Month: February 2012

Raw Milk Linked to Much Higher Rate of Disease Outbreaks Than Pasteurized Milk .

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The rate of dairy-associated disease outbreaks may be 150 times higher with unpasteurized (i.e., raw) milk products than with pasteurized milk, according to CDC estimates published in Emerging Infectious Diseases.

In their review of reports from 1993 to 2006, the researchers also found that states where raw milk was legal had more than double the rate of outbreaks.

In outbreaks associated with raw milk, 60% of sickened people were under 20 years old.

The authors conclude: “Consumption of nonpasteurized dairy products cannot be considered safe under any circumstances.”

Source:Emerging Infectious Diseases

Polypectomy Confirmed to Reduce Colorectal Cancer Mortality .

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Two studies in the New England Journal of Medicine show colonoscopy’s value in detecting colorectal cancer and reducing mortality.

In one, some 2600 patients with adenomatous polyps had them removed during colonoscopy. After a median follow-up of 16 years, colorectal cancer mortality was some 50% lower in that group, compared with a control group based on the U.S. population. (Similar findings occurred among a group of patients whose polyps were nonadenomatous.)

The other study is an interim report of a long-term comparison between screening with colonoscopy and fecal immunochemical testing. Some 57,000 asymptomatic average-risk adults were randomized to either one-time colonoscopy or immunochemical testing biennially over 10 years. After the colonoscopies and first round of chemical testing, cancer was detected equally in both groups. However, advanced adenomas were more likely to be found among those undergoing colonoscopy.

Editorialists conclude that “colonoscopy is an effective screening test.” Although patients are more likely to accept chemical testing than colonoscopy, fecal testing “is not a good test for detecting adenomas.”

Source: NEJM study on colorectal cancer mortality.

 

Dementia Associated with Increased Rate of Hospitalization.

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In a prospective cohort study, elders who developed dementia had higher rates of hospitalization — particularly for conditions potentially treatable in outpatient settings — than those who didn’t develop dementia.

Several retrospective, claims-based studies have been conducted to look at rates of hospitalization in patients reported to have dementia. These findings are imperfect, because dementia is often underdiagnosed in the outpatient setting. Now, researchers have conducted a prospective, longitudinal, 13-year study to analyze rates of hospitalization among 3019 adults, including 494 in whom dementia was identified during biennial screening. The researchers also sought to answer whether rates of hospitalization among elders (with or without dementia) differ between all-cause conditions and those deemed to be ambulatory care–sensitive conditions (ACSC) — those potentially treatable in outpatient settings.

The rate of hospitalization was significantly higher among individuals who received dementia diagnoses (86%) than among those who remained dementia-free (59%). The rate of at least one ACSC hospital diagnosis was 40% in the dementia group and 17% in the nondementia group. After adjustment for covariates, including residence in a nursing home before hospitalization, the ratio of admission rates between dementia patients and nondementia patients was 1.39, and the ratio of ACSC admission rates was 1.78 — both significant findings.

Comment: These findings confirm those of retrospective analyses of hospitalization rates for dementia patients. The authors break new ground by evaluating admissions from the time of incident dementia diagnosis. Because dementia reduces an individual’s self-care abilities, it may increase the risk for hospitalization. This study is a starting point in improving ambulatory-care interventions for modifiable factors that lead to hospitalization among dementia patients. The findings also provide further support for cognitive screening in ambulatory settings, which can help clinicians to identify adults with dementia and to provide more timely, proactive management in those with acute conditions.

 

Source:Journal Watch Neurology

 

Radiotherapy for Node-Positive Gastric Cancer.

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Adding radiotherapy to chemotherapy after curative resection with D2 lymph node dissection improved disease-free survival in node-positive patients.

Despite poor overall long-term survival in patients with gastric cancer, adjuvant therapy improves survival after gastrectomy. Adjuvant approaches include postoperative 5-fluorouracil chemotherapy and radiotherapy in the U.S., pre- and postoperative chemotherapy in Europe, and adjuvant chemotherapy in Asia. The role of postoperative radiotherapy in adjuvant management has been controversial, given that the quality of surgery varies between Eastern and Western countries. Also, some argue that the superior survival associated with systematic D2 lymph node resection — comprising removal of greater and lesser curvature, gastrohepatic, splenic, and celiac nodes — negates any potential benefit for postoperative radiotherapy.

To investigate this issue, researchers in Korea conducted the phase III, multicenter, randomized, ARTIST trial, which compared adjuvant capecitabine and cisplatin with or without radiotherapy in 458 patients with gastric cancer after curative resection with D2 lymph node dissection. Most patients (88.3%) were node positive, 57.8% had stage I–II disease, and 42.2% had stage III–IV disease. One group of patients received six, 3-week cycles of capecitabine (2000 mg/m2 daily on days 1–14) and cisplatin (60 mg/m2 on day 1). The other group received 2 cycles of the same chemotherapy, followed by 5 weeks of capecitabine (1650 mg/m2 daily) plus radiotherapy (4500 cGy in 180 daily cGy fractions) and 2 more cycles of chemotherapy. The primary endpoint was 3-year disease-free survival (DFS).

Among all patients, DFS was similar with radiotherapy plus chemotherapy or chemotherapy alone (78.2% and 74.2%). However, among node-positive patients, DFS was improved with radiotherapy plus chemotherapy versus chemotherapy alone (77.5% vs. 72.3%; P=0.0365); this improvement was retained in multivariate analysis (hazard ratio, 0.6865; P=0.0471). Rates of therapy completion were comparable with radiotherapy plus chemotherapy or chemotherapy alone (81.7% and 75.4%).

Comment: Adjuvant therapy improves survival in gastric cancer and is standard therapy. Asian and European trials demonstrate a survival benefit for chemotherapy alone, even without postoperative radiotherapy. The current trial now reopens the debate that, even after D2 gastrectomy, node-positive patients might benefit from adjuvant chemotherapy and radiotherapy. These data suggest that the benefit of radiotherapy seen in U.S. trials might not merely be a function of inadequate surgery performed in the U.S. Whether or not the overall 5% difference in DFS is meaningful and holds up under further study awaits completion of the authors’ follow-up trial, which will compare chemotherapy with or without radiotherapy in node-positive patients only.

Source: Journal Watch Oncology and Hematology

 

 

Mortality Rates and Antipsychotic Use in Nursing Homes.

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The mortality risks associated with use of antipsychotic drugs vary by drug, with haloperidol posing the highest risk, according to a BMJ study of nursing home residents in the U.S.

Researchers analyzed a merged dataset of Medicare and Medicaid claims comprising, after exclusions, some 11,000 first-time users of antipsychotic drugs. All had started using the drugs while living in a nursing home during 2001 to 2005. The primary outcome was death within 180 days after first use.

Compared with risperidone (the reference drug), haloperidol was associated with the highest risk (hazard ratio, 2.07), and quetiapine had the lowest risk (0.81). No clinically meaningful differences in mortality occurred with use of aripiprazole, olanzapine, or ziprasidone.

Editorialists comment that the study “strengthens the argument for avoiding haloperidol.” However, quetiapine has not been shown effective in treating neuropsychiatric symptoms in dementia, they write. While the drug may be safe, these results “should not support its use.”

Source:BMJ

 

FDA Advisers Recommend Approval of New Diet Pill

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FDA advisers have voted 20 to 2 to approve the diet pill Qnexa, a combination of phentermine and topiramate, Reuters reports. If approved, Qnexa will be the first new prescription weight-loss pill to hit the market in 13 years.

In 2010, the FDA rejected the pill’s approval over concerns that it could raise the risk for heart problems and birth defects. During this week’s meeting, advisers said the manufacturer should conduct a study on the potential for heart problems, while supporting the company’s intent to restrict its use to nonpregnant women. The advisers were split on whether the heart study should be performed before or after the pill’s approval.

Source:Physician’s First Watch

Do Antibiotics Help Uncomplicated Sinusitis?

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A placebo-controlled study says no.

Many studies have indicated that antibiotics are wildly overprescribed for sinusitis. However, randomized trials on the utility of these medications have had conflicting results, with statistical interpretation complicated by different enrollment criteria and high rates of spontaneous improvement.

In a double-blinded study, researchers randomized 166 adults reporting 1 to 4 weeks of standard sinusitis symptoms (including maxillary pain or tenderness in the face or teeth, and purulent nasal secretions) to receive 10 days of amoxicillin or placebo, along with a range of as-needed symptom-relief medications (acetaminophen, guaifenesin, dextromethorphan, pseudoephedrine, and nasal saline spray). Imaging studies were not performed.

Symptom improvement — evaluated on a standardized questionnaire called the “SNOT-16” — was indistinguishable between the groups at day 3, slightly favored amoxicillin at day 7, and was then indistinguishable again at day 10. Reported adverse effects of treatment and overall satisfaction with treatment did not differ between groups; recurrence rates were similar.

Comment: These data again support the decision to withhold antibiotics in patients with standard-issue sinus complaints. Unfortunately, clinicians must then do repeated battle with patients who are convinced that only an antibiotic will help them. For these patients, watchful waiting, with the promise of reevaluation should symptoms fail to improve, may be a realistic if not always achievable approach to treatment.

Source:Journal Watch General Medicine

 

Is Obstructive Sleep Apnea Associated with Cardiovascular Mortality in Women?

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Like men, women with severe OSA are at increased cardiovascular risk and should receive appropriate treatment.

Obstructive sleep apnea (OSA) is a recognized risk factor for cardiovascular death in men but hasn’t been well studied in women. To find out more, investigators at two sleep clinics in Spain prospectively followed 1116 women who underwent either polysomnography or respiratory polygraphy.

During a median follow-up of 72 months, 41 patients (3.6%) died of cardiovascular disease and 37 (3.3%) died of noncardiovascular disease. In untreated patients, cardiovascular mortality rates were as follows:

  • Control (patients without OSA): 0.28 per 100 person-years
  • Mild-to-moderate OSA: 0.94 per 100 person-years
  • Severe OSA: 3.71 per 100 person-years.

Patients treated with continuous positive airway pressure (CPAP; median adherence, 6 hours per day) had cardiovascular mortality rates similar to those of control patients, regardless of OSA severity. In multivariate analysis, untreated severe OSA was an independent predictor of cardiovascular mortality; no significant difference in cardiovascular mortality risk was found among control patients, those with CPAP-treated severe OSA, those with CPAP-treated mild-to-moderate OSA, and those with untreated mild-to-moderate OSA. Sensitivity analysis by type of diagnostic sleep study did not affect the results.

Comment: In this observational study of obstructive sleep apnea in women, untreated severe OSA was associated with increased cardiovascular mortality, whereas treatment of severe OSA with continuous positive airway pressure reduced the mortality risk to that of women without OSA. All women with suggestive symptoms should be evaluated for OSA, and those with OSA should receive appropriate treatment.

Source:Journal Watch Cardiology

Helicobacter pylori and Inflammatory Bowel Disease.

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Investigators conclude that H. pylori infection is inversely associated with IBD, whereas non–H. pylori chronic gastritis is positively associated with it.

Some preliminary studies have suggested that patients with Helicobacter pylori infection are less likely to have inflammatory bowel disease (IBD) than the general population.

To investigate this possibility further, investigators used a large national database of surgical pathology reports to examine biopsy results for patients who underwent both upper endoscopy and colonoscopy on the same day. The results from gastroscopy specimens were reviewed for the presence of esophagitis, gastritis, and H. pylori infection; those from colonoscopy specimens were evaluated for the presence of ulcerative colitis (UC), Crohn disease (CD), and indeterminate colitis.

IBD was identified in 1061 (1.6%) of 65,515 patients; the remaining patients were used as controls. The associations between H. pylori infection and IBD as well as between non–H. pylori gastritis and IBD were evaluated using multivariate logistic regression, with adjustment for potential confounders.

The presence of H. pylori infection was inversely associated with diagnosis of any IBD (adjusted odds ratio, 0.53; 95% confidence interval, 0.39–0.70), CD (AOR, 0.48; 95% CI, 0.27–0.79), UC (AOR, 0.59; 95% CI, 0.39–0.84), and indeterminate colitis (AOR, 0.43; 95% CI, 0.15–0.95). Conversely, the presence of non–H. pylori chronic gastritis was positively associated with these diagnoses: any IBD (AOR, 5.61; 95% CI, 4.35–7.14), CD (AOR, 11.06; 95% CI, 7.98–15.02, UC (AOR, 2.25; 95% CI, 1.31–3.60), and indeterminate colitis (AOR, 6.91; 95% CI, 3.50–12.30).

Comment: This well-designed study confirms suggestions that patients with H. pylori infection are at decreased risk for IBD. This finding, along with the positive association between non–H. pylori gastritis and IBD, raises questions about the mechanism underlying these associations. It should be noted that the prevalence of H. pylori infection was only 9% in the cohort overall, and even lower in the younger age groups. This might reflect the decreasing prevalence of the infection in the U.S. population or a potential selection bias. Less than 1% of the patients had no insurance, 3% were covered by Medicaid, and 69% had private insurance. Underrepresentation of patients from lower economic groups might have reduced the prevalence of H. pylori infection and introduced the possibility that the findings are due to factors associated with higher economic status.

Source:Journal Watch Gastroenterology

 

Canadian CT Head Rule Is Superior to New Orleans Criteria in Minor Head Injury.

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In patients with Glasgow Coma Scale scores of 15, both decision rules had 100% sensitivity for identifying significant intracranial injuries, but the Canadian CT Head Rule had higher specificity.

In a prospective cohort study, the authors compared sensitivity and specificity of the Canadian CT Head Rule and the New Orleans Criteria for identifying intracranial injuries in adults with minor head injury (defined as those with witnessed loss of consciousness, disorientation, or amnesia, and Glasgow Coma Scale [GCS] score 13 to 15). Of 431 consecutive patients enrolled at a single level I trauma center in the U.S., 314 who had GCS scores of 15 and underwent head computed tomography (CT) scanning were the focus of the study.

Of the 314 patients, 22 suffered any traumatic intracranial injuries, 11 had clinically important brain lesions (defined as acute traumatic lesions that would normally require hospital admission and neurological follow-up), and 3 had injuries requiring neurosurgical intervention. Both rules were 100% sensitive for identifying patients with each of these three outcomes, but the Canadian CT Head Rule had significantly higher specificity than the New Orleans Criteria (36% vs. 10%, 35% vs. 10%, and 81% vs. 10%, respectively).

Comment: The higher specificity of the Canadian CT Head Rule suggests its use could reduce CT ordering safely in head trauma patients with Glasgow Coma Scale scores of 15 without missing significant injuries.

Source: Journal Watch Emergency Medicine.