Common Infections May Contribute to Strokes

Common Infections May Contribute to Strokes. But researchers not exactly sure how pathogens raise risk of brain attack. Exposure to several common pathogens may increase the risk of having a stroke, a new study shows.

Led by Dr. Mitchell Elkind, an associate professor of neurology at Columbia University Medical Center in New York City, the research team found that the pathogens Chlamydia pneumoniae, Helicobacter pylori, cytomegalovirus and herpes simplex virus 1 and 2 may be implicated in accelerating arterial disease, which in turn increases the risk of stroke.

The team's work appears in the Nov. 9 online edition of the Archives of Neurology, and will be published in the January 2010 print issue of the journal.

"These are infections that regularly pop up when we study heart disease," said Elkind. "They are very common in the population."

Scientists are not completely sure how the pathogens harm arterial function, but several theories offer suggestions. One possibility is that chronic infection leads to inflammation in the blood vessels, which can constrict blood flow. Another possibility, said Elkind, is that the pathogens disrupt the normal functioning of the arterial walls.

Strokes occur when there is a disruption in the blood supply to the brain, such as a blockage in an artery or other blood vessel. When this happens, brain cells begin to die, causing brain damage and even death. Common functions affected or lost during a stroke include speech, movement and memory.

Stroke is the third-leading cause of death in the United States, according to the National Stroke Association. Strokes have many causes, but it is widely known that certain risk factors increase the chances of having a stroke. These include high blood pressure, diabetes, high cholesterol, smoking and obesity.

In recent years, evidence has been uncovering the role of pathogens in cardiovascular disease, particularly the pathogens featured in Elkind's research. Scientists reported several years ago that untreated gum disease and other oral infections can spread and cause heart disease.

Elkind's study tracked 1,625 adults from a multi-ethnic community in Manhattan for 7.6 years. During that time, 67 patients suffered a first stroke. Even taking into account other risk factors, such as high blood pressure and diabetes, Elkind's team found that the majority of the patients tested positive for one or more of the suspected pathogens.

"Each individual infection was positively, though not significantly, associated with stroke risk after adjusting for other risk factors," the researchers wrote. "The infectious burden index was associated with an increased risk of all strokes after adjusting for demographics and risk factors."

It is too early to tell which pathogens contributed to the strokes, to what extent they contributed and how they contributed (through simple exposure or chronic infection), said Elkind. What's more, there may be other pathogens involved that were not included in the study, he added.

It is also too early to make any clinical recommendations. If scientists conclusively determine that pathogens are capable of causing strokes years after people come in contact with them, possible treatments may include wider and longer use of antibiotics, Elkind added.

Dr. Kishore Ranade, a neurologist affiliated with the Mount Kisco Medical Group in New York, said he was impressed with the findings. He suspects that pathogens work with other risk factors to cause strokes.

"Cumulative data have been suggesting that pathogens play a role in heart disease in general," said Ranade. "And what's bad for the heart is bad for the brain." (HealthDay News)

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Ventilation Positions Comparable in Lung Syndrome Patients

Ventilation Positions Comparable in Lung Syndrome Patients. Face up or down doesn't affect death risk for acute respiratory distress, study finds. Lying face down instead of face up while receiving mechanical ventilation doesn't lower the risk of death for patients with acute respiratory distress syndrome (ARDS), according to Italian researchers.

Prone, or face-down, positioning is recommended for patients with ARDS, a serious and often fatal lung condition that may be associated with severe hypoxemia (abnormally low levels of oxygen in the blood, resulting in shortness of breath), according to background information in the study.

"Moreover, prone positioning has been advocated as a rescue maneuver for severe hypoxemia, owing to its positive effects on oxygenation, which have been repeatedly documented since its first description in 1976. However, no randomized clinical trial has yet demonstrated a significant reduction in mortality rate associated with prone positioning," wrote Dr. Paolo Taccone and colleagues.

Their study, published in the Nov. 11 issue of the Journal of the American Medical Association, included 342 adult patients with ARDS receiving mechanical ventilation, including 192 with moderate hypoxemia and 150 with severe hypoxemia. The patients were randomly selected to be prone or supine (face up) during ventilation.

Death rates for the prone and supine patients after 28 days were 31 percent and 32.8 percent, respectively, and 47 percent and 52.3 percent, respectively, after six months. Patients in the prone group had much higher complication rates, the study authors noted.

"Outcomes were also similar for patients with moderate hypoxemia in the prone and supine groups at 28 days (25.5 percent versus 22.5 percent) and at six months (42.6 percent versus 43.9 percent). The 28-day mortality of patients with severe hypoxemia was 37.8 percent in the prone and 46.1 percent in the supine group, while their six-month mortality was 52.7 percent and 63.2 percent, respectively," the researchers wrote.

"Do the findings of this trial, together with those of previous studies, represent the end of the prone position technique? Undoubtedly, the data of the present trial together with previous results clearly indicate that prolonged prone positioning, in the unselected ARDS population, is not indicated as a treatment. However, its potential role in patients with the most severe hypoxemia, for whom the possible benefit could outweigh the risk of complications, must be further investigated, considering the strong pathophysiological background, the post hoc result of our previous study, the most recent meta-analysis, and the favorable trend observed prospectively in this study," Taccone and colleagues concluded. (HealthDay News)

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Statins May Stave Off Gallstones

Statins May Stave Off Gallstones. But prescribing them for protection would be questionable, expert says. Long-term use of cholesterol-lowering statins appears to reduce the incidence of gallstones and the need for surgery to prevent the excruciating pain they cause, a new study indicates.

"We're talking about people who have been taking them for about 1½ years," said Susan S. Jick, director of the Boston Collaborative Drug Surveillance Study at Boston University and a member of the team reporting the finding in the Nov. 11 issue of the Journal of the American Medical Association. "The protective effect seems to grow over time. The relative risk for them is about half the risk of someone who is not exposed to a statin."

Jick, an epidemiologist, was part of an international effort in which physicians at the University of Basel in Switzerland analyzed data collected in the United Kingdom. They studied the association between the use of statins, which are prescribed to reduce the risk of cardiovascular disease, and the incidence of gallstones.

Gallstones form in the gall bladder, which contains a fluid called bile that helps digest fats. About 80 percent of the time, gallstones consist of hardened pellets of cholesterol. They can block the ducts that carry bile from the gall bladder to the small intestine, and persistent blockage is not only painful but can cause dangerous infections. In many cases, removal of the gall bladder is necessary, through a surgical procedure called a cholecystectomy.

The study compared 27,035 people who had a cholecystectomy with 106,531 who had no history of gallstones. The numbers included 11,264 people who took statins, 2,396 of them in the cholecystectomy group.

Among those diagnosed with gallstones, the researchers found a gradual reduction in the need for surgery related to how long they had taken statins. For example, 2.6 percent of the people with five to 19 statin prescriptions required surgery, compared with 2.4 percent of those not taking the medication. For those with 20 or more prescriptions, the incidence of surgery was 3.2 percent, compared with 3.7 percent for those not taking the drug.

The study indicates that all statins provide the protective effect and that the effect increases with higher doses, the report said.

But the study results do not indicate whether a statin should be prescribed solely to help prevent gallstones in someone who did not have them, said Dr. Farid Kehdy, an assistant professor of surgery at the University of Louisville.

"This would have to be studied thoroughly, prescribing a medication for something that may or may not occur," Kehdy said.

And prescribing a statin to reduce the chance that surgery would be needed is also questionable, he said.

"You would have to take it for a year and a half to reduce the risk ratio," Kehdy said. "Will a patient be willing to do that? It would be a daily burden if you don't know for sure."

Medical history indicates that such a prescription would be questionable, he said. Several decades ago, Kehdy said, physicians routinely prescribed a medication, ursodeoxycholic acid, to help dissolve gallstones, but the high cost, inconvenience and side effects of the medication led to abandonment of the practice.

So a decision to prescribe a statin should center on its known benefits in cardiovascular disease, with gallstones a side issue, he said.

"If you are on a statin, the risk of gallstones would be lessened," Kehdy said. "If someone does not have gallstones, would you want to take a statin for the sake of preventing gallstones? That question remains to be addressed." (HealthDay News)

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New Polyp Detection Method Could Be Cost-Saver

New Polyp Detection Method Could Be Cost-Saver. Optical technology is as accurate as colorectal tissue examination, study finds. Optical technology could help physicians detect small colorectal polyps during colonoscopies and save money, too, new research suggests.

In the report, published online Nov. 10 in The Lancet Oncology, the study authors explained that the technique could replace histopathology, which requires more testing and can be costly. Histopathology requires the examination of tissue.

Colorectal cancer is the second-leading cause of death from cancer, outranked only by lung cancer. It will kill an estimated 49,920 people in the United States this year, according to the American Cancer Society. But early detection, which allows doctors to remove pre-cancerous polyps, can prevent deaths.

In the study, British researchers examined the records of the diagnosis of 363 small colorectal polyps that were found in 130 people. Their aim was to determine if optical diagnosis was accurate.

They found that optical technology allowed colonoscopists to accurately pinpoint up to 93 percent of small colorectal polyps. This is about the same level as histopathology.

The researchers estimated that using optical diagnosis for the people in the study would have saved $22,000 in medical costs. By some estimates, use of optical technology instead of histopathology could save $95 million a year in the United States.

"Optical diagnosis for small colonic polyps could become acceptable standard of care in routine non-academic clinical practice," the study authors concluded. (HealthDay News)

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The Revolving Door of Heart Failure Hospitalization

The Revolving Door of Heart Failure Hospitalization. Better coordination urged to stem re-admission rate of nearly 1 in 4 people. Almost a quarter of the people on Medicare who are hospitalized for heart failure are back in the hospital within a month of discharge, a new study reveals.

That should not be happening, said Dr. Joseph S. Ross, an assistant professor of geriatrics and palliative medicine at the Mount Sinai School of Medicine in New York City, who added that there's plenty of blame to go around. Ross was lead author of the study, published online Nov. 10 in Circulation: Heart Failure.

"It's not just an issue for physicians," Ross said. "The whole clinical team, nurses, pharmacists, even patients play a role. If we want to do better, everyone has to get in the game together."

Heart failure, which is the progressive loss of the heart's ability to pump blood, affects an estimated 5.7 million people in the United States, with 670,000 new cases diagnosed every year, and is one of the more common reasons for hospitalization, according to the American Heart Association.

Hospitalization affords the chance to get treatment for heart failure properly organized, Ross said. But he added that the high re-admission rate found by the study -- more than half a million a year from 2004 through 2006 -- shows that this often is not done.

"The challenge is that there are multiple physicians involved -- the physician who manages the person as an outpatient, the cardiologist, the primary care physician," he said. "They have to touch base and make sure the patient has all the proper medications, that if they start to get sick again, if there are any red flags, proper treatment is started."

But too often, trouble means an emergency room visit, "and the emergency room admits them to the hospital without coordinating with the physician," Ross said.

Measures must be taken before someone is discharged from the hospital, he said. "Physicians and the hospital have to work together to make sure the patient has a smooth discharge out of the hospital, knows how to manage the disease, how to get in touch with the pharmacist, how to take the medications, knows how to eat," Ross said.

To remedy the problem, he has two suggestions. "One is that there needs to be incentives to help encourage physicians and hospitals to work together," Ross said. "There is this proposed Medicare move toward bundled payment -- one lump sum for all hospital care and 30 days afterward -- so that hospitals and physicians have to work together."

Second, there are "existing programs that we know work," Ross said. "We can pay physicians to make phone calls just to touch base with the patient and also reimburse them for e-mail. That would allow patients better communication with physicians, but they are not reimbursed in the current situation."

Dr. Gregg A. Fonarow, a professor of cardiovascular medicine at the University of California, Los Angeles, and a spokesman for the American Heart Association, said that efforts are under way to reform the current system.

He cited a Heart Association initiative, dubbed "Target: Heart Failure," that he said was "designed to improve clinical care for patients hospitalized for heart failure" and also an American College of Cardiology program, called "H2H," for hospital-to-hospital, "which helps hospitals work together to lower the 30-day readmission rate."

Also, the health-care reform effort now under consideration in Congress includes provisions for pilot programs to improve "these pretty dismal outcomes and mortality rates," Fonarow said.

But the existing situation "is in a sense shocking -- that despite all the advances for heart failure treatment, patients have not reaped the benefits," Fonarow said. "What is behind this remains one of the biggest challenges for cardiology."

"The most effective therapies, such as beta blockers, are underused, and when they are used, are applied at lower doses than are shown to be effective in clinical trials," he said. "So, many of these patients end up bouncing in and out of hospitals, not receiving important therapies at the right doses and not getting proper monitoring." (HealthDay News)

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Breast Cancer May Be Gone, But Pain Lingers

Breast Cancer May Be Gone, But Pain Lingers. Nearly half of patients have chronic pain, researchers find. Even three years after finishing treatment for breast cancer, almost 50 percent of women report long-term pain, a new Danish study finds.

The research, published in the Nov. 11 issue of the Journal of the American Medical Association, strengthens earlier findings, said study senior author Dr. Henrik Kehlet, a professor of perioperative therapy at Rigshospitalet at Copenhagen University. But this work indicates which women are most likely to experience persistent pain.

"Several previous scientific reports have shown a risk of chronic pain after breast cancer surgery," said Kehlet. The strength of this study, he noted, is the large number of participants -- more than 3,000 -- and the evaluation of many types of treatments.

Kehlet's team reviewed questionnaires filled out by 3,253 women who had undergone breast cancer treatment in Denmark between 2005 and 2006. Their treatments varied and included breast-conserving surgery, mastectomy, radiation, chemotherapy and dissection of the lymph nodes.

The women were asked whether they experienced pain, in what areas of the body, how bad it was and how often they experienced it.

In all, 1,543 -- 47 percent -- reported pain in one or more areas. Of those, 52 percent reported severe or moderate pain.

Among those who had severe pain, 77 percent said they had it daily. For those who reported their pain as light, 36 percent had it every day. Pain was reported in the breast area, the armpit, the arm and the side of the body.

The research was funded by the Danish Cancer Society, Breast Friends and a private organization that funds science research, the Lundbeck Foundation.

Women under 40 were more than three times more likely to have chronic pain than older women, the researchers found. Those having radiation therapy were more likely to have pain than those who had chemotherapy. Dissection of the axillary (under arm) lymph node was associated with increased likelihood of pain compared to dissection of the sentinel lymph node (the first node to which the cancer is likely to spread).

Why does the pain linger?

"There are multiple mechanisms to explain the risk of chronic pain," Kehlet said, "such as young age, risk of nerve damage during axillary dissection, radiation therapy or a general pain hyper-responsiveness in some patients."

More research is needed on the pain mechanism in those who experience high levels of discomfort, he said. The focus for now should be on identifying patients at high risk for pain and providing preventive treatment and nerve-sparing treatment when possible.

The results do not surprise Dr. Robert H. Dworkin, a pain specialist and professor of anesthesiology, neurology, oncology and psychiatry at the University of Rochester School of Medicine and Dentistry in New York, who has also published on lingering cancer pain.

But the findings may come as a surprise to oncologists and others who treat cancer patients, he said. "Women tend not to tell their surgeons about this continuing pain," he said, citing clinical experience. Why? "They fear that the fact they are in pain might mean a recurrence, and they don't want to deal with it," he said. Or, "they don't want to hurt the oncologist's feelings."

A third reason is "they don't want to distract the physician from thinking about the cancer," he said.

Even pain specialists can't say for sure why the pain lingers. "We have little understanding of what causes this kind of pain," Dworkin said.

A woman in pain after breast cancer treatment "should not be shy in talking to her physician about it," Dworkin said. He advises such women to ask for a referral to a pain specialist.(HealthDay News)

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Anemia Drugs May Cause Deadly Blood Clots

Anemia Drugs May Cause Deadly Blood Clots. Study raises more concerns about common treatment for chemo patients

New research on cancer patients adds to the controversy surrounding anemia drugs such as Procrit and Aranesp, concluding that they increase the risk of venous thromboembolism, potentially fatal blood clots.

These drugs, called erythropoiesis-stimulating agents (ESAs), are commonly prescribed to fight anemia associated with chemotherapy and chronic kidney disease. Recent studies have linked them with increased risk of death, stroke and new cancers.

"These drugs hit the market in the mid-1990s, and by 2002, 50 percent of patients on chemotherapy were receiving them," said lead researcher Dr. Dawn Hershman, co-director of the breast program at the Herbert Irving Comprehensive Cancer Center at New York-Presbyterian Hospital/Columbia University Medical Center in New York City.

Initial testing of these drugs was done on only 12 weeks of use, she noted. "Right from the beginning, there was concern that these drugs would cause some side effects, but the initial studies did not find any risk of thrombosis."

Her longer study was more informative. "We confirmed that these agents can increase the risk of thrombosis by twofold," Hershman added.

The report is published in the Nov. 10 online edition of the Journal of the National Cancer Institute in advance of print publication on Dec. 2.

For the study, Hershman's team collected data on 56,210 cancer patients treated with chemotherapy from 1991 through 2002. Of these patients, 15,346 also received ESAs.

The researchers found that 14.3 percent of patients receiving ESAs developed thromboembolism (deep vein thrombosis or pulmonary embolism) compared with 9.8 percent of those who did not receive an ESA.

ESAs stimulate red blood cell production and are intended to reduce the number of blood transfusions needed during chemotherapy. However, the rate of blood transfusions remained the same for both groups (22 percent). Survival in both groups was also similar, the researchers noted.

"These agents were approved to reduce the risk of blood transfusions by 50 percent," Hershman said. "There was absolutely no difference in the transfusion rate over the 10-year period from when these drugs hit the market," she said. "The majority of patients are getting these drugs and receiving transfusions."

Based on concerns raised by earlier studies, the U.S. Food and Drug Administration in 2007 required a black box warning label on ESAs about the risk for venous thromboembolism, tumor promotion and death. The warning suggested restricting the use of ESAs to specific tumor types, and addressed dosage, duration and targeted hemoglobin levels.

In 2006, U.S. sales of ESAs were $10 billion and accounted for the largest Medicare expenditure for any drug.

Hershman thinks the findings raise questions about the drug's approval process and whether adequate post-marketing research was undertaken to ensure their long-term safety.

These drugs do have a place, she said. "But we have to figure out what the best indication is and use every agent with caution. We should think about the drugs that we give."

Dr. J. Leonard Lichtenfeld, deputy chief medical officer at the American Cancer Society, said that "this study is one more in a list of several that suggests the value of ESAs was less than originally hoped, and the side effects were greater than previously understood."

Patients and doctors should be aware of all the risks and benefits before using the drugs, he said.

"If you are going to be treated with these drugs, do so with caution, do so with understanding, have a discussion with your physician about the need for these drugs and what the potential difficulties may be," he said. (HealthDay News) --

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