H1N1 Influenza May Increase Maternal Deaths

Fran Lowry

December 23, 2009 — Women with suspected or confirmed H1N1 influenza who are pregnant or who have delivered within the previous 2 weeks should receive prompt and aggressive antiviral treatment and be closely monitored, according to new research published online December 23 in the New England Journal of Medicine.

"As in previous influenza epidemics and pandemics, pregnant women with 2009 pandemic influenza A (H1N1) appear to have an increase risk of severe disease," write Janice K. Louie, MD, MPH, from the California Department of Public Health, Richmond, and colleagues.

"From April 23 to August 11, 2009, a total of 10% of the 1088 patients who were hospitalized or died from 2009 H1N1 influenza, as reported to the California Department of Public Health...were pregnant. A recent report from the first month of the outbreak noted that the rate of hospitalization among pregnant women was approximately four times the rate in the general population."

In this report, Dr. Louie and colleagues reviewed the clinical course of the disease and the characteristics of all hospitalized pregnant, nonpregnant, and postpartum women (those who had delivered less than 2 weeks previously) of childbearing age from data reported to the California Department of Public Health in the first 4 months of the pandemic.

During this time period, data were reported for 94 pregnant women, 8 postpartum women, and 137 nonpregnant women, for a total of 239 women.

The researchers found that most pregnant patients (89/94, 95%) were in the second or third trimester when they were hospitalized. Five women (5%) were in the first trimester. Thirty-two women (34%) had underlying conditions for influenza complications other than pregnancy. The most common condition was asthma.

Rapid antigen tests were falsely negative in 38% (58/153) of the patients tested. Of these 58 patients, 28 were pregnant. Only 7 pregnant women with false-negative results received early (≤2 days after the onset of symptoms) antiviral treatment.

Overall, only half of pregnant women received early antiviral treatment throughout the surveillance period, the authors report. Six pregnant patients and one postpartum patient received oseltamivir 150 mg every 12 hours — a dose that was twice the current recommended dose. Forty-five percent of pregnant women and 58% of nonpregnant women were treated with antibiotics.

Starting antiviral treatment more than 2 days after the onset of symptoms in pregnant women was associated with admission to an intensive care unit or death (relative risk, 4.3; 95% confidence interval [CI], 1.4 - 13.7).

In all, 18 pregnant and 4 postpartum women — almost one fifth — required intensive care, and 8 died: 6 during pregnancy and 2 after delivery (on day 1 and on day 8). The 2 deaths in the immediate postpartum period highlight the continued high risk immediately after delivery, the authors note.

Six of the patients who died had underlying medical conditions in addition to pregnancy, including hypothyroidism in 2 patients, asthma in 2 patients, gestational diabetes in 1 patient, and a history of Hodgkin's lymphoma in 1 patient.

None of these patients had received prompt antiviral treatment. In these patients, the median time from symptom onset to receipt of antiviral agents was 6.5 days (range, 3 - 36 days).

Six deliveries occurred in the intensive care unit. Four of these were emergency cesarean deliveries.

During the surveillance period, there were an estimated 188,383 births in the state of California. The 8 deaths from H1N1 influenza resulted in a cause-specific maternal mortality ratio of 4.3 (95% CI, 1.8 - 8.4), the authors report.

"More than two thirds of maternal deaths in the United States each year are directly related to obstetrical factors, and maternal deaths due to influenza have been rare," they write. "The high 2009 H1N1 influenza-specific maternal mortality suggests that this pandemic has the potential to notably increase overall maternal mortality in the United States in 2009."

The authors note limitations of their study. Despite enhanced surveillance, cases relied on passive reporting by clinicians, and this probably resulted in underreporting of cases. Also, recommendations for testing were based on the severity of illness, clinicians may have been more inclined to test pregnant women than nonpregnant women, and pregnant women may have been hospitalized more readily.

Finally, the records of nonpregnant women requiring intensive care were not reviewed as carefully as those of pregnant women because of time and resource constraints.

The authors conclude that pregnant and postpartum women should be counseled about the importance of vaccination against H1N1 influenza. The vaccine is expected to have the same safety profile among pregnant women as the seasonal influenza vaccine, and preliminary results from a trial of the 2009 H1N1 monovalent vaccine have shown a strong immune response in pregnant women — similar to that seen in nonpregnant adults — with no identifiable safety concerns, the authors note.

They also advise that critically ill pregnant and postpartum women who are hospitalized in non–tertiary care centers be transferred to facilities that provide "a higher level of care, including neonatal intensive care for premature infants."

N Engl J Med. Published online December 23, 2009.

Psychotherapy May Prevent Obesity in At-Risk Teens

By Kristina Fiore, Staff Writer, MedPage Today
Published: December 18, 2009
Reviewed by Zalman S. Agus, MD; Emeritus Professor
University of Pennsylvania School of Medicine. 

Psychotherapy may help prevent excessive weight gain in teen girls considered at risk for obesity, researchers say.

In a pilot trial, girls who participated in interpersonal psychotherapy saw their body mass index (BMI) stabilize over one year, while those who took traditional health education classes did not, Marian Tanofsky-Kraff, PhD, of the National Institutes of Health, and colleagues reported online in the International Journal of Eating Disorders.

The treatment also curbed binge-eating episodes, the researchers said.

Action Points  

---

• Explain that a small pilot study found girls who participated in interpersonal psychotherapy saw their body mass index (BMI) stabilize over one year, while those who took traditional health education classes did not. Their binge-eating habits were also curbed.
  

"We found very preliminary support that the therapy may reduce loss-of-control eating and prevent excess BMI gain," they wrote. All 38 girls enrolled in the trial were above average in weight, and some had previously reported episodes of loss-of-control of eating, or binge eating.
In loss-of-control eating, patients cannot control their food intake. This, of course, has been tied to risk of weight gain.
Interpersonal psychotherapy focuses on improving interpersonal relationships by targeting the underlying social difficulties that influence patients to engage in loss-of-control of eating, the researchers wrote.
The treatment has demonstrated effectiveness in reducing binge eating in obese adults.
It's "based on the assumption that binge eating occurs in response to poor social functioning and the consequent negative moods," Tanofsky-Kraff said in a statement.
Yet there is a dearth of intervention research in adolescents with binge eating, the researchers said.
So the researchers conducted the pilot program among 38 girls, ages 12 to 17, who were at risk for excess weight gain, and some of whom had reported episodes of loss-of-control of eating.
The girls were randomly assigned to therapy or to standard health education classes.
The researchers acknowledged that their team "made a concerted effort to maintain positive rapport and regular contact with study families, and girls were offered modest financial compensation."
Every participant completed a 12-week program, with 80% attendance required, and had follow-up visits through six months. A total of 35 returned for a complete assessment visit at one year. Two completed survey questionnaires instead, and one was lost to follow-up.
The researchers found that girls who had psychotherapy were more likely to stabilize or reduce their BMI than those who had health education classes (P=0.028).
Also, girls who had problems with binge eating at baseline experienced greater reductions in control-loss episodes if they had psychotherapy than those who had health education classes (P=0.036).
"This may provide a mechanism for the findings that more girls in the therapy group than the health education group experienced less-than-expected BMI growth at follow-up," the researchers wrote.
Even though the participants were compensated, the researchers speculated that the high level of attendance "may speak to an overarching desire on the part of the public to prevent obesity and find approaches that may bolster standard weight loss programs."
They acknowledged that the study was limited by a lack of statistical power due to its small size.
Still, Tanofsky-Kraff said that if psychotherapy "proves to be effective, we may be able to prevent not only excessive weight gain, but the development of related adverse health conditions in a subset of susceptible youth."

Soy may benefit breast cancer survivors

By Denise Mann, Health.com

Soy components such as folate, protein, calcium, and fiber may be responsible for health benefits reported in the study.

STORY HIGHLIGHTS

• Soy foods such as milk, tofu, and edamame are rich in naturally occurring estrogens
• But study says soy may actually reduce the amount of estrogen that's available to the body
• More studies are needed to confirm these findings, experts say

(Health.com) -- Women with breast cancer who eat more soy are less likely to die or have a recurrence of cancer than women who eat few or no soy products, according to a new study.

In the past, physicians have often warned breast cancer patients not to eat soy. The new research represents "a complete turnaround" from the previous understanding about the link between soy consumption and breast cancer, says Sally Scroggs, a registered dietician and senior health education specialist at M.D. Anderson's Cancer Prevention Center in Houston, Texas.

"We have gone from saying, 'No soy for breast cancer survivors' to, 'It's not going to hurt,'" Scroggs says. "Now it looks like we can say, 'It may help.'"

The study looked at more than 5,000 women in China who had undergone a mastectomy; they were followed for about four years. The women who consumed the most soy protein (about 15 grams or more a day) had a 29 percent lower risk of dying and a 32 percent decreased risk of breast cancer recurrence compared to the women who consumed less than about 5 grams of soy protein a day, according to the study, which appears in the December 9 issue of the Journal of the American Medical Association. The National Cancer Institute and the U.S. Department of Defense's Breast Cancer Research Program funded the study.

Health.com: How to take care of yourself after breast cancer surgery

We have gone from saying, 'No soy for breast cancer survivors' to, 'It's not going to hurt.' Now it looks like we can say, 'It may help.'
--Sally Scroggs, R.D.

RELATED TOPICS

• Breast Cancer
• M.D. Anderson Cancer Center
• Cancer

Women who ate between 9.5 and 15 grams of soy protein saw nearly the same decrease in risk as the women who ate more than 15 grams. In fact, the researchers found no additional benefits to eating more than 11 grams of soy protein a day. (An 8-ounce glass of soy milk and a cup of shelled edamame contain about 7 and 14 grams of soy protein, respectively.)

In all, 534 women had a breast cancer recurrence or died from breast cancer during the study period.

Soy foods--such as milk, tofu, and edamame--are rich in naturally occurring estrogens (especially isoflavones) that can mimic the effects of estrogen in the female body. Because the most common types of breast cancer depend on estrogen to grow, experts once feared that soy isoflavones could stimulate the estrogen receptors in breast-cancer cells, even though the estrogens in soy are much weaker than those produced by the body.

Health.com: 'I stayed in control of my breast cancer treatment'

 

The current study suggests the exact opposite: Soy may actually reduce the amount of estrogen that's available to the body.

"Soy isoflavones may compete with estrogens produced by the body. Soy isoflavones may also reduce the body's production of estrogen, and increase clearance of these hormones from the circulation--all of which together reduce the overall amount of estrogen in the body," says the lead author of the study, Dr. Xiao Ou Shu, M.D., Ph.D., a cancer epidemiologist at the Vanderbilt-Ingram Cancer Center of Vanderbilt University Medical Center in Nashville, Tennessee.

Shu says, however, that factors beyond estrogen may be at work. Other components of soy foods, such as folate, protein, calcium, or fiber (or some combination thereof) may also be responsible for the health benefits reported in the study, she says.

Health.com: New breasts to go with my cancer-free life

The new findings, which seem to contradict what many women have heard from their doctors over the years, could prove perplexing for women such as Andrea Mulrain, 44, a former music executive who was first diagnosed with breast cancer 10 years ago.

After her diagnosis, Mulrain's doctors told her to steer clear of all soy foods because these foods could encourage the growth of cancer cells. Mulrain had estrogen-sensitive breast cancer, which means that estrogen helps the cancer grow.

Her doctors eventually softened their stance a bit, and said she could consume soy in moderation. "I pretty much avoided soy for 10 years after diagnosis but recently was told it was OK to have soy in moderation as long as I read the labels and make sure it's not the main ingredient in any food," says Mulrain, who is currently being treated for a recurrence.

In the study, the association between soy consumption and lower risk of death and cancer recurrence was seen in women like Mulrain with estrogen-sensitive breast cancers, and in women taking tamoxifen, a drug designed to prevent cancer recurrence by blocking the effects of estrogen in the breast tissue.

Health.com: What you need to know if you choose breast reconstruction

Despite the study's findings, the final verdict on soy and breast-cancer recurrence is not yet in, according to an accompanying editorial written by Dr. Rachel Ballard-Barbash, M.D., of the National Cancer Institute in Bethesda, Maryland, and Marian L. Neuhouser, Ph.D., of the Fred Hutchinson Cancer Research Center in Seattle, Washington.

The follow-up period in the new study was relatively short, they say, and breast-cancer diagnosis and treatment may be different in China compared to the United States. Similarly, there may be differences in the types of soy foods that Chinese and American women eat. (In general, Chinese women consume significantly more soy than American women.)

More studies are needed to confirm these findings, especially as they apply to women with estrogen-sensitive breast cancer or those who take drugs such as tamoxifen to keep breast cancer at bay, say Ballard-Barbash and Neuhouser. Still, they say, "Patients with breast cancer can be assured that enjoying a soy latte or indulging in pad thai with tofu causes no harm, and when consumed in plentiful amounts may reduce risk of disease recurrence."

The study should be reassuring to women who have been trained to steer clear of soy, says Scroggs. "Don't freak out if there is some tofu mixed in with your vegetables at an Asian restaurant," she says.

Health.com: Breast cancer -- What should I do if I'm high risk?

Her soy prescription for breast-cancer survivors? "Eat soy in moderation, and your soy proteins should come from foods, not concentrated supplements," she says. "Soy is a complete protein so it is high in fiber and has a place in a healthy, balanced diet."

Eating more soy is beneficial because it tends to replace less healthy foods in people's diets, Scroggs says. "When people are eating soy protein, they are likely eating less of something else, such as red meat," she says.

Weight Loss Eases Apnea Symptoms in Obese Men

By Michael Smith, North American Correspondent, MedPage Today
Published: December 04, 2009
Reviewed by Zalman S. Agus, MD; Emeritus Professor
University of Pennsylvania School of Medicine and
Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

A low-calorie diet can reduce the symptoms of obstructive sleep apnea in obese patients and in some cases cure the condition, Swedish researchers said.

In a randomized controlled trial, obese men who spent seven weeks on a very low-calorie liquid diet saw their sleep apnea drop from severe or moderate to mild or normal, according to Kari Johansson, a PhD candidate at the Karolinska Institute in Stockholm, and colleagues.

At the same time, obese men in the control group -- who maintained their normal diet -- saw no change, Johansson and colleagues reported online in BMJ.
Action Points 

    * Explain to interested patients that obesity is a major risk factor for obstructive sleep apnea.


    * Note that this randomized controlled trial showed that a low-energy diet can relieve the symptoms of the disease, at least over a short term.

Only one other randomized trial has looked at the effect of weight loss in sleep apnea, Johansson and colleagues wrote, and that study did not include men with moderate or severe disease.

To help fill the gap, the researchers enrolled 63 men with a body mass index between 30 and 40. They randomly assigned 30 men to follow a seven-week, 550-kcal liquid regimen (the Cambridge Diet), followed by a two-week period of gradual reintroduction of normal food.

The remaining 33 men formed a control group and continued their normal diet, although two dropped out when they found they were to be controls.

At the start of the study, the average apnea-hypopnea index (AHI) was 37 in both groups -- meaning they averaged 37 episodes of stopped or shallow breathing per hour of sleep.

An index of less than 5 is regarded as normal, while scores of 5 through 14, 15 through 29, and 30 or more indicate mild, moderate, or severe obstructive sleep apnea, respectively.

At the end of the nine weeks, the researchers reported:

    * Men on the diet lost an average of 41 pounds, while those in the control group gained an average of 2.4 pounds.
    * On average, the dieting men lost 5.7 points on their BMI, compared with a gain of 0.3 points in the control group.
    * Twenty-two of the 30 dieters were no longer obese, while all of the control participants remained obese.
    * The average AHI among the dieters was 12 (mild), compared with 35 (severe) in the control group.
    * Five of the dieters were disease-free, with an AHI of less than 5, and half had mild disease. Only one participant in the control group was below 15 on the AHI.
    * Researchers identified eight transient adverse effects that might have been caused by the diet, including three cases of constipation and two of elevated alanine aminotransferase concentrations. There were no adverse events in the control group.

The main limitation of the study, Johansson and colleagues wrote, is that its short length made the long-term effect difficult to determine.

Even so, the study fills a "major gap" in evidence-based treatment of sleep apnea, according to Nathaniel Marshall, PhD, of the University of Sydney, and Ronald Grunstein, MD, PhD, of the Royal Prince Alfred Hospital, both in Sydney, Australia.

Writing an accompanying editorial, Marshall and Grunstein noted that much sleep apnea research has focused on mechanical interventions, such as continuous positive airway pressure machines.

The Swedish study provides "the first high-quality evidence that moderate-severe obstructive sleep apnea can be treated with weight loss," they wrote in the journal.

But they also noted that the study was only nine weeks long, "which leaves open the question of the long-term sustainability of the weight loss."

Obesity Outweighs Smoking as Life Expectancy Threat

By Crystal Phend, Senior Staff Writer, MedPage Today
Published: December 02, 2009
Reviewed by Zalman S. Agus, MD; Emeritus Professor
University of Pennsylvania School of Medicine and
Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner   
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Gains in life expectancy from lower smoking rates over the next decade will be offset, to some degree, by reductions in life expectancy based on the rise in obesity, researchers estimated.

If obesity and smoking rates had held steady, the average 18-year-old would have seen a 2.98-year increase in life expectancy over a 15-year period, according to Susan T. Stewart, PhD, of Harvard and the private nonprofit National Bureau of Economic Research in Cambridge, Mass., and colleagues.

But a 48% rise in obesity overrode the expected gain from a 20% reduction in smoking rates seen over the past 15 years, the researchers reported in the Dec. 3 New England Journal of Medicine.

Bottom line: a predicted net impact of 0.71 fewer life-years through 2020 -- one quarter of the anticipated increase.Action Points 
Explain to interested patients that these population-level predictions show the importance of tackling obesity for the nation's health, but the life expectancy estimates would not apply on an individual basis for those who lose weight or quit smoking.
Overall, life expectancy isn't expected to fall over the next decade, the researchers cautioned. Instead, their estimates suggest that "life expectancy will continue to rise but less rapidly than it otherwise would."

Still, the findings should be a wake-up call for policymakers and physicians, Stewart said in an interview.

"We know that the effects of obesity are not quite as intense as the effects of smoking, but obesity is more widespread," she said. "It was a little discouraging to see that obesity was winning."

"But if we were to put the same kind of effort into addressing obesity as we have fairly successfully put into addressing smoking, then perhaps we could have the same kind of positive effects for the future," she added.

The researchers forecast life expectancy and quality-adjusted life expectancy for a representative 18-year-old for each year from 2005 through 2020.

Since both obesity and smoking impact quality of life, the researchers also estimated quality-adjusted life expectancy using 2003 Medical Expenditure Panel Survey data.

Four iterations of the National Health Interview Survey from 1978 through 2006 revealed an average 1.4% decrease in smoking rates per year in the 15 years prior to 2005.

But Body Mass Index (BMI) trends based on National Health and Nutrition Examination Surveys (NHANES) from 1971 through 2006 showed an average 0.5% increase per year over the 15 years before 2005.

Assuming a continuation of past trends for the next 15 years, 21% of current smokers would quit by 2020, the researchers estimated.

Based on this factor alone, life expectancy for the typical 18-year-old would increase 0.31 years, with an extra 0.41 years of quality-adjusted life expectancy.

But over the same time frame, the normal weight population would drop by 35% in the U.S. with an estimated 45% of Americans expected to be obese by 2020.

The impact of this change alone would reduce life expectancy by 1.02 years and quality-adjusted life expectancy by 1.32 years.

Thus the net effect of the two risk factors together would be a 0.71-year reduction in life expectancy and 0.91-year drop in quality-adjusted life expectancy relative to the trend.

This same pattern was forecast for every year from 2005 to 2020, with the disproportionate effects of obesity becoming even more pronounced over time.

Even in sensitivity analyses based on more rapid declines in smoking and slower rises in obesity, the effects of obesity exceeded those of smoking on life expectancy.

The trends could be expected to have less absolute impact for older adults, who have fewer years of remaining life expectancy, Stewart said.

However, the results might underestimate the impact of obesity on youth, considering that earlier onset leaves more time for risks such as diabetes to arise, she said.

"Though perhaps not achievable," completely eliminating both smoking and obesity would increase life expectancy by 3.76 years while quality-adjusted life expectancy would rise by 5.16, the researchers wrote.

They cautioned that these population-level forecasts do not apply at the individual level to smokers who quit or people who lose weight.

Nevertheless, "even modest weight loss and reductions in smoking at the individual level can have substantial effects on population health," they concluded.

The study was supported by grants from the National Institute on Aging, the Harvard Interfaculty Program for Health Systems Improvement, and the Lasker Foundation. The researchers reported no potential conflicts of interest.

Diabetes Care Will Cost $336B by 2034

By John Gever, Senior Editor, MedPage Today
Published: November 27, 2009
Reviewed by Zalman S. Agus, MD; Emeritus Professor
University of Pennsylvania School of Medicine and
Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

More than 44 million Americans will have diabetes within 25 years under current trends, and the annual cost of caring for them will triple to $336 billion in constant 2007 dollars, researchers said.

The obesity epidemic, ever-earlier ages of diabetes onset, and increasing longevity of people with established diabetes are combining to enlarge the diabetic population far beyond anything envisioned in earlier projections, Elbert S. Huang, MD, MPH, of the University of Chicago, and colleagues reported the December issue of Diabetes Care.

"Without significant changes in public or private strategies, this population and cost growth are expected to add a significant strain to an overburdened healthcare system," the researchers warned.

Currently, some 24 million Americans are living with diabetes, Huang said in a briefing for reporters. "Already this represents a great economic burden for the country and for government programs like Medicare," he said.

Huang and colleagues estimated that costs to Medicare would rise nearly fourfold, from about $45 billion currently to $171 billion in 2034, in constant dollars.
Previous forecasts had projected slower growth in the number of diabetic patients. For example, a 2001 study by CDC researchers estimated that about 29 million Americans would be diagnosed with the disease in 2050.
Unlike earlier efforts, Huang and colleagues included trends related to obesity in their model for projecting future cases of diabetes, as well as data from the 2004 United Kingdom Prospective Diabetes Study (UKPDS) on the natural history of the disease.
The UKPDS data allowed the researchers to develop a model by which individuals with certain disease durations and ages were expected to have developed corresponding levels of cardiovascular, renal, ocular, and other complications.
"We know that the average cost of treating diabetes in newly diagnosed people is substantially different from the costs of treating someone who has lived with diabetes for 20 or 30 or 40 years and is suffering from microvascular or cardiovascular complications," Huang explained.
Data from the U.S. government's Medical Expenditure Panel Survey were used to attach treatment costs to care of diabetes and the associated complications at different patient ages and disease durations.
"Our model accounts for that natural history and the change in the life of a patient," he said. That is why the study forecast more rapid increases in costs than in the diabetic population -- because patients are living longer with these expensive complications.
The study also took account of trends in body mass index distribution. According to the group's projections, "overall obesity distribution in the nondiabetes population remains fairly stable over time, with [about] 65% of the population being overweight or obese."
Some 35% of the population will be overweight throughout the period, while the percentage classed as obese will decline from 30% currently to 27% by 2034, the researchers said.
The obesity projections were based on UKPDS and U.S. data on how body mass index changes with age. Actual obesity prevalences could be higher or lower if eating and exercise habits or anti-obesity medical treatments change significantly.
The current study did not analyze the potential effects of interventions aimed at reducing the incidence and severity of diabetes. But Huang said small-scale programs promoting healthy eating and exercise have shown the ability to affect the natural history of diabetes.
Matt Petersen, a spokesman for the American Diabetes Association, said "realistic and achievable amounts of changes in diet and physical activity do have a clinically significant effect on primary prevention."
But Huang acknowledged that, outside of formal clinical studies, "it's not clear that... community efforts are collectively making a big impact in terms of diabetes prevention."
On the other hand, he said data from the CDC's National Health and Nutrition Examination Survey indicate that blood glucose, cholesterol, and blood pressure control may be improving. (See 'Bad' Cholesterol Rates Plummet)
"I don't know if that's attributable to community efforts as much as to physician and patients becoming more aware of targets for diabetes care and slightly better delivery of drugs," Huang said. "I would say that the story is mixed in terms of diabetes prevention and diabetes care.
The researchers noted several limitations to their analysis:

• It did not account for possible future changes in diabetes screening rates, which could raise or lower the numbers of people receiving treatment.
• It did not account for immigration by people younger than 24.
• All individuals with body mass index values of 30 and higher were grouped together, leading to potential underestimation of the future diabetic population and costs.
• The model assumed no change in baseline age-specific rates of obesity.

Moderate-to-High Alcohol Intake Linked to Reduced CHD Risk in Men

Men who drink moderate to very high amounts of alcohol may have a reduced risk for coronary heart disease, according to an observational study in Heart.

Over 40,000 Spanish men and women completed questionnaires about their lifestyles, including alcohol intake, and were followed for a median of 10 years. During that time, 1.5% developed CHD.

After adjustment for lifestyle factors and comorbid conditions, men who regularly consumed moderate to very high amounts of alcohol (range: 5 to at least 90 g/day — the equivalent of roughly one to six standard drinks) had about half the risk for CHD as those who never drank. Findings were similar for all kinds of beverages consumed.

Among women, alcohol intake was not significantly associated with CHD.

Heart article (Free abstract; full text requires subscription)

FDA: Clopidogrel's (Plavix) Antiplatelet Effect Can Be Halved by Omeprazole (Prilosec)

The FDA is updating clopidogrel's label to warn against its concomitant use with the proton-pump inhibitor (PPI) omeprazole. The agency says omeprazole can reduce clopidogrel's antiplatelet effect.
New manufacturer-conducted studies indicate that clopidogrel's antiplatelet effect was reduced by nearly 50% in people receiving both drugs. Administering the drugs at different times does not diminish this drug interaction, the FDA warns.
Omeprazole blocks the enzyme CYP2C19, which converts clopidogrel into an active metabolite. Other drugs that should also be avoided in tandem with clopidogrel include cimetidine, fluconazole, ketoconazole, voriconazole, etravirine, felbamate, fluoxetine, fluvoxamine, and ticlopidine. (The agency says it does not yet have enough information to make recommendations about PPIs other than omeprazole, although esomeprazole — a component of omeprazole — should also be avoided with clopidogrel.)
The FDA notes that providers should also make sure that their patients on clopidogrel are not taking over-the-counter versions of omeprazole or cimetidine.

USPSTF Recommends Against Routine Mammography for Women in Their 40s

The U.S. Preventive Services Task Force now recommends against routine screening mammography for average-risk women aged 40 to 49. This represents a change from the USPSTF's 2002 recommendation statement, which advocated for routine screening starting at age 40.
Among the task force's other updates, published in Annals of Internal Medicine:

• Screening mammography should be performed every 2 years for average-risk women aged 50 to 74.
• Evidence is insufficient to recommend for or against screening in women 75 or older.
• Clinicians should not teach women how to perform breast self-exams.
• Evidence is insufficient to make recommendations on using clinical breast exams in addition to mammography.
• Evidence is insufficient to recommend for or against using digital mammography or MRI instead of film mammography.

In Journal Watch Women's Health, Dr. Andrew Kaunitz says that because the updated guidelines recommend less screening, women may be confused or even outraged. He calls for consistent "frank discussions" with patients about the benefits and risks of screening mammography.

(The American College of Radiology has spoken out against these guideline changes.)

Chocolate Is Associated with Lower Mortality Following First Heart Attack

Amount of chocolate consumption was related inversely to cardiac-related mortality during an 8-year follow-up

Several studies have suggested that chocolate, perhaps in a process mediated by its antioxidant content, protects the heart (JW Gen Med Jul 10 2007 and JW Gen Med Sep 23 2003). A Swedish team identified 1169 nondiabetic patients who were hospitalized with initial nonfatal myocardial infarctions. Detailed food histories for the preceding 12 months were completed by 86% of patients; participants were followed for an additional 8 years.

Compared with patients who never ate chocolate, those who ate chocolate less than once monthly suffered 27% less cardiac-related mortality (after multivariate adjustments); risk was 44% lower for weekly chocolate eaters and 66% lower for those who ate chocolate two or more times weekly. Nonfatal adverse cardiac events, strokes, and total mortality, however, were not related clearly to chocolate consumption. Consuming other sweets (e.g., cookies, cakes, ice cream) had no relation to cardiac mortality.

Comment: The strengths of this study are its size and long-term follow-up. The main weakness is that chocolate consumption was assessed only once, during hospitalization for initial MIs, and not during follow-up. To me, the most interesting result of the study is that chocolate strongly protected against cardiac mortality but not against adverse cardiac events. The same finding has been reported for ω-3 fatty acid supplements, which suggests that the primary beneficial effect of both chocolate and ω-3 fatty acid supplements is in suppressing arrhythmias.

— Anthony L. Komaroff, MD

Published in Journal Watch General Medicine September 3, 2009

Posible penile condyloma vs. cancer

 The above picture is not from the actual patient

Yesterday I saw a 28 y/o male patient with no history of chronic illnesses, who referred a penile rash/growth that first started 5 years ago, but that 5 months ago started to get way out of proportion.  He denies sexual contact with a person with genital warts (that he knows of). When I examined the patient his glans is 3-4 times bigger than the one in the picture, had multiple cauliflower-like growths and was secreting yellow/green liquid from various places, with incredible mal odor. He denies pain or pruritus.

He was already seen by one urologist who performed a biopsy and the results were mixed: condyloma (warts) vs. cancer. The recommendation was a partial penectomy (removing part of his penis). Obviously the patient refused and wanted a second opinion. He was sent to another urologist who recommended a circumsicion and laser removal of as much tissue as possible to avoid the penectomy. I explained the procedure, as well as the possible outcomes of treatment, to the patient.

He is scheduled to have surgery next week.

I immediately thought it was cancer, because I had no idea warts could get that bad. That was until I did research and found several pictures of similar people.

The following picture is from a patient with the same disease before surgery.

This picture is after the circumsicion and debridement.

I hope the surgery goes well, though my patient has it much worse.

Prophylactic Acetaminophen Reduces Immunogenicity of Childhood Vaccines

Children given acetaminophen with vaccinations have lower rates of fever in response, but the vaccinations produce a lower immunogenicity, reports a Lancet study.
Researchers, including some from the sponsoring vaccine manufacturer, followed over 400 infants receiving primary and booster immunizations. Half received acetaminophen via suppository in three doses over the first 24 hours after vaccination, and half received no prophylaxis.
The percentage of children with a temperature of 38 degrees C or higher was significantly lower in the acetaminophen group by some 40% to 50% both at primary and booster immunizations. However, vaccine immunogenicity was lower in the acetaminophen group — significantly so for some antigens, e.g., all 10 pneumococcal serotypes after the primary immunization. The authors hypothesize that the effect could result from acetaminophen's preventing inflammation.
Over 95% of all children had seroprotective antibody levels, but researchers argue that antipyretics "should ... no longer be routinely recommended" with vaccination. Editorialists agree, calling the case "compelling."

CD4 Level Predicts Cancer Risk in HIV

By Charles Bankhead, Staff Writer, MedPage Today
Published: October 07, 2009
Reviewed by Zalman S. Agus, MD; Emeritus Professor
University of Pennsylvania School of Medicine and
Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner 

A falling CD4 count predicted increased susceptibility to seven types of cancer in people infected with human immunodeficiency virus (HIV), according to a study of more than 50,000 patients.

The cancers include both AIDS-defining and non-AIDS-defining malignancies, investigators reported online in The Lancet Oncology. They speculated that early diagnosis and treatment of HIV could delay the onset of at least some of the cancers.

The authors also recommended cancer-specific screening for HIV-infected individuals.

"Our results suggest that combination antiretroviral therapy would be most beneficial if it restores or maintains the CD4 count above 500 cells per microliter, thereby indicating an earlier diagnosis of HIV infection and an earlier treatment initiation," Marguerite Guiget, PhD, of the University of Pierre and Marie Curie and the French national health institute (INSERM), and colleagues concluded.

"Access to cervical-cancer screening programs should be regularly offered to all HIV-positive women, and cancer-specific screening programs, such as for lung cancer and for anal cancer, need to be assessed in HIV-infected patients," they wrote.

Improved treatment for HIV and AIDS has led to longer patient survival. However, that increased life expectancy has also brought an increased susceptibility to cancer.

Antiretroviral therapy's effect on cancer risk had not been carefully studied, the authors said.

So they studied it using records from the national French hospital database. They analyzed cancer risk in 52,278 HIV-infected patients from 1998 to 2006. The analysis included three AIDS defining cancers (Kaposi's sarcoma, non-Hodgkin's lymphoma, and cervical cancer) and four non-AIDS-defining cancers (Hodgkin's lymphoma, lung cancer, liver cancer, and anal cancer).

For each type of cancer, the authors evaluated 78 models derived from immunodeficiency status (defined by current CD4 count), viral load, and combination antiretroviral therapy.

Immunodeficiency predicted increased risk for all of the cancers, and CD4 count was the most predictive factor for all except anal cancer.

In general, cancer risk correlated inversely with CD4 count. For Kaposi's sarcoma, for example, a CD4 count of 350 to 499 cells/µL almost doubled the risk of a CD4 count of 500 or greater (RR 1.9, 95% CI 1.3 to 2.7).

If the patient had a CD4 count <50 cells/µL, the risk for Kaposi's sarcoma was 25 times greater than it was for patients with CD4 levels of 500 or greater (RR 25.2, 95% CI 17.1 to 37.0, P<0.0001).

Similar associations between CD4 count and cancer risk were observed for non-Hodgkin's lymphoma, Hodgkin's lymphoma, liver cancer, and lung cancer (P<0.0001 for each). A higher CD4 count lowered the risk of cervical cancer (RR 0.7 per log₂, 95% CI 0.6 to 0.8, P=0.0002).

HIV RNA load exceeding 100,000 copies/mL tripled the risk of Kaposi's sarcoma (RR 3.1, P<0.0001) and non-Hodgkin lymphoma (RR 2.9, P<0.0001).

Combination antiretroviral therapy predicted a lower risk of Kaposi's sarcoma (RR 0.3, P<0.0001) and cervical cancer (RR 0.5, P=0.03) and a trend toward a lower risk of non-Hodgkin lymphoma (RR 0.8, P=0.07).

The risk of anal cancer increased with duration of time with a CD4 count <200 cells/µL (1.3 per year, P=0.0001) and with a viral load >100,000 copies/mL (1.2 per year, P=0.005).

Mediterranean Diet Associated with Reduced Risk for Depression

Adherence to a Mediterranean-style diet is associated with lower risk for developing depression, reports Archives of General Psychiatry.
Some 10,000 young adults in Spain completed food-frequency questionnaires to assess how well they followed a Mediterranean dietary pattern (i.e., high in fruits, vegetables, fish, nuts, cereal, and legumes; low in meat and whole-fat dairy; moderate alcohol intake; and high ratio of monounsaturated-to-saturated fatty acids).
After a median 4 years' follow-up, people in the top three quintiles of diet adherence had lower hazard ratios for incident self-reported depression than those in the lowest quintile. High consumption of fruits and nuts, legumes, and fish were each separately associated with lower depression risk.
The authors speculate that the observed effect may be explained by the diet's beneficial impact on endothelial function, which may, in turn, improve production of brain-derived neurotrophic factor — reported to be reduced in depression.

Beneficial Effect of Weight Loss on Obstructive Sleep Apnea in Patients with Diabetes

From Archives of Internal Medicine article

Participation in an intensive lifestyle intervention leading to weight loss is associated with improvements in obstructive sleep apnea among patients with diabetes, reports Archives of Internal Medicine.
Researchers studied some 260 overweight older patients (mean age, 61) with type 2 diabetes and obstructive sleep apnea (average apnea-hypopnea index, 23 events per hour) for 1 year. Patients were randomized either to an intensive lifestyle intervention using restricted caloric intake and moderate exercise, or to a series of three group sessions focusing on diet, exercise, and social support.
By year's end, intensive-intervention patients had lost significantly more weight and showed a significant improvement in sleep apnea, compared with controls. In the control group, patients showed a worsening in their sleep apnea, despite maintaining stable weight. The greatest improvements in the apnea-hypopnea index were among patients with the highest initial values and the greatest weight loss.

Why we eat too much, and how to get control

By Rachel Grumman (CNN.com)

We all know we're supposed to eat healthy portions. So why is it that a rough day at the office or even just the smell of chocolate-chip cookies can cause us to throw our best intentions out the window?

If you overeat, think about what triggered your overindulgence so you can do better next time.

We tapped the nation's leading experts for the unexpected reasons why so many of us overdo it -- so you can break the cycle and prevent an unwanted pile-on of pounds.

You're not getting enough sleep

Missing out on your zzz's not only puts you in a mental fog, it also triggers a constellation of actual metabolic changes that may lead to weight gain. A lack of shut-eye harms your waistline because it affects two important hormones that control appetite and satiety--leptin and ghrelin--says Kristen L. Knutson, Ph.D., a research associate specializing in sleep and health at the University of Chicago's Department of Medicine. Health.com: Potential side effects of sleeping pills

According to a study published in the Annals of Internal Medicine, people who slept only four hours a night for two nights had an 18 percent decrease in leptin (a hormone that signals the brain that the body has had enough to eat) and a 28 percent increase in ghrelin (a hormone that triggers hunger), compared with those who got more rest. The result: Sleep-deprived study volunteers reported a 24 percent boost in appetite. Short sleep can also impair glucose metabolism and over time set the stage for type 2 diabetes, Knutson notes.

How to get control:

When we're exhausted, we hunger for just about everything in sight, especially if it's sugary or high in carbs. That may be because these foods give us both an energy boost and comfort (since lack of sleep is a stressor), Knutson says. To quell the urge for fattening foods and still get the energy kick you need, reach for a combination of complex carbs and protein.

"If you're feeling tired, you want carbs. But go for high-fiber carbs for long-lasting energy," says Keri Gans, R.D., a spokeswoman for the American Dietetic Association (ADA). "Fiber burns slower than simple sugars, and adding in some protein keeps you satisfied longer."

At breakfast, have whole-wheat toast with egg whites or a high-fiber cereal with fruit and a yogurt. And for a food-free way to perk up during the day, take a 10-minute walk outside. You also can prevent uncontrollable cravings in the first place by prioritizing a good night's sleep -- get seven to nine hours a night in a slumber-friendly bedroom (one that's as dark and quiet as possible and reserved for shut-eye and sex only).

A final tip: If you're plagued by sleep problems, ask your doctor for a referral to a sleep specialist. Health.com: Ways to eliminate bedroom distractions and get sleep

You're sabotaged by stress

Constant stress causes your body to pump out high doses of hormones, like cortisol, that over time can boost your appetite and lead you to overeat. "Cortisol and insulin shift our preferences toward comfort foods--high-fat, high-sugar, or high-salt foods," says Elissa Epel, Ph.D., an associate professor at the University of California, San Francisco (UCSF), Department of Psychiatry and a leader of the UCSF Center on Obesity Assessment, Study, and Treatment. Health.com: Feeling stressed? Why you may feel it in your gut

Fat cells also produce cortisol, so if you're overweight and stressed, you're getting a double-whammy in terms of exposure. Overweight women gained weight when faced with common stressors such as job demands, having a tough time paying bills, and family-relationship strains, according to a study published in the American Journal of Epidemiology.

Cortisol, together with insulin, also causes your body to store more visceral fat, which is a risk factor for heart attack and stroke, Epel notes. What's more, stress makes it harder to stick with a healthy eating plan. "It's a reason why people go off diets," notes Marci Gluck, Ph.D., a clinical research psychologist at the Obesity and Diabetes Clinical Research Section of the National Institutes of Health in Phoenix, Arizona. Folks who normally restrict their eating, tend to overeat in response to stress.

How to get control:

Sure, real-life pressures can put you in nonstop-nibble mode. But working stress-reduction techniques into your busy days can really help. Yoga, meditation, and deep-breathing exercises are powerful tools that keep tension in check. And spending 20 minutes doing progressive muscle relaxation--alternately tensing and relaxing muscle groups--significantly lessens stress, anxiety, and cortisol, according to a study published in the International Journal of Obesity and Related Metabolic Disorders. Health.com: How to grocery shop on a diet

Exercise will also do the trick. "Try dancing to your favorite tunes, running in place, playing a sport, or taking a simple walk," says Elisa Zied, R.D., an ADA spokeswoman and author of "Nutrition at Your Fingertips." When you're feeling edgy, make a habit of turning to these activities rather than diving into your candy stash. If you're feeling completely overwhelmed by stress, talk to a counselor who specializes in stress management.

You've got fatty foods (literally) on the brain

We're hardwired to hunger for fatty, sugary, salty foods because, back when our ancestors were foraging for every meal, palatable eats meant extra energy and a leg-up on survival, says Dr. David A. Kessler, former commissioner of the Food and Drug Administration (FDA) and author of "The End of Overeating: Taking Control of the Insatiable American Appetite."

So it's not just a lack of willpower that's tripping you up, but rather your outdated survival mode. In fact, when you eat fat-rich foods, your brain not only gets a signal that your body is satisfied but also forms long-term memories of the experience, according to new research published in the Proceedings of the National Academy of Sciences. What once helped early humans survive is now giving us ever-expanding waistlines.

Adding to the challenge to control overeating, the mere sight of food can cue up a craving. "[Cravings] are based on past learning and memories as well as the sight or smell of food, time of day, or location," Kessler says. "You'll walk down the street and start thinking about chocolate-covered pretzels because you've had them before on the same street."

Health Library

• MayoClinic.com: Whole grains -- Hearty options for a healthy diet

How to get control:

Avoid eating your favorite treat if you're in a particular mood, if it's a certain time of day, or if you're in a specific place; this will prevent you from creating a triggering link between those feelings or locations and that treat, Kessler says. And since the smell and sight of fatty, sugary foods is pure temptation, try to keep yourself from passing the bakery or ice cream shop you can't resist.

Also, pay attention to what you're thinking when temptation strikes. "Once the brain is activated [by a craving], having that inner dialogue of, 'No, I shouldn't have that,' only increases the wanting," Kessler notes. Instead, focus on something you want more than that slice of cheesecake--from being healthier for your kids to feeling less winded when you walk to work--to help override the urge. Health.com: Surprising myths about excess weight

If logic is out the window, indulge in healthier versions of your favorites such as low-fat frozen yogurt with almonds when you crave a sundae or a calcium-rich glass of nonfat chocolate milk when you need a chocolate fix.

You Pigged Out -- Now What?

• Forgive yourself. "Having one overindulgent meal should not derail you from your healthful eating habits, while being too negative will make you more likely to throw up your hands in despair and overindulge at the next meal or several meals for days to come," Elisa Zied, R.D., says.

• Give yourself a do-over. Immediately start with lean protein, veggies, whole grains, and fruit, and drink plenty of water, Zied suggests.

• Learn from it. Think about what triggered your overindulgence--not to punish yourself, but to choose smarter next time. "If you keep a food journal, you might see you ended up pigging out because you waited too long to eat," Keri Gans, R.D., says.

• Add on exercise. To feel in control again, simply tack on a few extra minutes to your regular walk, gym routine, etc. At the same time, "try not to think of exercise as a punishment for overindulging," Zied says. If you do, you'll grow to dread the gym.

Disseminated viral warts

Today I saw a 24 y/o patient complaining of warts. He had them for over 10 years now. His right arm was almost completely covered in them; both hands were also badly affected. He has no history of previous illness (besides the warts), takes no medications, denies any illicit drug use or sexual promiscuity. 

If it were just a few warts then it would be a simple case.  But since they’re so many, and so widespread, the suspicion for a possible complication of something else pops up. For example HIV, Syphilis, or a rare condition that causes warts to grow out of proportion like that.

I ordered a syphilis test and a HIV test to confirm. The next step, after receiving the results, would be a dermatologist referral. The problem in treating this is that they're too many. Usually they can be burned, frozen or treated with podophyllin. This would be extremely difficult for various reasons: 1) to be burned you need localized anesthesia...in this case he would need MANY injections or a complete arm blockade and I don't think that is feasible for this. 2) Freezing them would also be very painful and lengthy. 3) Podophyllin is applied in small drops to each wart and can cause irritation, contact dermatitis, and in some rare cases nausea, vomiting, diarrhea, seizures and coma. Imagine the risk in treating so many warts. 

The following picture is not from the patient, but his are similar, just a lot more.

The following picture is from a somewhat similar disease called Epidermodysplasia Verruciformis: (EV) is an extremely rare disorder of warts, the pathogenesis of which is poorly elucidated. Individuals with EV have a severe and apparently congenital susceptibility to infection with HPV that may be inherited in an autosomal recessive fashion. EV is clinically characterized by widespread warts that appear in childhood— typically flat warts as well as lesions that are scaly, red/brown macules— which do not revert and often develop into skin cancers. The HPV strains specific to the scaly (scary!) warts that characterize EV are HPV-5 and HPV-8.

The following is a link to a video of a man with this disease.

Video of EV patient

63% of Physicians Favor Public Option

By Emily P. Walker, Washington Correspondent, MedPage Today
Published: September 14, 2009

  

WASHINGTON -- A solid majority of physicians favor creating a new public insurance option that would operate alongside existing private plans, according to a survey published online in the New England Journal of Medicine.
About 63% of doctors, across a smattering of specialties and in various geographic regions, support a public insurance option. That figure is in line with national consumer polls that have shown the majority of Americans support a public plan.
While most physicians' groups have voiced a collective opinion on the issue, the opinions of individual doctors are less clear.
"Given the enormity of the current effort to reform healthcare and its potential effect on the future of generations of Americans, policymakers need to hear the views on the whole range of physicians on the key elements of reform," wrote Salomeh Keyhani, MD, and Alex Federman, MD, MPH, from the Mount Sinai School of Medicine in New York.
To examine individual perceptions, Keyhani and Federman collected data from 2,130 physicians from the American Medical Association's Masterfile and stratifed the responses of those doctors into four groups: primary care doctors, medical specialists, surgical specialists, and other specialties.
Physicians were asked which options they most support: a public option only; private options only; or a mixture of private and public insurance options.
The majority of physicians (63%) said they support a mixture of public and private plans -- a cornerstone of the plan President Barrack Obama outlined in his recent address to Congress.
Meanwhile, 27% of respondents said they favored offering private insurance plans only, but creating subsidies to help low-income people afford insurance.
Just 10% favored a healthcare system in which a public, government-run plan was the only insurance option, which would mean private insurance companies would no longer exist in their current form.
Primary care physicians were the most likely to support a public option, while those in fields with less patient contact, such as radiologists and anesthesiologists, were less likely to support a public option, although 57% of those specialists still supported a public option.
Doctors who own their own practices were less likely than non-owners to support a public plan (58% versus 67%; P<0.001).
Physicians who are paid salary only tended to support adding a new public plan more than physicians who are paid through billing insurance companies or the government (69% versus 59%; P<0.001).
Support of the public plan was fairly universal across geographic regions as well, but the biggest majority of support came from those practicing in the Northeast (70%).
Among AMA members, about 62% of respondents supported the public plan.
"Support of the public and private options was consistent across a wide range of physicians, including those from the traditionally conservative southern regions of the United States, those with a financial stake in their practice, and members of the AMA, despite that group's history of opposition to reform efforts" the article's authors concluded.
The AMA -- which has fought past reform efforts, including the creation of another public program, Medicare -- has offered its support for legislation in the House, which would create a public option. The data from the new survey suggest that view is consistent with individual AMA member views.
The plan outlined by the Senate Finance Committee does not contain a public insurance option. It would set up state-by-state cooperatives, which would allow patients to pool together to purchase insurance, and to have an ownership stake in their insurance plan.
There are no plans in Congress that would establish a single-payer system.
The study authors point out several limitations to their survey, including a low response rate of just 43%, however, they add there were no significant differences between the characteristics of responders and non-responders.
The study authors reported no relevant conflicts of interest.
In a second Perspective, also published Monday online in NEJM, researchers sought to gauge physicians' personal attitudes about healthcare reform.
For that survey, researchers led by Ryan Anteil of the Mayo Medical School mailed an eight-page questionnaire about moral and ethical beliefs in medical practice. Physicians were asked to respond to how much they agreed with the following statements:

• "Addressing societal health policy issues, as important as that may be, falls outside the scope of my professional obligation as a physician."
• "Every physician is professionally obligated to care for the uninsured and the underinsured."
• "I would favor limiting reimbursement for expensive drugs and procedures that would help expand access to basic healthcare for those currently lacking such care."

The survey also asked for physicians' moral perceptions on using cost-effectiveness data to determine which treatments are offered to patients.
Of the 991 returned surveys (a response rate of 51%), 78% of respondents said that addressing societal health policy issues is in the scope of professional obligation of a physician.
About 73% said physicians are obligated to care for the uninsured and underinsured.
Most respondents (67%) said they would favor limiting reimbursements for expensive treatments to expand access. Not surprisingly, surgeons and sub-specialists were more likely to oppose cutting payment for pricey procedures than were primary care doctors.
A little more than half (54%) said they were morally opposed to using cost-effectiveness as a factor in deciding which treatments a patient should receive.
As would be expected, there were differences between physicians who described themselves as "conservative" or "liberal" on social issues.
Liberals agreed more strongly that doctors have an obligation to address societal issues, and that physicians are obligated to care for the uninsured and underinsured, and that cutting reimbursements for expensive procedures should help pay for reform.
Conservatives, however, tended to object more strongly than liberals to using cost-effectiveness data in making clinical decisions.
The authors say the data suggest that efforts to mobilize physicians can increase their sense of professional responsibility, but "also that such efforts may encounter considerable opposition from some quarters of the profession, particular to elements of reform that impinge on physicians' decision-making autonomy or threaten to reduce reimbursement for the costly interventions they provide."
The study authors reported no potential conflicts of interest.

Deep Vein Thrombosis vs. Cellulitis

Today I saw a 68 year old male, with history of Diabetes and Hypertension who was complaining of right calf edema, pain and erythema since he woke up this morning. He refers he “thinks he got bitten by something”.

The picture here is not from the patient himself.

                                                     This is what his varicose veins look like.

Around the center area of the calf there is a round spot, about 3.5” in diameter, which was erythematous and tender. This was present only on one leg.

The patient denies fever or recent trauma. He had a positive

Homans sign

* Discomfort in the calf muscles on forced dorsiflexion of the foot with the knee straight has been a time-honored sign of DVT. However, Homans sign is neither sensitive nor specific: it is present in less than one third of patients with confirmed DVT, and is found in more than 50% of patients without DVT.

The patient had to be sent to the ER for a possible Deep Vein Thrombosis. Also, it could be a Cellulitis. The patient’s history of varicosities suggest circulatory problems, so correlating one with the other I though it more prudent to have him get an ultrasound to discard or diagnose Deep Vein Thrombosis at the ER. I should get the results in the next few days.