Advertisement

Hypnotics, Elderly, & the Risk of Falls

Research has shown that the prevalence of insomnia increases with age. The appropriate treatment of insomnia in older patients can be challenging for several reasons, including the prevalence of comorbid conditions, increased use of a variety of medications (espe­cially central nervous system active compounds), and a compromised ability to metabolize and/or excrete these medications. This compromised function has typically resulted in lower recommended doses for many therapies, especially for hypnotic agents for which starting doses for the elderly are often half or less than those for adults. The purpose of using lower doses is to minimize adverse events (eg, amnestic effects or residual sedation) and thereby maxi­mize daytime functioning and patient safety. “Minimizing the risks of falls and fall-related injuries is a paramount consideration in the treatment of insomnia in the elderly.” An important consideration for safety in the elderly popula­tion is the risk for falls and fall-related injuries. A recent article by Frey et al in the Journal of the American Geriatrics Society evaluated the effect of sleep inertia on balance and cognition during nighttime awakenings in both adults and the elderly. The authors found that zolpidem produced clinically significant balance and cognitive impairments upon awakening from sleep. However, the study did not directly evaluate the incidence of falls; instead, it used the results of performance on tandem walking as a predictor of falls. These tandem walks occurred 120 minutes after a scheduled sleep opportunity and, thus, were designed to test the effects of zolpidem and sleep inertia in the first half of the night when those effects would be greatest. While the study is methodologically sound, it...

An Exciting Time for Regenerative Medicine

Previous transplants of tissue-engineered tracheas have been performed, but the tracheas used on those occasions were taken from organ donors and then reseeded with the patients’ own stem cells. In 2011, my colleagues and I performed an operation that gave a 36-year old male patient a new trachea made from a synthetic scaffold seeded with his own stem cells. The patient had been suffering from late-stage tracheal cancer. Despite maximum treatment with radiation therapy, the tumor had reached approximately 6 cm in length and was extending to the main bronchus. It was progressing and almost completely blocked the trachea. No suitable donor windpipe was available, so transplantation of a synthetic tissue-engineered trachea was performed as the last possible option for the patient. The patient made a full recovery and was discharged from the hospital following the operation. Synthetic Tissue-Engineered Trachea The international team that completed the procedure also involved Prof. Alexander Seifalian, PhD, from University College London, who designed and built the nanocomposite tracheal scaffold, and Harvard Bioscience, which produced a specifically designed, shoebox-sized bioreactor that was used to seed the scaffold with the patient’s own stem cells. The cells were grown on the scaffold inside the bioreactor for about 2 days. The scaffold was rotated while its surface was soaked with stem cells obtained from a bone marrow biopsy from the patient’s hip. The patient’s stem cells settled into the pores within the scaffold and began to grow into each other, slowly transforming from individual cells into genuine tissue. A few days after implantation of the new trachea, the patient’s own blood vessels actually started to grow into...
Testing for Diabetes in Asymptomatic Patients

Testing for Diabetes in Asymptomatic Patients

In the United States, about 7 million people have undiagnosed diabetes, representing nearly one-fourth of all diabetes cases. Approximately 35% of adults aged 20 and older—or 79 million Americans—have prediabetes, a condition in which patients have blood glucose levels higher than normal but not high enough to be classi­fied as diabetes. These people are at increased risk of developing type 2 diabetes, heart disease, and stroke. “Clinicians should have a high index of suspicion for undiagnosed diabetes in people who are older, obese, physically inactive, or have a history of abnormal glucose tolerance, including gestational diabetes,” explains Robert E. Ratner, MD. Those with hypertension, dyslipidemia, and a family history of diabetes are also at high risk. Furthermore, racial and ethnic minorities have been shown to be at greater risk for diabetes. In people with these risk factors, periodic glucose testing should be performed to evaluate their dia­betes status. “We need to identify people with prediabetes so that preventive measures can be undertaken.” “The movement toward screening for diabetes in people without symptoms has become increas­ingly important because of the growing number of cases of undiagnosed diabetes and prediabetes,” explains Dr. Ratner. “To decrease the burden of the diabetes and obesity epidemics, clinicians need to diagnose patients as early as possible so that treatments can be administered early and so that diabetes-related complications can be man­aged and perhaps avoided. We need to identify people with prediabetes so that preventive mea­sures can be undertaken. The greatest opportunity for case-finding is in the clinical setting.” Type 2 Diabetes & Future Disease According to the American Diabetes Association’s Standards of Medical Care in...

Analyzing Satisfaction With E-Prescription Use

A qualitative analysis suggests that physicians and pharmacists appear to be generally satisfied with the transmission of new e-prescriptions. However, they reported inconsistent use of the electronic renewal process, resulting in inefficient workarounds for both physicians and pharmacists. E-prescribing reduced manual prescription entry, but pharmacy staff often was required to complete or edit certain fields....

Assessing Mortality From Oral Cavity & Pharyngeal Cancer

An American Cancer Society study has found that mortality rates for African-American and Caucasian patients with oral cavity and pharynx can¬cer decreased between 1993 and 2007, particularly among those with at least a high school education. Mortality rates increased among Caucasian men with less than a high school education. Researchers suggest that their observed differences may be explained by the prevalence of smoking and risky sexual behaviors among the different educational attainment populations....

Program Improves Anticoagulation Use in At-Risk Patients

At hospitals participating in the Get With the Guidelines (GWTG)-Stroke Program, anticoagulation use among ischemic stroke patients with atrial fibrillation appears to have increased to high overall levels between 2003 and 2010. Research¬ers found that anticoagulation use improved from 88.4% to 95.2% during the 7-year span at hospitals participat¬ing in the GWTG-Stroke Program. Older age, diabetes, and African-American or Hispanic ethnicity were associated with a decreased likelihood of receiving anticoagulation....

A Novel Agent for a Rare Bone Marrow Disease

The FDA has approved ruxolitinib (Jakafi, Incyte) for myelofibrosis, a rare bone marrow disease. The agent inhibits the JAK1 and JAK2 enzymes, which play a role in blood regulation and immunological functioning.  

More Americans Reaching Age 90 & Older

A United States Census Bureau report has found that the 90-and-older popu-lation nearly tripled over the past 30 years, hitting nearly 2 million in 2010. The report, available at www.census.gov, provides an overview of the age group, as well as demographic and socio-economic com¬parisons with younger age groups....

End-of-Life Preferences in Elderly With HF

A European study has found that elderly patients with heart failure (HF) appear to be willing to discuss end-of-life preferences with their physicians. The analysis revealed that 74% of HF patients were not willing to trade survival time for improved quality of life. More than half (51%) wished to be resuscitated, but 39% did not and 10% were undecided....

Major Depression & Migraine Linked

Migraine appears to be strongly associated with later development of major depressive episodes (MDEs), according to findings from a Canadian study. Patients with migraine were 60% more likely to develop MDEs when compared with those without migraine....

Video Monitoring Improves Hand Hygiene Practices

New York investigators suggest that remote video auditing combined with feedback appears to produce significant and sustained hand hygiene improvements. Prior to implementing the video-auditing program, hand hygiene rates were less than 10.0%. Rates improved to 81.6% and 87.9% at 16 and 75 weeks, respectively, following implementation....
First iPad App for Children With Autism

First iPad App for Children With Autism

App developers and education and informatics researchers from the University of Edinburgh have collaborated on a new iPad game  called FindMe — the first-ever attempt to fuse autism research with iPad gaming. The app could help improve social skills in autistic children as young as 18 months. Young children are know to respond well with the best monitors for gaming that were incorporated into the ipads. Children with autism have a strong visual memory, but they cannot use a mouse or keyboard; they can, however, use touchscreens, tablets, and other mobile technologies. Like most children’s games, FindMe is very simple. It challenges children to find an onscreen character in different scenes. Using the iPad’s touch screen, players simply tap the character to move onto the next, more complex level. While it may be a simple visual exercise for children who are not autistic, children who are may find it challenging to “see” the person due to non-human objects and other distractions.  Each time the child correctly identifies the person in the scene, they are rewarded with a cartoon animation sequence. Each level becomes more complex with the ultimate goal being to help children practice simple social skills repetitively. Versions of the game under development will focus on other common difficulties in autism, such as being unable to follow a pointing finger or monitor where another person is...
Biochip Measures Glucose in Saliva

Biochip Measures Glucose in Saliva

Needle pricks may be a glucose test of the past as people with diabetes may soon be able to use their saliva to test their glucose, according to a new paper published in Nano Letters.  This is a major achievement considering that glucose concentrations in saliva are 100 times lower than those in blood. Researchers at Brown University developed the new technique that uses nanotechnology and surface plasmonics — the study of interaction between electrons and photons. The new biochip does not measure fluids or chemical compounds, but light waves. The engineers etched thousands of plasmonic interferometers onto a fingernail-sized biochip. Other chemicals or substances (eg, anthrax or biological compounds) can be detected by this technique, and it may be possible to use the biochips to screen for multiple biomarkers in an individual patient—all at once, with unprecedented...

Boosting Surgical Trainee Confidence

During the transition from medical school to independent practice, residency training is critical for the development of physician confidence. According to recent studies, confidence in one’s own capabilities during surgery residencies increases significantly during the internship year. That is largely because interns have greater clinical responsibility for patient care than senior medical students. Other investigations have suggested that a developed sense of confidence may play a role in residents’ career satisfaction as well as the decisions to change specialties or professions during residency or to pursue additional specialty training. Characterizing Residents’ Confidence “Confidence is important in surgical residencies because it encompasses several personal attributes that may lead to professional satisfaction and success,” says Julie Ann Sosa, MD, MA, FACS. “The key is that these attributes—things like enthusiasm, assertiveness, independence, trust, handling criticism, and emotional maturity—must be channeled properly. These factors all have implications for job satisfaction and performance.” Little has been studied with regard to what is being done to develop surgical confidence during surgical residency training. There is a paucity of research reporting the confidence levels of general surgery residents across all postgraduate training years, Dr. Sosa explains. “Characterizing residents’ confidence and residency program factors that influence confidence among surgical residents is important to understand the decisions residents make regarding their training, especially with regard to attrition and further specialization.” New Study Data on Resident Confidence In the August 2011 Archives of Surgery, Dr. Sosa and colleagues sought to characterize factors that shaped surgery resident confidence and determine whether confidence was truly associated with future specialty training. In a cross-sectional study, the research team surveyed general surgery residents...

Managing Thyroid Disease During Pregnancy

The effects of pregnancy on the thyroid gland are profound. The gland is required to produce a 50% increase in thyroxine (T4) and triiodothyronine (T3). While a healthy thyroid should respond well to pregnancy, women with limited thyroidal reserve or iodine deficiency who become pregnant can develop hypothyroidism. “Women in high-risk groups need to be tested as early as possible for hypothyroidism during the first trimester.” Knowledge about the interaction between the thyroid gland and pregnancy has exploded over that last 15 to 20 years. In response to the emerging data, the American Thyroid Association (ATA) recently created clinical guidelines on the diagnosis and treatment of thyroid disease during pregnancy and postpartum. They were published in the October 2011 issue of Thyroid. Pregnancies At-Risk for Thyroid Disease According to the ATA guidelines, about 10% of pregnant women are thyroid peroxidase (TPO)-antibody positive but have normal thyroid function. These women have a two- to four-fold increased risk of miscarriage when compared with women who don’t have the antibody. Among women without the antibody but with slightly elevated thyrotropin (TSH) levels, the risk of miscarriage is increased by 60% when compared with women without hypothyroidism. Women with either the TPO antibody or mild hypothyroidism are also at risk for preterm delivery. The 10% of all women who are TPO-antibody positive have a 50% chance of developing postpartum thyroiditis. Thyroid Screening Recommendations Women in high-risk groups need to be tested as early as possible for hypothyroidism during the first trimester, according to the ATA guidelines. These groups include (but are not limited to) women: With a history of thyroid dysfunction or prior thyroid...
New Autism Definition May Exclude Many

New Autism Definition May Exclude Many

Proposed changes to the definition of autism, currently under review by an expert panel appointed by the American Psychiatric Association, are expected to significantly reduce the soaring rate of autism diagnoses. The panel is completing work on the 5th edition of its Diagnostic and Statistical Manual of Mental Disorders, or “The DSM.” Cases of of autism and related disorders such as Asperger syndrome or “pervasive developmental disorder, not otherwise specified” (PDD-NOS) have skyrocketed since the early 1980s, and many researchers believe the numbers are inflated due to vague criteria. The proposed change would consolidate all three diagnoses under one category, autism spectrum disorder, removing Asperger syndrome and PDD-NOS from the manual. Under the current criteria, one can qualify for the diagnosis by exhibiting six or more of 12 behaviors. Under the proposed criteria, the patient would have to exhibit deficits on a much narrower menu: three deficits in social interaction and communication and at least two repetitive behaviors. “We need to carefully monitor the impact of these diagnostic changes on access to services and ensure that no one is being denied the services they need,”  Mark Roithmayr, president of Autism Speaks, told  The New York Times. “Some treatments and services are driven solely by a person’s diagnosis, while other services may depend on other criteria such as age, IQ level or medical history.” Physician’s Weekly wants to know… What do you think about changing the definition of autism? What benefits and/or pitfalls do you...
Updated Guidelines for Preventing CVD in Women

Updated Guidelines for Preventing CVD in Women

Tremendous strides have been made in the awareness, treatment, and prevention of cardiovascular disease (CVD) among women since the first guidelines for the prevention of CVD in women were published by the American Heart Association (AHA) in 1999. Despite these advances, CVD remains the leading cause of death among women in the United States, and rates are alarmingly high among women aged 35 to 54. Each year, 55,000 more women than men suffer a stroke, and the rates of obesity and diabetes continue to rise in women. To keep up with emerging data, the AHA updated its guidelines for preventing CVD in women in the March 22, 2011 issue of Circulation. A major evolution from previous guidelines in the 2011 update is that both efficacy and effectiveness of preventive therapies were considered. “These are real-world guidelines that take into account the efficacy of a recommendation—what has been proven through clinical research—and the effectiveness—what is experienced in practice,” explains Lori J. Mosca, MD, MPH, PhD, FAHA, who chaired the AHA expert panel that developed the guidelines. Women treated in clinical practice are often older, sicker, and have more comorbidities when compared with those who participate in clinical trials. As such, side effects, cost implications, and absolute net benefits of therapies may be different in the research setting than in the practice setting. “Health professionals need to balance the benefit-to-risk ratio as well as the likelihood of adherence in the real-world setting. All these factors should be taken into consideration when making decisions about preventive therapy.” “Women are more likely to experience stroke relative to myocardial infarction when compared with men....
Internists Cite Wasteful Medical Screenings

Internists Cite Wasteful Medical Screenings

The overuse of some screening and diagnostic tests that fail to provide high-value, cost-conscious care plays an important role in the rising healthcare costs in the United States. Now more than ever, there is a push to recognize that more care is not necessarily better care. In this month’s issue of the Annals of Internal Medicine, an ad hoc group of internists convened by the American College of Physicians (ACP) has identified a series of common clinical situations in which the use of screening and diagnostic tests does not reflect high-value care. “Efforts to control expenditures should focus not only on benefits, harms, and costs but on the value of diagnostic tests—meaning an assessment of whether a test provides health benefits that are worth its costs or harms,” write Amir Qaseem, MD, PhD, MHA, from the ACP. By consensus, the ACP committee members identified 37 clinical scenarios in which screening does not promote patient health. These include the following: Ordering imaging studies for non-specific low back pain Utilizing MRI instead of mammography to screen for breast cancer in women at average risk Conducting serologic testing for suspected early Lyme disease Obtaining electrocardiograms to screen for cardiac disease in patients at low to average risk for coronary artery disease Performing coronary angiography in patients with chronic stable angina who have well-controlled symptoms on medical therapy, or who lack specific high-risk criteria on exercise testing Assessing brain natriuretic peptide in the initial evaluation of typical heart failure findings Routinely repeating echocardiography in asymptomatic patients with mild mitral regurgitation and normal left ventricular size and function Obtaining exercise electrocardiogram for screening low-risk,...

Breast Cancer, Diabetes, & Outcomes

Diabetes and cancer are major causes of illness and death worldwide. The CDC has released a report showing that the prevalence of diabetes has increased to 25.8 million in America, or 8.3% of the national population. It’s estimated that 2.5 million of these individuals are survivors of breast cancer. Research has shown that diabetes increases the risk of breast cancer. Furthermore, two of the major risk factors for type 2 diabetes—older age and obesity—have also been associated with breast cancer. A concern for physicians managing patients who have diabetes and are diagnosed with breast cancer is that care for the preexisting diabetes often goes on the back burner; the breast cancer takes center stage. Patients may sometimes view their breast cancer diagnosis as a greater threat to their lives than their diabetes. Alarming Data on Breast Cancer-Diabetes Relationship In order to better understand the relationship between breast cancer and diabetes, my colleagues and I conducted a systematic review and meta-analysis of previous research. Published in the January 2011Journal of Clinical Oncology, our investigation looked in depth at eight studies involving patients with preexisting diabetes and breast cancer outcomes. Six of the studies reported a risk estimate effect on all-cause mortality in patients with breast cancer. We then qualitatively summarized other prognostic outcomes. When compared with those who did not have diabetes, women with breast cancer and preexisting diabetes had a 49% greater risk of death. “When compared with those who did not have diabetes, women with breast cancer and preexisting diabetes had a 49% greater risk of death.” Another important finding from our research was that three of four...

Conference Highlights: Transcatheter Cardiovascular Therapeutics 2011

The Cardiovascular Research Foundation, in partnership with the American College of Cardiology, held Transcatheter Cardiovascular Therapeutics (TCT) 2011 from November 7-11 in San Francisco. The features below highlight just some of the studies that emerged from the TCT meeting. » Predicting PCI Outcomes » Radiation Exposure: Comparing Radial & Femoral Routes » Gender Differences After MI in PCI Recipients Predicting PCI Outcomes The Particulars: The risk assessment score ACEF (age, creatinine level, and ejection fraction) has previously been used to predict outcomes in cardiovascular patients. It is calculated by dividing age by ejection fraction and adding 1 to the score if creatinine levels are greater than 2 mg/dL. The ACEF score has been validated in randomized trials of cardiovascular patients but has not been evaluated in routine clinical practice for PCI recipients. Data Breakdown: A study of patients undergoing PCI in routine clinical practice found that 21.2% of those in the high ACEF tertile had the highest 3-year death rate. Rates were 7.8% for those in the middle tertile and 3.3% in the low tertile. Take Home Pearl: In patients undergoing PCI in routine clinical practice, the ACEF risk assessment score appears to be a good predictor of mortality. Radiation Exposure: Comparing Radial & Femoral Routes [back to top] The Particulars: Data on PCI- and coronary angiography-related radiation exposure when the radial and femoral routes are used are limited. The current evidence base has also been contradictory. Data Breakdown: Between June 2004 and December 2008, 3,973 patients who had PCI or coronary angiography were assessed in a study. The average radiation exposure for those who underwent PCI via the...
Page 1 of 212
[ HIDE/SHOW ]