

"Although the study does not have immediate clinical implications, our findings may suggest that patients who were prescribed statins and take it persistently may benefit from the many effects of statins, which go far beyond cholesterol reduction, including the reduction of rheumatoid arthritis risk," Chodick said.

A previous study on the same group indicated that persistent use of statins was associated with substantially lower all-cause mortality, which could not be explained only by the prevention of cardiovascular disease, he said.

"We believe that a major part of the improved survival among statin users comes from the anti-inflammatory effects demonstrated by lower risk of rheumatoid arthritis. Unfortunately, our previous study indicated that, despite their benefits, many patients on statins discontinue their treatment," Chodick said.

This work received no outside or corporate finding, the researchers noted.

Dr. Robert Myerburg, a professor of medicine and physiology at the University of Miami Miller School of Medicine, stressed that "this is a study looking for an association, and it doesn't prove that starting statins early in life will prevent or delay the onset of rheumatoid arthritis."

The only way to prove the connection is with a clinical trial, Myerburg said. "At this point, I would not use a statin for that [prevention of rheumatoid arthritis] indication," he said.

Working Overtime Adds to Heart Risk for Out-of-Shape Men

But being physically fit seems to protect those who work longer hours, researchers say

Out-of-shape men who work long hours more than double their risk of dying from heart disease compared to non-fit men working fewer hours, researchers report.
The study also found that when men are fit, working long hours doesn't boost heart risk at all.
The new study included 5,000 Danish men, aged 40 to 59 years, who worked at 14 different companies. Their fitness levels were assessed at the start of the study and they were followed-up for more than 30 years. During that time, 587 (about 12 percent) of the men died as result of narrowed and hardened arteries (also known as ischemic heart disease).
The study, released online Sept. 6 in advance of publication in an upcoming print issue of the journal Heart, also found the following:

• Compared with men who worked less than 40 hours per week, unfit men who worked 41 to 45 hours a week were 59 percent more likely to die of heart disease, although they were not more likely to die of other causes.
• Compared with unfit men, those who were physically fit and worked longer hours were 45 percent less likely to die of heart disease and 38 percent less likely to die of other causes.
• Being both unfit and working more than 45 hours per week more than doubled a man's risk of dying of heart disease compared with those who worked less than 40 hours per week.

"The finding that working more than 45 hours a week is associated with more than a doubled risk of [death from heart disease] among men with low physical fitness, and not among men with moderate or high physical fitness, is a new observation," Andreas Holtermann, of the National Research Centre for the Working Environment in Copenhagen, and colleagues said in a news release from the journal's publisher.
"If the relationship is causal, it obviously has major implications for the prevention of heart disease," they added.

Heart Health Rises With Education in Rich Nations

But findings don't apply to low- or middle-income countries, study says

A higher level of education is associated with reduced risk of heart disease and stroke for people who live in rich countries, but not for those in low- and middle-income nations, finds a new study.
Highly educated men in high-income countries had the lowest level of cardiovascular disease, according to the researchers. The findings show that the results of research conducted in richer nations can't be applied to poorer nations.
"We can't simply take studies that are conducted in high-income countries, particularly as they relate to socioeconomic status and health outcomes, and extrapolate them to low- and middle-income countries. We need dedicated studies in those settings," Dr. Abhinav Goyal, an assistant professor of epidemiology and medicine (cardiology) at Emory Rollins School of Public Health and Emory School of Medicine in Atlanta, said in an American Heart Association news release.
Goyal is lead author of a two-year study that included more than 61,000 people from 44 countries who were diagnosed with heart disease, stroke or cardiovascular disease risk factors, such as high blood pressure, obesity, clogged blood vessels and smoking.
The researchers were surprised to find that nearly half of highly educated women in high-income countries smoked, compared with 35 percent of those with the least amount of education. In middle- and low-income countries, 21 percent of highly educated women smoked, compared with 14 percent of those with the least education.
"We can't assume that just because certain groups are more educated than others that they're going to have healthier lifestyles. Everyone needs to be educated about the risk of heart disease in particular and counseled to adopt healthy lifestyles and to quit smoking," Goyal said.
Among men in high-income countries, 66 percent of those with the most education smoked, compared to 75 percent of those with the least education. In low- and middle-income countries, smoking rates were similar for men of all education levels, the study found.
The study was published Sept. 7 in the journal Circulation.

Many HIV-Infected Kids Could Use Cheaper Treatment Safely

Study found that returning to nevirapine still kept viral load down for most

For HIV-infected children in the developing world, treatment choices have been limited by concerns over the possible development of resistance to drugs they received as infants during failed attempts to prevent their infection in the first place.
But a new U.S. National Institutes of Health-funded study suggests there may be a way to administer one particularly cheap and practical HIV drug -- nevirapine -- safely and effectively to many of these children.
The finding was detailed by study co-author Louise Kuhn, a professor of epidemiology at the Mailman School of Public Health at Columbia University in New York City, and Dr. Lynne Mofenson, chief of the pediatric, adolescent and maternal AIDS branch of the Eunice Kennedy Shriver National Institute of Child Health and Human Development, during a recent teleconference.
The study itself will be published in the Sept. 8 issue of the Journal of the American Medical Association.
Mofenson noted that globally 430,000 infants become infected with HIV. About 90 percent of these children live in sub-Saharan Africa.
To tackle this immense problem, public health officials often turn to nevirapine. A single dose of the drug given at birth to the newborn of an HIV-infected mother can reduce the risk of HIV transmission by as much as 50 percent, Mofenson explained.
However, those infants who go on to become infected run the risk of developing a nevirapine-resistant strain of virus. And resistance testing, though available, is far too expensive to be considered a practical screening tool in the developing world.
So, about three years ago the World Health Organization recommended that HIV-infected children who had first been given nevirapine not be given the effective and cost-effective treatment again in favor of a costly protease inhibitor cocktail that is difficult to store and transport.
In this latest study, the researchers focused on the treatment of 195 children infected with HIV who were cared for at one hospital in Johannesburg, South Africa, between 2005 and 2009.
For these children, nevirapine at birth had failed to prevent HIV infection.
As a result, each child was placed on a protease inhibitor regimen, which involved three drugs: ritonavir-boosted lopinavir, stavudine and lamivudine. All the children fared well on this cocktail, having maintained a desirably low viral load for a minimum of three months over the course of their first year of treatment.
At the launch of the study, about half the children were randomly switched to a nevirapine treatment: namely, replacing ritonavir with nevirapine in the drug cocktail. The other children stayed with their standard protease inhibitor regimen. Blood samples were taken at 4, 12, 24, 36 and 52 weeks.
The authors found that children who had fared well (for an average of nine months) under a non-nevirapine protease-inhibitor drug regimen appeared to fare even better once they switched to a nevirapine treatment.
"Those children who changed to nevirapine were actually more likely to maintain the virus below 50 copies per milliliter (ml) in the blood, which is the lowest detectable limit that we use to measure the amount of virus in the blood," explained Kuhn.
Among the nevirapine group, 66 percent of the children remained below this threshold. For the standard treatment group, just 42 percent achieved that goal.
However, they cautioned that about one in five of the children who switched to nevirapine did not fare well, with viral loads rising beyond 1,000 copies/ml.
Nevertheless, with a majority of children reacting well to the switch, Kuhn and her colleagues suggest the approach could cut costs and improve treatment, so long as viral loads are monitored.
"What this shows is that this is a unique and innovative, but also reasonable, alternative strategy, and it will allow us to treat many more children," Mofenson said. "Because compared with the protease inhibitors we use now, nevirapine is much less expensive -- about $55 a year per child compared to about $280 a year for the PIs."
"So this will allow us to treat five times as many children for the same price," she noted. "Which is why this is so critical."
Kuhn added that nevirapine offers other crucial pluses.
"Our group is very, very encouraged by these results, because the biggest factor in HIV treatment is adherence," she explained. "The drugs don't work if you don't take them. And here the big problem is that it's very, very difficult for parents to get their children to take what we currently offer them two times a day because they are really horrible, foul-tasting drugs."
"So if we can move to something like nevirapine - which has a kind of a sweet taste that children don't really mind so much -- it would be very helpful," she said.
Dr. Geoffrey A. Weinberg, a pediatric infectious disease expert at Golisano Children's Hospital at the University of Rochester Medical Center in New York, agreed that a nevirapine treatment option would be helpful.
"The important message is that many children will do better with anti-HIV therapy based on nevirapine," he said.

Health Care Reform: Is There a Doctor in the House?
Reform could strain, or possibly improve, the primary-care experience


Health reform will put insurance cards in the hands of tens of millions of previously uninsured Americans. Many will need physicals, immunizations, preventive screening tests and care for chronic health conditions.

So, how tough will it be to get a doctor's appointment?

Some experts worry that there could be longer wait times to see a doctor, particularly in rural areas and underserved markets where primary-care physicians are in short supply.

"The reality is there's going to be a potential primary-care crisis as health care is expanded," said Dr. John D. Goodson, an internist in primary care at Massachusetts General Hospital and an associate professor of medicine at Harvard Medical School in Boston.

A primary-care practice is often a patient's first and ongoing contact with the medical system. Primary-care physicians are generalists trained in family medicine, general internal medicine or general pediatrics. They diagnose and treat acute and chronic conditions, provide preventive services and counseling, coordinate care and make necessary referrals to specialists.

Yet primary-care physicians make up only 35 percent of America's physician workforce, and the pipeline of fresh talent is tapering off. Fewer than 20 percent of U.S. medical students are choosing to practice primary-care medicine, according to the Council on Graduate Medical Education, which advises and makes recommendations to the U.S. Department of Health and Human Services and Congress on physician workforce matters.

Studies project a shortage of 44,000 to 46,000 primary-care doctors by 2025 unless action is taken to lure more medical students into the field and retain experienced primary-care doctors.

And future demand for generalist physicians is expected to swell as the population ages.

"You can put people in the health insurance plans, but if you don't have enough providers to take care of these people, I think that the system will not work," said Janet Selway, president-elect of the American College of Nurse Practitioners, who sees an expanded role for nurses with advanced education and training.

Massachusetts experienced a shortage of primary-care physicians in the wake of the commonwealth's universal health insurance law, which was enacted in 2006. But it had only two years to prepare for the onslaught of patients. The full impact of the federal health reform law won't be felt until 2019.

The Patient Protection and Affordable Care Act -- the sweeping health reform bill signed into law by President Barack Obama in March -- includes a number of programs to strengthen primary-care. But is it enough?

In a "Perspective" article published in the Annals of Internal Medicine in April, Goodson argued that, to avert a primary-care crisis, medical schools must prioritize and support primary-care training, and policymakers have to do something about the nation's lopsided physician reimbursement system, which favors specialists.

"The starting pay for a radiologist coming out of a training program could be $400,000 to $500,000 a year, whereas a trainee coming out of a general medicine program or a family medicine program could be $150,000 a year," he told HealthDay. "I mean, this is just patently absurd."

Goodson and other primary-care advocates also see the need for a better way to take care of patients' acute and chronic health-care needs without burning out doctors.

One potential solution is a team-based model of care called the "medical home." In a medical home, every patient has a personal physician. But instead of acting alone, the physician leads a cadre of non-physician providers. The team may include physician assistants, nurse practitioners and others who are responsible for coordinating patient care.

"In many ways, it's the ideal incarnation what you wish you primary-care physician -- what he or she -- would be able to do to support your care," said Susan Stuard, executive director of the Taconic Health Information Network and Community, a partner in the Hudson Valley Initiative, an effort to improve health-care delivery in six New York counties.

Stuard's organization has helped more than 600 Hudson Valley-area primary-care physicians, including a number of solo and small practices, implement electronic health records. Having information technology in place to coordinate care, avoid repetitive lab tests and ensure timely screenings is a key component of the medical home concept, she said.

Group Health Cooperative in Seattle, an early adopter of the medical home model, recently published results of a pilot program comparing the medical home experience at one clinic with its other practice sites. After two years, patients in the medical home had better experiences and better quality of care, and physicians reported less workplace stress. The study was published in the May issue of Health Affairs.

However, results of a two-year medical home experiment involving 36 primary-care practices across the country found small improvements in quality of care but not in patient experiences. That study appeared in a special supplement to the May/June issue of the Annals of Family Medicine.

"The issue with the medical home is, how it can be done in a way that's really going to serve the needs of the patient best," Goodson said.

Emergency Visits for Stomach Pain Rose Over Decade

Use of medical imaging also increased, U.S. government study found

More Americans are visiting hospital emergency departments because of abdominal pain, but the percentage of emergency visits that involve chest pain are decreasing, a new government report shows.
Between 1999-2000 and 2007-2008, the number of emergency department visits for abdominal pain increased 31.8 percent, from 5.3 million to 7 million. The percentage of these visits that involved abdominal pain increased 7.6 percent during this period, from 10.5 percent to 11.3 percent, the study found.
At the same time, the number of emergency department visits for chest pain increased from 5 million in 1999-2000 to 5.5 million in 2007-2008, but the percentage of emergency visits that involved chest pain decreased 10 percent, from 10 percent to 9 percent, said the researchers at the U.S. Centers for Disease Control and Prevention's National Center for Health Statistics.
The researchers analyzed 1999 to 2008 data from the National Hospital Ambulatory Medical Care Survey. The data was for patients aged 18 and over whose emergency department visit was not injury-related.
Overall, the percentage of noninjury emergency department visits rose 22.1 percent from 50.5 million in 1999-2000 to 61.7 million in 2007-2008.
The researchers also found an increase in the use of advanced medical imaging for noninjury emergency department visits. The use of this type of imaging to diagnose a patient indicates a doctor's perception about the seriousness of the case.
Between 1999-2000 and 2007-2008, the use of advanced medical imaging increased 367.6 percent (from 3.4 percent to 15.9 percent) for chest pain visits, 122.6 percent (from 19.9 percent to 44.3 percent) for abdominal pain visits and 122.1 percent (from 8.6 percent to 19.1 percent) for all other emergency department visits, according to the report.
The percentage of chest pain-related emergency department visits that led to a diagnosis of acute coronary syndrome decreased 44.9 percent, from 23.6 percent to 13 percent. The percentage of abdominal pain-related visits that resulted in a serious diagnosis decreased from 17.4 percent to 17.1 percent.
The percentage of emergency patients with abdominal pain who arrived by ambulance increased by 26.9 percent, from 10 percent in 1999-2000 to 12.6 percent in 2007-2008, while there was no significant change for patients with chest pain, 25.5 percent and 25.8 percent, respectively, the investigators found.
"Advanced imaging may increase the amount of time that a patient spends in the ED [emergency department], thereby slowing throughput and contributing to ED crowding and its adverse consequences. However, advanced imaging may help a physician to rule out conditions, thereby avoiding further unnecessary or risky diagnosis and therapy, and it may help confirm certain conditions, thereby leading to more effective and efficient therapy. Targeted research is needed to clarify the extent to which medical imaging for ED visits for chest or abdominal pain is improving the diagnosis and treatment of serious conditions," the authors concluded.

Many Heart Patients Place False Hope in Angioplasty

In non-emergency scenarios, the artery-opening procedure won't prevent heart attack, experts note

Many heart patients harbor the misguided notion that angioplasty, a common procedure to open clogged arteries, will also cut their risk of heart attacks and death, a new study shows.
In fact, the evidence suggests that angioplasty only reduces angina (cardiac-linked chest pain) in stable heart patients -- people whose condition has not changed recently and who are not experiencing a heart attack. The procedure does not reduce the risk of heart attack or death for these patients.
However, the new study found that 88 percent of stable patients who underwent angioplasty at a hospital in Massachusetts thought the procedure would reduce their risk of heart attack. And two-thirds of the patients didn't even suffer the kind of pain that angioplasty would likely remedy, the study authors noted.
Furthermore, most patients stuck to their beliefs even after spending time with a cardiologist who explained the risks and benefits to them, and had them sign an informed consent form prior to the angioplasty.
The study "shows the disconnect between what doctors know and what patients understand. In order to have real informed consent, patients have to understand not just the risks, but also the benefits of whatever treatment is proposed," said study author Dr. Michael Rothberg, of the Division of General Medicine and Geriatrics at Baystate Medical Center in Springfield, Mass.
The findings were published in the Sept. 7 issue of the Annals of Internal Medicine.
During angioplasty, a tube is inserted at the groin and snaked up to the affected artery, where a balloon opens the blockage. A stent (a flexible mesh tube) is often left in place to help prop open the artery and maintain blood flow. Angioplasty involves some risk but the rate of death during the procedure is less than 1 percent, experts note.
In the study, patients underwent catheter-based diagnostic procedures for a variety of reasons including a positive stress test, shortness of breath, a previous heart attack or other heart conditions.
Angioplasty is often performed at the same time if a blockage is found. Patient-informed consent for both procedures was required.
The study involved 153 patients with stable heart disease who had varying levels of symptoms. According to the authors, less than one-third (31 percent) of those who agreed to undergo elective cardiac catheterization had the type of activity-limiting angina pain that angioplasty might be expected to ease.
Nevertheless, almost three-quarters of all the patients still believed that if they didn't undergo angioplasty, they would suffer a heart attack within the next five years.
In contrast, 63 percent of cardiologists surveyed in the study realized that for stable heart patients, the procedure mainly reduces pain (from angina) and improves quality of life.
The authors also noted that these benefits can often be achieved with medication alone.
Only patients who are actually having a heart attack or coronary event can expect a reduced risk of future heart attacks and death from angioplasty, according to prior research cited in the study.
The number of angioplasties done for stable heart patients has, in fact, decreased lately, said Rothberg. According to the American Heart Association, about 1.3 million such procedures are done in the United States each year.
Dr. Henry H. Ting, associate dean for quality, and professor of medicine at the Mayo Clinic in Rochester, Minn., said he was not surprised by the study findings.
Ting pointed to a survey at the Mayo Clinic that found that 80 percent of patients signed consent forms they had not read, and did not know the benefits or risks of the treatment they were having.
Ting, who conducts research on informed consent, said the problem of patient understanding isn't limited to angioplasty but is common in many areas of medicine.
"We [doctors] don't do a good job of knowledge transfer in a way that patients and family members can understand," said Ting. "Graphs and charts are not going to work for many of our patients."
One reason for patients' misunderstanding is the common belief, cited in the study, that if a treatment is offered, it must have curative benefits.
And Dr. Gregg C. Fonarow, associate chief of the division of cardiology at the University of California, Los Angeles School of Medicine said that, "it's not counterintuitive for patients to conclude" that if angioplasty widens an artery it will reduce the risk of heart attacks and death, even though it is not true.
Fonarow, who is also professor of cardiovascular medicine and science at the school, contends that "the importance of this study is not that the patients should not have had the procedure." Instead, he said, the study highlights the different perspectives of doctors and their patients.

Kids on HIV Drug Cocktail May Need Revaccination

Immunity to childhood diseases can wane more quickly than in children without the virus, researchers say

HIV-infected children who undergo highly active antiretroviral therapy (HAART) may need to be revaccinated to maintain their immunity against preventable childhood diseases, researchers from Johns Hopkins have found.
HAART is a combination of three or more potent drugs that target HIV, the virus that causes AIDS.
A research team at the Johns Hopkins Bloomberg School of Public Health reviewed 38 published studies and found that most children treated with HAART are still susceptible to vaccine-preventable diseases but respond well to revaccination.
"Because of the progressive effects of HIV infection on the ability of the immune system to mount an effective response, many infected children have poorer responses to vaccines than do uninfected children," senior study author Dr. William Moss, an associate professor in the epidemiology department, said in a Bloomberg news release.
"In addition, fewer children infected with HIV achieve protective immunity, and those who do might experience greater and more rapid waning of immunity. These results suggest that children on HAART would benefit from revaccination, but levels of protective immunity might need to be monitored and some children may need additional vaccine doses to maintain protective immunity," Moss said.
Currently, there are no standard or official recommendations on revaccination of HIV-infected children on highly active antiretroviral therapy.
"Vaccination policies and strategies for children infected with HIV on HAART should be developed in regions of high HIV prevalence to ensure adequate individual and population immunity," lead author Catherine Sutcliffe, a research associated in the epidemiology department, said in the news release.
"Without such recommendations, as treatment programs scale up and more children receive HAART and live into adolescence and adulthood, a larger proportion of these children could be susceptible to childhood diseases," she noted.
The review appears in the September issue of The Lancet Infectious Diseases.

Elderly May Benefit From Minimally Invasive Shoulder Surgery
Significant pain reduction reported by 96% after operation to repair rotator cuff tears, researchers find

WEDNESDAY, Sept. 8 (HealthDay News) -- Minimally invasive arthroscopic surgery to repair torn shoulder muscles in elderly people can reduce pain and improve function, a new study finds.

Many doctors are reluctant to perform this type of surgery in older patients because of fears of complications. But the researchers at Rush University Medical Center in Chicago said their findings show that seniors shouldn't be excluded from having this surgery.

About 20 percent of people older than 65 suffer tears in the rotator cuff, the group of four muscles and their tendons that form a "cuff" over the top of the upper arm bone and stabilize the back of the shoulder joint. These tears can cause considerable pain and loss of range of motion.

"In people over the age of 70, pain is the main issue, and pain relief is a fairly reliable outcome after surgery," said study leader and orthopedic surgeon Dr. Nikhil Verma. "Patients do not require that their shoulder function be fully restored. They just want the pain to be gone." Verma is assistant professor of orthopedic surgery at Rush.

With that requirement, Verma said, "age is not a contraindication" for the surgery.

This study included 39 patients over age 70 who underwent surgery to repair rotator cuff tears after pain medication and other treatments failed to help them. The patients were followed for two years after their surgery.

Significant pain reduction was reported by 96 percent of patients, and there were major improvements in shoulder function, range of arm motion and muscle strength, the study found.

Following the surgery, shoulder function was nearly the same as what could be expected in a healthy shoulder for people in this age group, the researchers noted.

The study appears online and in the October print issue of Arthroscopy: The Journal of Arthroscopic and Related Surgery.

The American Academy of Orthopaedic Surgeons (AAOS) notes that that the best treatment varies from patient to patient. Non-surgical alternatives to conventional and arthroscopic rotator cuff surgery, according to the AAOS, include the use of a sling; rest and avoiding activities that cause symptoms; anti-inflammatory medications or steroid injections; and strength-building exercises and physical therapy.

The AAOS also cautions that -- like any operation -- the surgery is not without risk. Possible side effects, according to the academy, include infection, difficulty moving the shoulder after the operation and a re-tear requiring another surgery.

Room Air Sometimes as Good as Oxygen Therapy: Study
Comparison found no significant difference in breathlessness levels among terminally ill

Oxygen therapy may be unnecessary for some terminally ill people who have trouble breathing, and could be replaced by treatment with ordinary room air, a new study suggests.

People who are near death often experience breathlessness, and the condition is common in terminally ill patients with conditions such as heart failure, lung cancer and chronic obstructive pulmonary disease, the study authors explained in the report published online Sept. 4 in The Lancet.

Oxygen therapy is normally used when people have low levels of oxygen in their bodies. But in terminally ill people, it's sometimes used even when their oxygen levels aren't dangerously low, Dr. Amy Abernethy, of Duke University Medical Center, and colleagues pointed out in a university news release.

In the study, the investigators randomly assigned terminally ill patients with breathlessness to receive treatment with oxygen or normal room air through prongs in the nose. The patients were told to take treatment for at least 15 hours a day. A total of 211 patients completed seven days of treatment.

The researchers found that there wasn't a statistically significant difference between the groups of patients in regards to breathlessness levels.

"Less burdensome strategies should be considered after brief assessment of the effect of oxygen therapy on the individual patient," the study authors concluded.

The study is valid and suggests the value of using room air instead of oxygen in some cases, Dr. R. Sean Morrison, director of the National Palliative Care Research Center at Mount Sinai School of Medicine in New York City, who was not involved with the study, said in an interview.

In addition to being expensive and often not covered by insurance, oxygen therapy "requires specialized equipment and can create anxiety about getting tanks refilled in time," Morrison said.

Still, he added, "we do know that in the setting of oxygen deficiency, oxygen is beneficial."

Talks With Plastic Surgeon Urged Before Mastectomy

Where woman goes for treatment may influence breast reconstruction decision, study suggests

Breast cancer patients who've had a mastectomy are more likely to have breast reconstruction if a plastic surgeon is part of the treatment decision team, new research shows.
The study also found that where a woman goes for breast cancer treatment -- ranging from small private practices to large medical complexes -- affects the type of care she receives when it comes to breast reconstruction.
"Breast reconstruction is a very complex treatment issue that requires a lot of discussion. Our results suggest that discussion can be quite different depending on where a patient gets initial treatment," lead author Dr. Steven J. Katz, professor of internal medicine at the University of Michigan Medical School and of health management and policy at the U-M School of Public Health, said in a university news release.
"Patients with similar characteristics or preferences may get a different story from different surgeons -- and this depends largely on whether a plastic surgeon is on the treatment decision team from the get-go. Plastic surgeons are the ones with the expertise to explain the increasingly complicated procedure options," Katz noted.
He and his colleagues surveyed 1,780 breast cancer patients and 291 surgeons about treatment choices, and found that about one-third of women who undergo mastectomy go on to have breast reconstruction.
There are many reasons why a woman may not have reconstruction, but the researchers concluded that 31 percent of the variation could be attributed solely to how often a woman's surgeon talked to a plastic surgeon prior to mastectomy.
"This is a deeply intimate and important decision that women have to make. It should be made with the right information about reconstruction options in consultation with a plastic surgeon involved up front in the treatment planning," Katz said. "Patients should be particularly attentive to engaging their surgeons on the first visit about this important treatment option."
The study findings were released online Aug. 28 in advance of publication in the October print issue of the journal Medical Care.

Unvaccinated Teen's Life Forever Changed

Mother says trauma could have been avoided if vaccine had been available

Carl Buher came home from the football game feeling rotten.

A strong, healthy, 14-year-old high school freshman, Carl had attended a day's worth of school and then played in the game, but it felt as if he were coming down with the flu. That made sense: A lot of his teammates had recently had the flu, and he figured they'd just passed it on to him.
So he came home, ate, did his homework and went to bed, recalled Carl's mother, Lori Buher of La Conner, Wash.
When she woke him up in the morning, Carl told her he'd been up all night vomiting. "We figured he had the flu, so he stayed home from school," Buher said.
The first sign that Carl might be sicker than they thought came in the form of purple bruises that began to form, first on his face and then down his arms and legs. By 2 p.m., Buher took her son to the doctor, concerned for his health.
The doctor diagnosed Carl quickly and, as it turned out, accurately: The teen had contracted meningococcal meningitis.
The diagnosis took Buher by surprise. "He had none of the symptoms you hear about," she said. "No stiff neck. No terrible headache. No high fever."
The family physician sent Carl to the local hospital's emergency room. Within hours he was being airlifted to Seattle Children's Hospital.
"His heart stopped twice on the helicopter," Buher said. "They had to revive him."
This was in 2003, and Buher knew about meningitis and knew that a vaccine was available to prevent it. But at the time, the vaccine -- Menomune -- wasn't recommended for kids Carl's age. Teens headed for college were supposed to get the vaccine, but even that was a shaky proposition. Buher's two college-age kids were on a waiting list for Menomune vaccination but hadn't received it yet because supplies were short.
Now her son Carl was incredibly sick with the disease. She and her husband hurriedly made the hour's drive to Seattle. "When we got there, they had a social worker waiting to help us prepare for his death," she remembers. "It was so overwhelming."
Doctors put Carl in a drug-induced coma, in which he lingered for five weeks. His mother recalls that he was given more than 25 different medications to keep his body functioning.
Nonetheless, meningitis ravaged Carl's body. He had to have both legs amputated below the knee, and he also lost three fingers. The purple bruising turned out to be his skin dying, which led to gangrene. Carl endured skin grafts all over his body, 13 in all, and still bears the scars. His weight fell from 185 to 119 pounds.
But Carl is 21 now and a junior at Gonzaga University in Spokane, Wash., majoring in civil engineering. He graduated from high school as class valedictorian in 2007.
"He had just started walking on his prosthetics by then because it took the skin so long to heal," Buher said. His doctors and parents declared him fully healed in 2008 -- five years after he first fell ill.
"He's very strong," Buher said of her son these days. "He's still not nimble with the prosthetics, but he can do what he wants to do."
Buher said it breaks her heart that all of this might have been prevented, and she urges parents to get their kids vaccinated.
"It's just so sad," she said. "Kids die, or they are left with these terrible, disfiguring amputations. For us, we were able to survive this. For so many families, their children die -- and it's just unnecessary."

Get Ready for Baby's Bath

Be prepared before you put baby in the tub

A bit of preparation can make bath time less stressful for parents and safer for baby.
The American Academy of Pediatrics offers these suggestions:

• Fill the tub before you put baby into it.
• Place the soap and shampoo next to the tub.
• Grab one or two washcloths to have nearby.
• Have a towel (warm, dry and cozy is best) ready to use immediately after the bath.
• Set up the bottle of baby's lotion and a clean diaper.
• Have a clean change of clothes out and ready.

Heart Arrhythmia May Have Symptoms

Here are possible warning signs

When the heart beats irregularly, it's called arrhythmia.
In many cases, when the heart beats too fast, too slow or irregularly, there are no obvious warning signs, the University of Virginia Health System says.
But you should contact your doctor without delay if you have any of these symptoms:

• Feeling dizzy or lightheaded, or actually fainting.
• Feeling like your heart is fluttering.
• Noticing that your heart has skipped a beat, or feeling an extra beat.
• Feeling tired and weak.
• Being short of breath.
• Having chest pain.

Life's Key Moments Occur Within Relationships, Study Finds

Personal highs, lows less important than events shared with others, researchers say

It isn't personal success or failure that make up the best and worst moments of a person's life, but the events that occur within social relationships, new research has found.
"Most of us spend much of our time and effort focused on individual achievements, such as work, hobbies and schooling," study co-author Shira Gabriel, an associate professor of psychology at the University at Buffalo, said in a university news release.
"However, this research suggests that the events that end up being most important in our lives, the events that bring us the most happiness and also carry the potential for the most pain, are social events -- moments of connecting to others and feeling their connections to us," Gabriel explained.
Gabriel and colleagues reached their conclusion after conducting four studies involving a total of 376 people.
Most previous research has suggested that the most intense emotional experiences occur during independent events that don't involve other people, such as achieving a personal goal.
"We found, however, that it was not independent events or individual achievements like winning awards or completing tasks that affected participants the most, but the moments when close relationships began or ended; when people fell in love or found a new friend; when a loved one died or broke their hearts. In short, it was the moments of connecting to others that touched peoples' lives the most," Gabriel said.
The study findings were released online in advance of publication in an upcoming print issue of the journal Self and Identity.

No Surprise: Walking, Cycling Linked to Healthier Weights

Researcher admits finding seems obvious, but says scientific proof still important to encourage activity

A new study confirms what seems obvious: people who live in communities where walking and cycling are common are less likely to be overweight or obese.
The researchers analyzed statistics about walking and cycling in 14 countries, and also studied data about walking and cycling to work in all 50 states and in 47 of the largest U.S. cities.
They found that the highest levels of walking and cycling among the countries studied were in Switzerland, the Netherlands and Spain, while the lowest levels were in the United States, Australia and Canada. Among U.S. cities, the highest rates of walking and cycling to work were in Boston, Washington, D.C., San Francisco, Minneapolis and Seattle.
The researchers also found a connection between more walking and cycling and lower levels of obesity and diabetes, according to the report released online Aug. 19 in advance of publication in the October print issue of the American Journal of Public Health.
"It's really important to promote walking and cycling as safe, convenient and feasible modes of getting around on an everyday basis," lead author John Pucher, a professor who studies transportation at Rutgers University in New Jersey, said in a Center for Advancing Health news release.
He acknowledged that the link between higher levels of exercise and healthier weight may seem obvious, but said there is a need for scientific evidence to prove it.
"As obvious as it is, it's shocking that Americans don't want to do anything about it. It's amazing how unconcerned most Americans are about this," Pucher said.

Parents Can Take Steps to Boost Kids' Health, Well-Being
Pediatrician offers tips to start the school year right

As children head back to school, parents can help make sure their little ones stay healthy and happy all year, an expert suggests.

Adequate sleep and rest are essential, Dr. Peter Richel, a pediatrician at Northern Westchester Hospital in Mt. Kisco, N.Y., said in a hospital news release. His advice in this regard? Establish fixed bedtime routines and avoid booking too many extracurricular activities.

Also make sure your children get three healthy meals a day, he added. Breakfast is particularly important, and eating together as a family helps promote good communication skills.

To lower disease risk, children should be properly vaccinated against illnesses such as tetanus, diphtheria and pertussis, and parents should consider other vaccines such as hepatitis A and varicella boosters against chicken pox. Seasonal flu and H1N1 vaccines are additional options that most parents can request for their kids, Richel noted.

Regular exercise is also important and it should include some form of aerobic activity, such as taking a brisk walk, Richel suggested. This could mean limiting the time kids spend in front of computers, TVs and video games.

Reading and music enrich children's lives, the pediatrician added. Very young children should be read to, and older kids should be encouraged to read during leisure time. Singing and learning to play an instrument are also great activities for children.

Encourage your kids to do their best, but don't demand perfection, he stressed. Keep in mind that each child is an individual who needs support, but not pressure.

Sickle Cell Kids at Greater Risk of 'Swine Flu' Complications

Findings highlight need to vaccinate against H1N1, seasonal flu, researchers say

Children with sickle cell disease experience more life-threatening complications from the H1N1 swine flu than from seasonal flu, a new study has found.
This means that doctors and parents need to be aware that children with sickle cell disease are more likely to need emergency treatment and to be hospitalized, Dr. John Strouse of Johns Hopkins Children's Center and colleagues explained in a Hopkins news release.
The study authors analyzed the medical records of 123 children with sickle cell disease treated for any kind of flu between September 1993 and December 2009. Of those, 29 were infected with the 2009 H1N1 swine flu virus.
Both seasonal flu and the H1N1 virus caused typical flu symptoms, such as fever, cough and a runny nose, in most of the children. However, those infected with H1N1 were nearly three times more likely to develop acute chest syndrome, a leading cause of death in children with sickle cell disease. It is marked by lung inflammation, reduced ability to absorb oxygen and shortness of breath.
In addition, compared to children with seasonal flu, H1N1-infected children had a more than five-times increased risk of ending up in the intensive care unit, and were more likely to require a ventilator for breathing.
The study, released online in advance of publication in an upcoming print issue of the journal Blood, underscores the need for vaccination against the H1N1 and the seasonal flu strains, the researchers said.
Sickle cell disease, an inherited disorder characterized by abnormally shaped blood cells, affects about 100,000 people in the United States, mostly black Americans. An earlier study from Hopkins Children's Center showed that children with sickle cell disease are hospitalized with seasonal flu nearly 80 times more often than other youngsters.

Exposure to Violence May Aggravate Asthma, Study Finds Researchers link stress of inner-city life to increased hospitalizations People with asthma who witness violence in their neighborhoods are at increased risk for asthma-related hospitalization and emergency department visits for asthma or any cause, finds a new study. It included 397 adults with moderate to severe asthma who lived in an inner-city community and were followed for six months by University of Pennsylvania School of Medicine researchers. Nearly one-quarter of the participants had previously been exposed to violence, and these people had nearly twice the rate of subsequent hospitalizations or emergency department visits for asthma as those who hadn't been exposed to violence. The study also found that exposure to violence was associated with lower asthma-related quality of life, and that younger adults were more likely to be exposed to violence and more likely to have had an emergency care visit in general. The study appears in the September issue of the Journal of Allergy & Clinical Immunology. It's not clear how exposure to violence affects asthma, but the researchers suggested that it may be a marker for physical or social conditions that contribute to the development of asthma, exacerbate symptoms, and interfere with successful treatment and management of the disease. These conditions may include air pollution, inadequate housing and limited access to pharmacies. It's also possible that the stress of living in a poor, violence-affected community directly affects the health of people with asthma, the researchers said, adding that the two theories were not mutually exclusive. "Because overall ED visits increased and there was a trend toward increase in overall hospitalizations, our findings suggest that exposure to violence is associated with far reaching health effects beyond the single condition of asthma," lead author Dr. Andrea J. Apter, a professor of medicine and chief of the allergy and immunology sections in the division of pulmonary, allergy and critical care medicine, said in a U Penn news release.

Lower Risk of Surgery Than Thought for Kids With Crohn's

More study needed on early treatments to alter the course of the bowel disease, researchers say

The risk of bowel surgery for children with Crohn's disease is much lower than reported in previous studies, according to new findings.
Crohn's disease involves chronic inflammation of the gastrointestinal tract. The exact cause is not known, but the condition is often associated with an immune response problem. Some recent studies have found that the risk of bowel surgery is as high as 34 percent one year after diagnosis and as high as 47 percent five years after diagnosis.
This new multi-center study included 854 children under 16 years of age who were newly diagnosed with inflammatory bowel disease (IBD), which consists of two main conditions: ulcerative colitis and Crohn's disease. Over five years of follow-up, the researchers found that the risk of bowel surgery in these children was nearly two times lower than reported in previous studies.
However, they did find that children diagnosed with Crohn's disease between ages 13 and 16 had an increased risk of bowel surgery.
The researchers also found that starting treatment at diagnosis with immunomodulator therapy -- which balances and improves the body's immune response -- did not affect the risk of surgery. Neither did race, gender or family history of inflammatory bowel disease.
The study appears in the September issue of the journal Clinical Gastroenterology and Hepatology.
"Our study findings indicate that changing disease behavior over time influences the risk of surgery, and treatments focused on early intervention to alter the natural course of the disease will need to be assessed in studies that ideally involve randomized controlled trials," wrote senior author Dr. Neal LeLeiko, director of pediatric gastroenterology and nutrition at Hasbro Children's Hospital in Providence, R.I., and colleagues.