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Cardiovascular Articles

  • REFILE-Travel with medications, medical devices can be daunting

    (Corrects gender of Dr. Bauer in paras 15, 16 and 18, and changes "county" to "country" in para 16.)

    By Kathryn Doyle

    NEW YORK (Reuters Health) - For international travelers who need to carry medical devices and medications with them, it's not easy to find out the travel requirements at their destinations, and embassies in general aren't much help, according to a new study.

    "The problem is known to exist but has not previously been published as we have," said lead author Moses Mutie of the Faculty of Health at the University of Canberra in Bruce, Australia.

    "Most embassies focus on trade and tourism," Mutie told Reuters Health by email. "Health issues are not often a priority."

    The Australian researchers considered the situation of a traveler from their own country going to one of 25 other countries popular with Australian tourists, including destinations in Africa, the Americas, Europe, Southeast Asia and the Western Pacific.

    The researchers explored embassy and consular websites looking for the quantities and different types of medication allowed in the country for personal use, required documentation, customs information and details about travelling with medical equipment.

    They also sent a standardized email to each embassy asking those same questions.

    Two weeks later, 11 embassies had responded, two of which forwarded the questions to the Pharmacy Board of the home country but did not respond further, the authors report in Travel Medicine and Infectious Disease.

    Of the eight countries that did respond, their recommendations varied widely, and tended to be much more strict than the recommendations of the International Narcotics Control Board (INCB), an independent body implementing United Nations Drug Control Conventions.

    According to the INCB recommendations for individual travelers, you should carry a copy of the prescription, but there are no other certifications or requirements for less than 20 doses of any medication, or less than a 30-day supply of narcotics or psychotropics, such as Ambien or Haldol.

    Many embassies, however, said all drugs required special certification of ownership and personal use, beyond a valid prescription. In some countries, a visitor is required to consult a local clinician to validate ongoing need for the medication.

    Some countries warn that if authorities are in doubt, they have the right to deny entry or confiscate the medications, the authors write.

    Drugs on Schedule I of the U.S. Controlled Substances Act, including hallucinogens or stimulants with no medical use, like THC or cocaine, can never be brought across national borders.

    Neither the embassy and consular websites nor the email responses addressed medical equipment.

    Travel health and traveling with medications is a "huge mess" and "supremely unsatisfactory," said Dr. Irmgard Bauer of the Division of Tropical Health and Medicine at James Cook University in Townsville, Australia, who was not part of the study.

    Patients should turn to their treating doctor and a travel clinic, with both having the obligation to find out what is required, she told Reuters Health by email.

    "Travellers on longer trips could also be referred to a colleague in the country of destination to continue treatment and prescribe the medication," she said. "In some cases, it may mean that travel cannot happen."

    Specific outcomes for a traveler with too much medication or not enough documentation depend on the country, its law, and the person working at customs that day, Bauer said.

    "With narcotics, an arrest is not unlikely," she said. "In some countries, this will not be pleasant."

    The situation can be toughest for last minute travelers, Mutie said, but ideally there will be sufficient time to search for information ahead of time and talk to your doctor, who should be the principal source of the required information.

    Dr. Natasha Hochberg, an infectious disease physician at Boston University School of Public Health, suggested "that international travelers with chronic medical conditions seek care at least 4 to 6 weeks in advance of travel at a travel clinic to address issues related to bringing medications overseas but also to address the need for immunizations and prophylactic medication and to discuss health-promoting topics."

    Hochberg, who was not involved in the new study, added, "Travelers bringing medication overseas should bring the medication in their carry-on luggage to prevent possible loss in checked baggage, keep it in the original bottle that the medication came in, take enough to last for their trip as well as some extra in case of changes to the itinerary, and have adequate documentation including the original prescription and possibly a signed letter on travel clinic letterhead."

    For medical devices, Mutie suggests planning ahead and checking with the airline. Airlines, he notes, have published clear medical clearance guidelines in this area.

    In future, embassy websites should be designed with the user in mind, since embassies are established to provide a service, he said.

    SOURCE: http://bit.ly/1lfNmeb Travel Medicine and Infectious Disease, August 6, 2014.

  • New recommendations for overweight people with heart risks

    By Kathryn Doyle

    NEW YORK (Reuters Health) - Overweight patients with risk factors for heart disease should be sent by their doctors for "intensive behavioral counseling" about diet or exercise, according to new recommendations from the United States Preventive Services Task Force (USPSTF).

    That includes overweight people with high blood pressure, high cholesterol, 'metabolic syndrome' or blood sugar levels higher then normal and on the cusp of type 2 diabetes.

    A literature review commissioned for the government-backed USPSTF, published in the Annals of Internal Medicine, found that intensive behavioral counseling can help lower these patients' risk for heart problems.

    "My message for patients would be that we have the ability by changing our behavior to modify our risk for heart disease and stroke and your doctors can help you do that," Dr. Michael L. LeFevre, the chair of the Task Force, told Reuters Health by phone.

    LeFevre is also vice chair in the Department of Family and Community Medicine at the University of Missouri School of Medicine in Columbia.

    The recommendations are targeted to health care providers more than to patients, LeFevre said.

    To patients, he says, "The most important thing that we can do right now is have you lose some weight, be more active but just offering that advice and giving you a pamphlet, we don't really find any evidence that that's helpful."

    Instead, the Task Force review found, intensive behavioral counseling - involving multiple sessions with experts in nutrition and exercise over an extended period, for several months to a year - can help people lose weight and bring down their blood pressure and cholesterol.

    The researchers reviewed 74 studies of various lifestyle interventions and found that with intensive counseling, many health markers were improved one and two years later, and the risk of diabetes decreased.

    "This crystalizes 25 years of research and a huge number of studies but I don't think this is new or earth shattering information," said Dr. Jennifer S. Lin of the Kaiser Permanente Center for Health Research in Portland Oregon.

    Lin was the lead author of the literature review.

    There is a great deal of data on people with heart attack and stroke risk factors and most of those studies focused on a combination of diet and exercise counseling, so those kinds of programs have the most evidence behind them at this point, she said.

    "On average we're talking about a few milligrams of cholesterol per deciliter of blood or a couple of millimeters of Mercury decrease in blood pressure," Lin told Reuters Health by phone.

    "We're calling that a modest benefit applied to a population but even these modest benefits translate into health outcomes that patients can actually feel," she said.

    Patients can't necessarily feel when their blood pressure goes down, but they can feel if they do or do not have a heart attack, she said.

    The best counseling interventions are not only frequent but conducted by trained dietitians, nutritionists, health educators and physiologists, she said.

    "They're more than just didactic, more than classroom based interventions, they're individualized," she said.

    One-on-one counseling gives experts time to assess the barriers to healthy diet and exercise for each person and help them overcome them, LeFevre said.

    "We need to see people repeatedly, to work with them and reinforce what's going on," LeFevre said.

    The USPSTF issued the same recommendation for the first time in 2012, but only for obese patients without heart disease risk factors.

    While family physicians could provide these counseling services themselves, most of the programs studied involved referrals to experts in the same office or elsewhere in the community, he said.

    "To be perfectly honest, a rate limiting step for implementation of this guideline is that there are a lot of doctors out there but (they) don't really have the time or skills to do this themselves, or the resources," LeFevre said.

    Even sending patients to other experts means finding those people and coordinating care with nutrition and exercise programs and checking in periodically to see how things are going, he said.

    Right now, larger health organizations like Kaiser Permanente in California or Group Health in Washington are most likely to be able to do this, he said. For doctors outside large health systems, it is much easier to order a blood test or write a prescription than coordinate long-term behavioral counseling, he said.

    "It's problematic that this kind of care is generally not paid for by the U.S health system," Lin said. "Those resources should be made more available."

    There are commercial diet and exercise programs which are legitimate and good at what they do but the patient needs to pay out of pocket, she said.

    "Many primary care physicians and many patients would not have access to these types of interventions," she said.

    SOURCE: http://bit.ly/1i46lF7 Annals of Internal Medicine, August 25, 2014.

  • Heart doctors overstate benefits of procedures for stable chest pain

    By Will Boggs MD

    NEW YORK (Reuters Health) - Cardiologists sometimes overstate the benefits of an invasive procedure for chronic angina and patients make decisions based on what cardiologists tell them.

    Symptoms of angina, such as chest pain, arise from clogged arteries in the heart and may improve faster with so-called percutaneous coronary interventions (PCI) than with medication. Evidence suggests, however, that when angina is stable - that is, when it occurs predictably, like after a certain amount of exercise - then PCI does not reduce the risk of death or heart attack.

    But patients with stable angina often think PCI does lower those risks. Three new reports in JAMA Internal Medicine explore why and how this might be happening.

    In the first study, a team led by Dr. Sarah L. Goff from Tufts University School of Medicine in Springfield, Massachusetts analyzed conversations about PCI between 20 cardiologists and 40 patients with stable coronary artery disease.

    In a PCI procedure, doctors inject a dye into the blood vessels of the heart, and if X-ray imaging (angiography) shows an artery is clogged, it's reopened using tools inserted into the heart through an artery in the arm or groin. Usually, a small metal device called a stent is inserted, to keep the artery open.

    In only two encounters did cardiologists tell patients that PCI could improve their angina symptoms but would not reduce their risk of MI or death.

    In five encounters, the benefits of PCI were explicitly overstated, and in a number of encounters the cardiologists implicitly overstated the benefits of angiography and PCI.

    Cardiologists discussed the risks of the procedure in only a limited way, and no cardiologist mentioned the possibility of kidney failure as a risk.

    In 30 encounters, cardiologists took the lead in the decision-making process in ways that could discourage patients from participating.

    "When patients with chronic stable angina are advised to undergo (angiography) and possible stent placement, they should ask what factors specific to their health history the cardiologist considered before recommending the procedure, what the risks of the procedure are, what the benefit is likely to be, what research the risks and benefits presented were derived from, what medications they will need to take after a stent is placed, what the alternative options are for them," Goff told Reuters Health by email.

    She added, "If they do not understand what the cardiologist says at any point in the decision process, they should feel comfortable asking for clarification."

    "I think it is very important to know that this study is not intended to be critical of cardiologists," Goff cautioned. "We could not, with this study design, assess patient understanding and it is quite possible in the few transcripts we analyzed where the cardiologists made the benefits quite clear that the patients still believed having a stent placed would prevent an MI and/or death."

    Dr. Clara Carpeggiani from CNR Institute of Clinical Physiology, Pisa, Italy told Reuters Health by email that patients should be explicit when asking their cardiologists about their options. She said they should ask:

    - What coronary angioplasty or PCI?

    - What is the purpose of the procedure?

    - What are the benefits?

    - What are the risks?

    - Are there alternative therapies? What are their risks and benefits?

    The Society for Cardiovascular Angiography and Interventions offers another resource: five things physicians and patients should question, available here: http://bit.ly/1nuFIYz.

    In another study, Dr. Michael B. Rothberg from the Cleveland Clinic in Ohio and his colleagues had volunteers read one of three descriptions of the risks and benefits of PCI for stable angina. One description had no information about the effects of PCI on heart attack risk; one description said PCI will not reduce the risk for heart attack; and one explained why PCI does not reduce the risk for heart attack.

    Compared with the other two groups, those who received no information about the relationship between PCI and heart attack risk were most likely to believe that PCI prevents heart attack, were most likely to choose PCI, and were least likely to agree to medical therapy.

    "We were not surprised to find that in the absence of information, most people assumed that PCI would prevent a heart attack," Rothberg told Reuters Health. "We were surprised that even after they were told that PCI would not prevent a heart attack, more than 30 (percent) continued to believe it would. We were even more surprised to find that many people falsely remembered the physician saying that PCI would prevent a heart attack, even though he never said that, and in some cases said the opposite."

    "We were also surprised to find that when patients were told that PCI does not prevent a heart attack, they were more likely to agree to take medications-something they should all do regardless of whether they decide to have PCI," Rothberg said.

    Finally, in a third study, Dr. Steven M. Bradley from the Veterans Affairs Eastern Colorado HealthCare System in Denver and colleagues used records from the National Cardiovascular Data Registry to show that when angiography was performed in patients without angina symptoms, there was a higher risk that PCI would be done inappropriately.

    "Future studies need to define the aspects of care delivery that lead to optimal patient selection for coronary angiography and PCI," Bradley told Reuters Health. "This may include greater patient involvement in the decision process and application of the Appropriate Use Criteria in measurement, reporting, and clinical decision support of high-quality patient selection for coronary angiography and PCI."

    SOURCE: http://bit.ly/IZGqPC JAMA Internal Medicine, August 25, 2014.

  • CORRECTED-For diabetics, losing weight may delay kidney problems

    By Kathryn Doyle

    NEW YORK (Reuters Health) - Healthy eating, staying active and losing weight are already recommended for people with type 2 diabetes, and new research suggests these steps may also delay or prevent chronic kidney disease.

    About 35 percent of U.S. adults with diabetes have some degree of kidney disease, and diabetes is the major cause of kidney failure and dialysis, according to the study's lead author Dr. William C. Knowler.

    "This result along with many others tends to reinforce the value of weight loss interventions and hopefully motivates people with diabetes to lose weight," said Knowler, who is chief of the Diabetes Epidemiology and Clinical Research Section of the National Institute of Diabetes and Digestive and Kidney Diseases in Phoenix, Arizona.

    He and his coauthors reexamined data from an existing study of lifestyle modifications for people with type 2 diabetes.

    For the original study, more than 5,000 overweight or obese Americans with type 2 diabetes ages 45 to 76 were divided into two groups. Half received diabetes support and education and the other half aimed to lose seven percent of their body weight through reduced calorie diets and increased physical activity.

    People were recruited for the study between 2001 and 2004. For the first year or so, the weight-loss group met regularly with dieticians, case managers and physical activity experts to stay on track toward their calorie, activity and weight-loss goals.

    The study continued, with encouragement to stick to diet and exercise programs, through 2012. As with many weight loss programs, the first year is the critical period for weight loss and later years are spent maintaining it, which can be difficult, Knowler said.

    At the one-year mark, the diet and exercise group had lost an average of 8.6 percent of their body weight, compared to less than one percent lost in the support-and-education group.

    Over the entire study period, people in the diet and exercise group were 31 percent less likely to develop very high risk chronic kidney disease, according to urine tests.

    The study's primary aim was to investigate the power of weight loss to reduce the risk of heart problems or stroke, and as the researchers published previously, no benefit was seen there.

    Knowler emphasized, however, that the weight loss program did improve the outlook for kidney disease and many other aspects of health, including depression, knee pain, urinary incontinence and heart rate recovery after exercise.

    Dr. Dick de Zeeuw writes in an accompanying editorial in The Lancet Diabetes and Endocrinology that he found the kidney-health benefit with no heart benefit difficult to reconcile.

    de Zeeuw, of the Department of Clinical Pharmacy and Pharmacology at the University of Groeningen in The Netherlands, also writes that using very high risk chronic kidney disease as the marker of success or failure in the study doesn't line up with what most trials like this would do if a drug were being tested instead of a lifestyle change.

    Nevertheless, these results reinforce the existing recommendation that people with type 2 diabetes should maintain a healthy weight, he told Reuters Health.

    "In one sense it doesn't add anything to existing recommendations because for overweight people, weight loss and increased activity are recommended already," Knowler said. "But we don't really put a lot of force behind that recommendation."

    For most people, telling them to lose weight and handing out some pamphlets is not enough, he said. This study indicates that an intense program of major behavioral change, including counseling, group session and mutual reinforcement can work.

    "Any approach that results in sustained weight loss should work just as well," Knowler said.

    SOURCE: http://bit.ly/1oRix03 The Lancet Diabetes and Endocrinology, online August 11, 2014.

  • For older women, working out may keep heart rates regular

    By Kathryn Doyle

    NEW YORK (Reuters Health) - Physically active older women are less likely to suffer from atrial fibrillation, the most common form of irregular heartbeat, than less active women, according to a new U.S. study.

    Contrary to suggestions that exercise might raise the risk of abnormal heart rhythms, the analysis based on more than 80,000 postmenopausal women found the risk of atrial fibrillation was lowered by up to 44 percent with regular physical activity.

    "This is one of the reasons we ended up doing the study, we wanted to quell some of those concerns," said senior author Dr. Marco V. Perez of the Stanford Center for Inherited Cardiovascular Disease in California.

    "These are women not engaged in extreme forms of exercise, and what we found was that women who engaged in more exercise actually had a lower risk of AF," Perez told Reuters Health. "The more obese you were, the more you benefitted."

    Atrial fibrillation (AF), sometimes shortened to "AFib," affects more than 1 million U.S. women, and raises their risk of stroke and death even more than it does for men with the condition.

    Perez and his team analyzed data from the large, long-term Women's Health Initiative study. They focused on 81,317 postmenopausal women who had been followed over an average of 11 years.

    Using hospital records and Medicare claims, the researchers found that 9,792 of the women developed AF, at an average age of 63.

    Higher body mass index, a measure of weight relative to height, increased the risk for AF, as did lower levels of physical activity.

    Women who exercised an amount equivalent to five or six 30-minute walks per week or to more vigorous activity like biking twice a week, were 10 percent less likely to develop AF than sedentary women, the authors report in the Journal of the American Heart Association.

    "By the time you're 80, your risk of AFib is about 10 percent, so if you can decrease your risk by 10 percent that is significant," Perez said.

    Obese women were most likely to develop AF, but more physical activity reduced that risk. Obese, sedentary women's AF risk was 30 percent higher than that of a sedentary woman with normal BMI, and 44 percent higher than that of a normal-weight woman who exercised.

    But obese women who exercised had a 17 percent higher risk for AF than normal-weight women who exercised.

    There are other benefits as well, Perez said, since AF leads to hospitalizations and healthcare expenditures.

    Women who exercise more could also be doing other things that lower their risk of AF, but in the Women's Health Initiative data he and his team were able to account for education, income and other lifestyle factors, he said.

    "Physical activity in itself is known to help reduce cardiovascular risk factors, one of the most important of which is high blood pressure, a known mediator of risk of atrial fibrillation," said Dr. Usha B. Tedrow, director of the Clinical Cardiac Electrophysiology Program at Brigham and Women's Hospital in Boston.

    Exercise is also known to reduce inflammation, which may play a role, Tedrow told Reuters Health by email. She was not part of the new study.

    "Atrial fibrillation is a disease where many components of the condition are not under the patient's control," she said. "This study suggests one more piece of the puzzle that can allow patients slightly more control over this disease."

    Perez would recommend that postmenopausal women make time for exercise, within reason and under supervision of a doctor if starting a new and strenuous program, he said.

    High blood pressure and diabetes are also closely tied to AF, so treating those conditions is extremely important as well, he said.

    SOURCE: http://bit.ly/1nbvrQZ Journal of the American Heart Association, August 20, 2014.

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Surgery Articles

  • Robotic prostate removal tied to surgical changes, costs

    By Andrew M. Seaman

    NEW YORK (Reuters Health) - The introduction of robotic surgery for prostate cancer may have led to changes in the number of surgeons performing prostate removals and in the overall cost, according to a new study.

    With the technology being used more widely, fewer doctors are performing the procedure and the overall cost of prostate removal has gone up, researchers found.

    While studies examining the benefits and potential harms of robotic surgery have produced mixed results, the researchers write in BJU International that there is little information on how the innovation influenced prostate removal in the U.S.

    "We knew by anecdotal reports as well as the scientific literature that it had become relatively widespread but we didn't know how that had been done," said Dr. Steven Chang, the study's lead author from Harvard Medical School, Brigham and Women's Hospital and the Dana-Farber Cancer Institute in Boston.

    Robotic-assisted radical prostatectomy, which is the removal of the prostate with the help of a robot, began after U.S. regulators approved Intuitive Surgical, Inc.'s da Vinci Surgical System in 2000.

    Before that, surgeons would remove the prostate through a relatively large incision in so-called open surgery - or through a small incision with the help of a camera, in laparoscopic surgery.

    For the new study, the researchers used data on nearly 490,000 men who had their prostates removed between 2003 and 2010. Of those, 338,448 had open or laparoscopic surgery and 150,921 had robotic-assisted surgery.

    Overall, there was a dramatic increase in the number of prostate removals with the new technology. The proportion of surgeons doing at least half of their prostate removals with the robot increased from 0.7 percent in 2003 to about 42 percent by 2010.

    Surgeons who had been doing more than 24 prostate removals each year were the most likely to start using the new technology.

    The researchers also found that the number of surgeons performing prostate removals decreased during the study period from about 10,000 to 8,200.

    Chang said the finding that fewer surgeons are performing the procedure is likely because the ones who were only doing a few every year decided to stop altogether.

    "It was fairly obvious that the people who adopted this technology had a higher volume per year than people who did not adopt this technology," he said.

    "We have seen a concentration of da Vinci use among high volume surgeons, which we think is a positive for the healthcare system," said Dave Rosa, the executive vice president and chief scientific officer of Intuitive Surgical, Inc., in a statement emailed to Reuters Health.

    "Da Vinci use for radical prostatectomy has been shown to have clinical advantages over open prostatectomy in most of the dozens of comparative clinical studies published," Rosa added.

    The current study was not designed to analyze which type of surgery is safer or leads to fewer complications, Chang said.

    "I don't think anyone really knows that answer and I don't know if that study will ever be done," Dr. Jeff Karnes, who was not involved with the new study, told Reuters Health.

    When it comes to prostate removal, the surgeon's experience is likely more important than whether it's done with or without a robot, said Karnes, an urologist from the Mayo Clinic in Rochester, Minnesota.

    Chang and his colleagues also found that the introduction of the new technology was tied to an increase in overall U.S. spending on prostate removals.

    They write that the increase in cost is likely related to an increased number of prostate removals and increased cost for each procedure.

    Robotic-assisted prostate removals cost more than open surgeries throughout the study but the researchers found that the cost of the older surgical methods also increased toward the end of the study.

    They can't say, based on their data, why the cost of open or laparoscopic surgeries began to increase, but they suggest it may be due to slower surgeons continuing to use open surgeon or innovations in open surgery that drove the price up.

    Alternatively, Karnes said it could also be a result of riskier prostate removals, which take more time, needing open surgery.

    Intuitive Surgical, Inc.'s Rosa said a thorough study would take into account overall societal costs in an economic analysis. Those costs include how the patients faired after the procedure.

    "Costs can be calculated very differently in economic studies depending on the methodology used," he said.

    Chang said a goal in the future would be to do a more thorough cost analysis that includes more indirect costs.

    Overall, Karnes said he is not surprised by the results of the study.

    "We know that when a hospital acquires the technology the number of robot procedures go up in that hospital," he said.

    For patients faced with prostate removal, he said it's likely best to make a decision on open or robotic-assisted surgery based on the surgeon's experience and performance.

    SOURCE: http://bit.ly/1luyDMz BJU International, online August 26, 2014.

  • Second D.C.-area man stricken with flesh-eating bacteria -media

    By John Clarke and Ian Simpson

    Aug 22 () - (Reuters) - A flesh-eating bacterial disease has infected another Washington, D.C.-area man, local media reported on Thursday, just days after a man was released from a hospital following a near-deadly bout with the germ.

    Joe Wood of Stafford, Virginia, said he was swimming in the Potomac River near the town of Callao earlier this month when a scratch on his left leg became infected with vibrio vulnificus, an aggressive bacteria that feeds on flesh, Washington D.C.'s WTOP radio reported.

    Wood was admitted to the Mary Washington Hospital in Fredericksburg on July 5 where an infectious disease specialist performed skin graft surgery on Tuesday, the report said. Doctors told the radio station that Wood would likely survive.

    The report could not be immediately confirmed as the hospital did not return repeated calls by a Reuters reporter on Thursday.

    The news comes just days after a 66-year-old Maryland man was released from a hospital after nearly losing a leg and his life to the flesh-eating bacterial infection that he contracted in Chesapeake Bay earlier in the month.

    The bacterial strain causes severe illness characterized by fever and chills, septic shock and lesions. Symptoms include vomiting and diarrhea.

    Vibrio cases are on the rise in the region. In a 2009 study, the Chesapeake Bay Foundation found that the increase in infections was linked to pollution and unusually hot summers.

    In Maryland, the number of all vibrio cases, including the strain that afflicted the two men, reached 57 last year, a 10-year high, according to the Maryland Department of Health and Mental Hygiene.

    Virginia had eight vibrio vulnificus cases last year, according to the Virginia Department of Health. There have been 27 cases involving vibrio species overall so far this year.

    Nationwide, there are as many as 95 cases of vibrio vulnificus infections each year, 35 of which result in death, according to CDC statistics.

  • Men, substance users less likely to have weight-loss surgery

    By Ronnie Cohen

    NEW YORK (Reuters Health) - A one-size-fits-all approach to weight-loss surgery may be keeping obese men, substance users and older people out of the operating room, a new study suggests.

    The study analyzed data from a Canadian program intended to encourage obese people to undergo weight-loss surgery. More than half the patients dropped-out without having the operation, researchers found.

    Men, smokers, drinkers, drug users and people age 60 and older were the most likely to quit the program before having the operation, senior author Dr. Fayez Quereshy from the University of Toronto in Ontario told Reuters Health in a telephone interview.

    More than one-third of U.S. adults are obese and cost an estimated $147 billion a year in medical care, according to the Centers for Disease Control and Prevention.

    Weight loss operations, formally known as bariatric surgery, are known to cut obesity-related disease and healthcare costs. Prior research has shown they result in substantial weight loss and can reverse the course of some related diseases (see Reuters story of December 24, 2013 here: http://reut.rs/1BDFesE).

    In some studies, the surgery has been more effective in helping obese people shed weight than diet, exercise, therapy and drugs (see Reuters story of October 31, 2013 here: http://reut.rs/1z2YCLN).

    The operations reduce the size of the stomach so patients can eat only small amounts of food. Doctors recommend the procedures for people who are severely obese or moderately obese with serious weight-related health problems.

    But while bariatric surgery is becoming increasingly popular, the drop-out rate has also been growing, the authors write in the Journal of the American College of Surgeons.

    In the current study, they examined the records of 1,664 patients referred to the bariatric-surgery program between 2008 and 2011. Patients ranged in age from 19 to 80, with an average age of 48. They waited an average of nearly 15 months to have the surgery, the authors write.

    Body mass index (BMI), a ratio of weight to height, was higher than 40 in nearly nine of every ten people. A BMI of 40 would be roughly equivalent, for example, to a height of 5 foot 2 inches (157 cm) and a weight of 218 pounds (99 kg), or a height of 6 feet (183 cm) and a weight of 294 pounds (133 kg).

    About one in every 13 people had a BMI above 60, roughly equivalent to a height of 5 foot 2 inches and a weight of 330 pounds (150 kg),

    Most patients - 74 percent - referred to the program were women. Men were not only less likely to be referred, they were also nearly half as likely to undergo the surgery.

    Heavier patients were more likely to have the operation and older patients (i.e., those over 60) were less likely, the study found.

    Distance from home to the program appeared to have no impact on attrition.

    Smokers, drinkers and other substance users were more likely to quit before surgery. The study did not determine if they left the program on their own or were refused treatment. Substance abusers must demonstrate prolonged abstinence to be eligible for weight-loss surgery, the authors write.

    Knowing which patients are dropping out should help administrators tailor future bariatric-surgery services, Quereshy said.

    The best way to most efficiently move more patients through the system, he believes, would be to tailor the care for certain groups of people. For example, he suggested, patients with limited social networks should be connected to social workers early on.

    "In environments where resources are scarce and obesity-related complications carry a significant cost burden and patient complications, we need to think of novel ways to reduce wait times, patient dropouts and disappointments while improving satisfaction," Quereshy said.

    Bariatric surgeon Dr. Erik Dutson, from the University of California, Los Angeles, said the study's message rings just as true in America as it does in Canada. He was not involved with the current study.

    "If we are going to continue to look at bariatric surgery as the gold standard for weight loss, then we should keep our eyes open about preemptively anticipating problems with patients and make special care considerations for certain subgroups," Dutson said.

    Bariatric surgery is not risk-free. Gastric-bypass operations, for example, carry the risk of blood clots, breathing problems, heart attacks, strokes, infections and allergic reactions to anesthesia, according to the National Institutes of Health.

    Still, Dutson believes that bariatric surgery is the safest way to reduce obesity and prevent related complications, such as diabetes. He described the operation as safer than a gall bladder removal.

    "It's ironically safer to undergo an operation than to not undergo an operation," he said.

    SOURCE: http://bit.ly/1p7pDN9 Journal of the American College of Surgeons, online August 11, 2014.

  • Knee replacement may go poorly for people who think life isn't fair

    By Kathryn Doyle

    NEW YORK (Reuters Health) - People who tend to blame others for their suffering and think setbacks in their lives are irreparable tend to report more pain after knee replacement surgery, according to a new study.

    This is not the first time feelings of personal injustice have been tied to longer recovery times and increased disability after injury, the authors write.

    "Pain is a complex phenomenon that is influenced by biological, social, and psychological factors," said lead author Esther Yakobov, a doctoral student in clinical psychology at McGill University in Montreal.

    "Studies conducted with patients who suffer from chronic pain because of an injury demonstrated that individuals who judge their experience as unfair, focus on their losses, and blame others for their painful condition also tend to experience more pain and recover from their injuries slower than individuals who do not," she told Reuters Health by email.

    But those studies had been with victims of injuries, where externalizing blame is a bit easier than for degenerative conditions like osteoarthritis, she noted.

    For the new study, a group of 116 men and women with severe osteoarthritis, between ages 50 and 85 years old and scheduled for knee replacement surgery in Canada, first filled out questionnaires assessing perceived injustice, how much they think about or worry about pain and their fear of movement or re-injury.

    They rated their agreement with statements like, "It all seems so unfair" and "I am suffering because of someone else's negligence."

    With another clinical questionnaire the patients gauged their pain levels and physical functioning.

    After the knee replacement surgeries, which were all deemed successful, the patients rated their pain and function again at a one-year checkup.

    The more a patient agreed before surgery that life seems unfair and others are to blame for their problems, the more pain they reported experiencing one year after surgery. That was true even when age, sex, other health conditions and pre-surgery pain levels were accounted for, according to the results in the journal Pain.

    The more the patient thought about pain and felt helpless because of it before surgery, the more severe their disability during recovery seemed to be.

    "A decade ago, we reported that preoperative anxiety and depression influenced the outcome after surgery," said Dr. Victoria Brander, a physical medicine and rehabilitation specialist at Northwestern Orthopaedic Institute in Chicago.

    This new study adds to the effort to refine the concept, identifying specific psychological characteristics that serve as risk factors for complicated or painful recovery, Brander, who was not part of the new study, told Reuters Health by email.

    "All of these psychological factors point to the fact that patients who perceive themselves as helpless, those who are afraid, those who feel loss of control, have a more difficult time," Brander said.

    "The contrary is also true - patients who exhibit high levels of 'self-efficacy' (that is, patients who have a high degree of confidence in their own ability to achieve a goal) appear to do best after knee replacement," she said.

    Osteoarthritis, the wearing away of cartilage, joint lining, ligaments and bone in a joint, affects one third of people over age 65 in the U.S., according to the Centers for Disease Control and prevention.

    Knee replacement surgery can relieve pain and restore mobility, but about 20 percent of patients will have a problematic recovery or intense pain, based on previous research.

    How individuals perceive pain as just or unjust can vary widely between patients, and it can be influenced by many factors, so it's hard to say if having a more negative outlook is common or uncommon, Yabokov said.

    Researchers don't yet know if people with more negative outlooks only perceive their pain as worse than others or if their psychological state affects the physiology of healing and actually leads to more pain, she said.

    Nevertheless, findings like this suggest patients should be screened for their psychosocial outlook before surgery, she said.

    "This might suggest the usefulness of screening patients in terms of 'catastrophizing,' perceived injustice, fear of movement, and recovery expectancies before treatment or surgery," she said. "With this screening information, appropriate psychological intervention that targets specific risk factors of each patient can then be matched to patients' needs."

    SOURCE: http://bit.ly/1qOr9BB Pain, online July 25, 2014.

  • Hundreds rally in Ireland after rape victim says denied abortion

    By Conor Humphries

    DUBLIN (Reuters) - Hundreds of people rallied in Dublin to call for a change to Ireland's abortion laws on Wednesday after a rape victim said she was refused a termination and instead gave birth by Caesarean section.

    The young migrant's case has reignited a debate about Roman Catholic Ireland's abortion laws, among the most restrictive in Europe, that sparked large protests before parliament voted to allow limited access to abortion for the first time last year.

    "I'm here because I was horrified. This poor girl suffered because she didn't understand the convoluted, stupid system here in Ireland," said Aoife McLysaght, a 38-year old science professor, holding a sign saying 'Forced pregnancy is torture'.

    "We are trying to put pressure on the government, but it seems to be one of those things they'd prefer to ignore. I feel it's only a matter of time before this law is changed. I just want that time to be sooner so fewer people suffer."

    The young foreign national, who cannot be named for legal reasons, told the Irish Times that she became pregnant as a result of rape that took place before she arrived in Ireland.

    She sought help to end the pregnancy when she discovered she was expecting a child, but was turned down by medical authorities. While Irish women seeking abortions typically travel to Britain, which has less strict laws, the woman said she could not do this because she did not have enough money.

    Under the Protection of Life During Pregnancy bill, which was passed a year ago in the wake of the death of an Indian woman who was refused an abortion, a pregnancy can be terminated if the life of the mother is in danger, including by suicide.

    The woman said she had attempted to commit suicide, but was interrupted. But by the time she was assessed by a psychiatrist, she was told her pregnancy was too far advanced to halt it.

    Protesters gathered in central Dublin chanted 'repeal the eighth' in reference to the eighth amendment to the constitution which followed the passing of a 1983 referendum giving the unborn an equal right to life as its mother.

    A United Nations human rights committee told Ireland last month that it should revise its abortion laws to provide for additional exceptions in cases of rape, incest, serious risks to the health of the mother or fatal fetal abnormality.

    The Committee's Chairman Nigel Rodley said Irish law treated women who were raped as a "a vessel and nothing more."

    Ireland's Health Service Executive said in a statement it could not comment on the circumstances of the case until an investigation to be completed by late September.

    Prime Minister Enda Kenny's government has indicated it does not plan to address the issue before the next general election, due by early 2016. It would need to hold another referendum to further amend the law.

    The Pro Life Campaign group said in a statement that the clamor for wider access to abortion laws was obscene as a premature baby clings to life and a chilling and disturbing reminder of the inhumane reality of legalized abortion.

Neonatal Articles

  • U.S. to propose birth control exception for religious companies -source

    By Caroline Humer

    (Reuters) - The Obama administration will ensure access to birth control coverage for employees of closely-held companies that object to contraception on religious grounds, proposing a new accommodation to health benefits mandated by the Affordable Care Act, a source familiar with the plan said on Friday.

    The move follows a Supreme Court ruling in June that allowed certain for-profit companies to refuse to cover contraceptives due to the religious beliefs of their owners.

    President Barack Obama's healthcare reform law requires companies to provide free birth control coverage as a preventive service included in their health plans.

    The U.S. Department of Health and Human Services had already provided an exception to non-profit groups with religious affiliations, such as certain universities or hospitals, in 2013. The exception requires insurers to cover the cost of birth control for employees of such organizations, separate from the benefits paid for by the employers.

    On Friday, it was expected to propose an extension of that rule to closely-held companies in rules published in the Federal Register, the source said.

    The rule is in direct response to the Supreme Court ruling in favor of Hobby Lobby Stores Ltd, a family-owned chain of craft stores, and Conestoga Wood Specialties Corp of Pennsylvania. The two companies combined employ nearly 14,000 people. The accommodation is expected to impact at nearly 50 additional companies who have filed similar lawsuits.

    At the time, the justices ruled that for-profit companies can make claims under a 1993 federal law called the Religious Freedom Restoration Act that was enacted to protect religious liberty. They had suggested that the government could extend the accommodation made for non-profit groups.

    HHS also proposed on Friday an interim rule for non-profits to lay out additional ways that these companies can provide notice to the government in writing of their religious objections to providing contraception coverage.

    The interim rule for non-profits is largely in response to a Supreme Court order in July, issued days after the Hobby Lobby ruling, that gave a temporary exemption to a Christian college in Illinois. It had said that the initial process for informing insurers of their religious standing also violated their beliefs.

  • U.S. EPA makes strides in air toxics but work remains in cities -report

    By Reuters Staff

    WASHINGTON (Reuters) - The United States has made progress in reducing dangerous air pollution since 1990 but work remains to reduce risks for the country's most overburdened urban areas, the U.S. Environmental Protection Agency's top official said on Thursday.

    The EPA released to Congress its second report on integrated air toxics, citing "substantial progress" toward reducing levels of contaminants such as arsenic, mercury and lead since it launched an Integrated Urban Air Toxics Strategy in 1999.

    Air toxics, also known as toxic air pollutants or hazardous air pollutants, are pollutants that may increase the risk of cancer or other serious health effects, such as birth defects.

    EPA Administrator Gina McCarthy pointed to milestones such as a 60 percent reduction in mercury from coal-fired power plants and an 84 percent cut in lead levels in outdoor air among the agency's accomplishments.

    But she told reporters that more work needs to be done to understand air toxics better and reduce remaining risks, which are most prevalent in low-income urban areas.

    "There is more that we have to do and more that we can do," McCarthy said on a conference call.

    The report she cited highlighted six areas where the current EPA air toxics program must improve, including emissions data; ambient data in more areas covering more pollutants; better monitoring technologies; and research on health impacts of air toxics.

    McCarthy said the agency is focused on addressing environmental justice by recognizing that some of the most economically disadvantaged communities are most at risk of the negative health effects of air pollution.

    The agency will complete studies of air toxic pollution in the neighborhoods of South Philadelphia and North Birmingham, Alabama, to get better data that can help inform local decision making.

    "Environmental justice is the core of EPA's mission - striving for clean water and healthy air for every American," McCarthy said.

    For the complete 139-page EPA report, see: http://www2.epa.gov/sites/production/files/2014-08/documents/082114-urban-air-toxics-report-congress.pdf

  • California law aims to protect rights of sperm donors, surrogates

    By Sharon Bernstein

    SACRAMENTO, Calif. (Reuters) - A bill aimed at protecting the parental and adoptive rights of non-traditional families in California was sent to Governor Jerry Brown on Wednesday in an effort to close gaps in a state law that have led to at least one high-profile legal case.

    The measure by San Francisco Assemblyman Tom Ammiano, a Democrat, would require sperm donors, surrogate mothers and the people with whom they work to have a child to fill out a series of forms detailing the rights and responsibilities of each person.

    "My bill represents an opportunity to have state law keep pace with the changes in reproductive technology," Ammiano said. "With a few simple changes, we can help families thrive without needless legal battles or expensive court actions."

    Legal issues around the parental rights of sperm donors have made headlines recently over a debacle involving actor Jason Patric, who donated sperm to a now-former girlfriend and is suing for the right to be part of the child's life. Under current law, sperm donors do not typically have parental rights unless otherwise agreed by the parties involved.

    Ammiano's bill would require people who use sperm donors or surrogate mothers to fill out a series of forms outlining the parental rights and responsibilities of the donor or surrogate before conception.

    The forms required under the legislation are designed to eliminate any gray area about who has the right to visit or care for a child conceived through in vitro or other non-traditional reproductive methods.

    The bill would also create an expedited adoption process for same-sex parents. The process is meant to protect families who move from California to states where a non-biological parent is not recognized under state law unless the child has been legally adopted.

    The measure also requires couples using a surrogate to spell out how they will pay for the medical expenses of the surrogate and the care of the newborn.

  • Hundreds rally in Ireland after rape victim says denied abortion

    By Conor Humphries

    DUBLIN (Reuters) - Hundreds of people rallied in Dublin to call for a change to Ireland's abortion laws on Wednesday after a rape victim said she was refused a termination and instead gave birth by Caesarean section.

    The young migrant's case has reignited a debate about Roman Catholic Ireland's abortion laws, among the most restrictive in Europe, that sparked large protests before parliament voted to allow limited access to abortion for the first time last year.

    "I'm here because I was horrified. This poor girl suffered because she didn't understand the convoluted, stupid system here in Ireland," said Aoife McLysaght, a 38-year old science professor, holding a sign saying 'Forced pregnancy is torture'.

    "We are trying to put pressure on the government, but it seems to be one of those things they'd prefer to ignore. I feel it's only a matter of time before this law is changed. I just want that time to be sooner so fewer people suffer."

    The young foreign national, who cannot be named for legal reasons, told the Irish Times that she became pregnant as a result of rape that took place before she arrived in Ireland.

    She sought help to end the pregnancy when she discovered she was expecting a child, but was turned down by medical authorities. While Irish women seeking abortions typically travel to Britain, which has less strict laws, the woman said she could not do this because she did not have enough money.

    Under the Protection of Life During Pregnancy bill, which was passed a year ago in the wake of the death of an Indian woman who was refused an abortion, a pregnancy can be terminated if the life of the mother is in danger, including by suicide.

    The woman said she had attempted to commit suicide, but was interrupted. But by the time she was assessed by a psychiatrist, she was told her pregnancy was too far advanced to halt it.

    Protesters gathered in central Dublin chanted 'repeal the eighth' in reference to the eighth amendment to the constitution which followed the passing of a 1983 referendum giving the unborn an equal right to life as its mother.

    A United Nations human rights committee told Ireland last month that it should revise its abortion laws to provide for additional exceptions in cases of rape, incest, serious risks to the health of the mother or fatal fetal abnormality.

    The Committee's Chairman Nigel Rodley said Irish law treated women who were raped as a "a vessel and nothing more."

    Ireland's Health Service Executive said in a statement it could not comment on the circumstances of the case until an investigation to be completed by late September.

    Prime Minister Enda Kenny's government has indicated it does not plan to address the issue before the next general election, due by early 2016. It would need to hold another referendum to further amend the law.

    The Pro Life Campaign group said in a statement that the clamor for wider access to abortion laws was obscene as a premature baby clings to life and a chilling and disturbing reminder of the inhumane reality of legalized abortion.

Neuroscience Articles

  • Former U.S. swim star Van Dyken takes first steps since paralysis

    By Susan Heavey

    WASHINGTON (Reuters) - Olympic swimming champion Amy Van Dyken took her first steps this week since being paralyzed from the waist down when she severed her spinal cord in an all-terrain vehicle crash earlier this summer.

    In videos and images she posted online, Van Dyken is seen standing and starting to walk with the help a robotic exoskeleton device aimed at supporting patients' bodies and helping them move.

    "I feel good. Woo hoo!" she said in one video, posted late Thursday.

    "Here it is... I'm WALKING!!!" she wrote in another post.

    Another photograph shows Van Dyken, who won a total of six gold medals at the 1996 and 2000 Olympics, standing alongside her husband, former Denver Broncos punter Tom Rouen.

    Van Dyken's steps come just eight days after her release from a rehabilitation center in Colorado.

    In June, Van Dyken crashed her all-terrain vehicle near her Arizona home and was left with no movement in her legs despite several surgeries. Since then, she has vowed to one day walk again and has been active on social media documenting her recovery.

    It was not immediately clear what kind of exoskeleton device Van Dyken used. An assistant in one photo appears to be wearing a shirt with the logo for Indego, a wearable, motorized device sold by Parker Hannifin Corp markets for use in medical clinics.

    ReWalk Robotics Inc, which has plans take the company public, also sells a system for both clinical and personal use. It won approval from the U.S. Food and Drug Administration earlier this year to market it as long as it continues to gather data on its use.

    Such devices also have helped other paraplegics, including a man who earlier this summer kicked the first ball of the World Cup. A British woman in 2012 used a robotic exoskeleton to complete the London Marathon, although it took her 17 days.

  • U.S. EPA makes strides in air toxics but work remains in cities -report

    By Reuters Staff

    WASHINGTON (Reuters) - The United States has made progress in reducing dangerous air pollution since 1990 but work remains to reduce risks for the country's most overburdened urban areas, the U.S. Environmental Protection Agency's top official said on Thursday.

    The EPA released to Congress its second report on integrated air toxics, citing "substantial progress" toward reducing levels of contaminants such as arsenic, mercury and lead since it launched an Integrated Urban Air Toxics Strategy in 1999.

    Air toxics, also known as toxic air pollutants or hazardous air pollutants, are pollutants that may increase the risk of cancer or other serious health effects, such as birth defects.

    EPA Administrator Gina McCarthy pointed to milestones such as a 60 percent reduction in mercury from coal-fired power plants and an 84 percent cut in lead levels in outdoor air among the agency's accomplishments.

    But she told reporters that more work needs to be done to understand air toxics better and reduce remaining risks, which are most prevalent in low-income urban areas.

    "There is more that we have to do and more that we can do," McCarthy said on a conference call.

    The report she cited highlighted six areas where the current EPA air toxics program must improve, including emissions data; ambient data in more areas covering more pollutants; better monitoring technologies; and research on health impacts of air toxics.

    McCarthy said the agency is focused on addressing environmental justice by recognizing that some of the most economically disadvantaged communities are most at risk of the negative health effects of air pollution.

    The agency will complete studies of air toxic pollution in the neighborhoods of South Philadelphia and North Birmingham, Alabama, to get better data that can help inform local decision making.

    "Environmental justice is the core of EPA's mission - striving for clean water and healthy air for every American," McCarthy said.

    For the complete 139-page EPA report, see: http://www2.epa.gov/sites/production/files/2014-08/documents/082114-urban-air-toxics-report-congress.pdf

  • Researchers reverse autism symptoms in mice by paring extra synapses

    By Sharon Begley

    NEW YORK (Reuters) - Although many things have gone wrong in the autistic brain, scientists have recently been focusing on one of the most glaring: a surplus of connections, or synapses.

    Neuroscientists reported on Thursday that, at least in lab mice, a drug that restores the healthy "synaptic pruning" that normally occurs during brain development also reverses autistic-like behaviors such as avoiding social interaction.

    "We were able to treat mice after the disease had appeared," neurobiologist David Sulzer of Columbia University Medical Center, who led the study published in the journal Neuron, said in a telephone interview. That suggests the disease could one day be treated in teenagers and adults, "though there is a lot of work to be done," he said.

    A synapse is where one neuron communicates with another, forming functional circuits. With too many synapses, a "brain region that should be talking only to a select number of other regions is receiving irrelevant information from many others," Ralph-Axel Müller of San Diego State University said by email. He has done pioneering work in overconnectivity and was not involved in the Neuron study, which he deemed "extremely exciting."

    According to the latest government estimates, one in 68 children in the United States has some form of autism.

    For the new study, Columbia's Guomei Tang painstakingly counted synapses in a key region of the cortex of 26 children with autism who had died from other causes and compared that to 22 healthy brains also donated to science.

    In the autistic brains, synaptic density was more than 50 percent higher than that in healthy brains and sometimes two-thirds greater.

    It is not clear if too many synapses are the main reason for autism, but many genes linked to autism play a role in synapse pruning. And the discovery that synapse pruning reversed autistic behavior in the lab mice suggests overconnectivity may be key.

    Sulzer's team used rapamycin, an immunosuppressant drug that prevents organ rejection and is sold by Pfizer as Rapamune. They chose rapamycin because it works by inhibiting a protein called mTOR whose overactivity, they found, inhibits synapse pruning.

    Even if the findings are confirmed - and Sulzer notes that treatments that work in lab animals often fail in people - it is unlikely that rapamycin would be used in people with autism: Its wide-scale immune-suppressing effects would likely cause serious side effects.

    "But there could be better drugs," Sulzer said, such as a molecule that dials up production of synapse-pruning proteins.

    One remaining puzzle is how the mice's brains, or the drug, know which synapses to keep and which to prune. "But the mice started behaving normally" after receiving the synapse-pruning drug, "which suggests the right ones are being pruned," Sulzer said.

    In addition to government funding, the Columbia scientists received grants from the Simons Foundation. It was established by hedge fund pioneer and Renaissance Technologies founder Jim Simons, whose daughter was diagnosed with autism.

    SOURCE: http://bit.ly/1pNZZNz Neuron, online August 21, 2014.

  • For older women, working out may keep heart rates regular

    By Kathryn Doyle

    NEW YORK (Reuters Health) - Physically active older women are less likely to suffer from atrial fibrillation, the most common form of irregular heartbeat, than less active women, according to a new U.S. study.

    Contrary to suggestions that exercise might raise the risk of abnormal heart rhythms, the analysis based on more than 80,000 postmenopausal women found the risk of atrial fibrillation was lowered by up to 44 percent with regular physical activity.

    "This is one of the reasons we ended up doing the study, we wanted to quell some of those concerns," said senior author Dr. Marco V. Perez of the Stanford Center for Inherited Cardiovascular Disease in California.

    "These are women not engaged in extreme forms of exercise, and what we found was that women who engaged in more exercise actually had a lower risk of AF," Perez told Reuters Health. "The more obese you were, the more you benefitted."

    Atrial fibrillation (AF), sometimes shortened to "AFib," affects more than 1 million U.S. women, and raises their risk of stroke and death even more than it does for men with the condition.

    Perez and his team analyzed data from the large, long-term Women's Health Initiative study. They focused on 81,317 postmenopausal women who had been followed over an average of 11 years.

    Using hospital records and Medicare claims, the researchers found that 9,792 of the women developed AF, at an average age of 63.

    Higher body mass index, a measure of weight relative to height, increased the risk for AF, as did lower levels of physical activity.

    Women who exercised an amount equivalent to five or six 30-minute walks per week or to more vigorous activity like biking twice a week, were 10 percent less likely to develop AF than sedentary women, the authors report in the Journal of the American Heart Association.

    "By the time you're 80, your risk of AFib is about 10 percent, so if you can decrease your risk by 10 percent that is significant," Perez said.

    Obese women were most likely to develop AF, but more physical activity reduced that risk. Obese, sedentary women's AF risk was 30 percent higher than that of a sedentary woman with normal BMI, and 44 percent higher than that of a normal-weight woman who exercised.

    But obese women who exercised had a 17 percent higher risk for AF than normal-weight women who exercised.

    There are other benefits as well, Perez said, since AF leads to hospitalizations and healthcare expenditures.

    Women who exercise more could also be doing other things that lower their risk of AF, but in the Women's Health Initiative data he and his team were able to account for education, income and other lifestyle factors, he said.

    "Physical activity in itself is known to help reduce cardiovascular risk factors, one of the most important of which is high blood pressure, a known mediator of risk of atrial fibrillation," said Dr. Usha B. Tedrow, director of the Clinical Cardiac Electrophysiology Program at Brigham and Women's Hospital in Boston.

    Exercise is also known to reduce inflammation, which may play a role, Tedrow told Reuters Health by email. She was not part of the new study.

    "Atrial fibrillation is a disease where many components of the condition are not under the patient's control," she said. "This study suggests one more piece of the puzzle that can allow patients slightly more control over this disease."

    Perez would recommend that postmenopausal women make time for exercise, within reason and under supervision of a doctor if starting a new and strenuous program, he said.

    High blood pressure and diabetes are also closely tied to AF, so treating those conditions is extremely important as well, he said.

    SOURCE: http://bit.ly/1nbvrQZ Journal of the American Heart Association, August 20, 2014.

  • Former Tennessee Titans player Tim Shaw says he has ALS

    By Tim Ghianni

    NASHVILLE, Tenn. (Reuters) - Former Tennessee Titans linebacker Tim Shaw revealed he has ALS, also known as Lou Gehrig's disease, in a video that shows him dumping a bucket full of ice water over his head as part of an ALS fundraiser.

    "I'm here today to stand up and fight with all of you against this disease," he said in the video posted on Tuesday, before dousing himself as part of the "Ice Bucket Challenge" to fight ALS - amyotrophic lateral sclerosis.

    After taking the challenge, Shaw, 30, called on the Titans organization, Penn State head coach James Franklin, the school's football team and his Clarenceville, Michigan, community to do the same.

    Shaw was drafted by the Carolina Panthers from Penn State and also played for the NFL's Jacksonville Jaguars and Chicago Bears. Shaw spent three years as a Titan before leaving football in 2013.

    The challenge has become popular on social media, with celebrities such as former President George W. Bush and basketball star LeBron James posting videos online showing themselves getting doused with cold water.

    The challenge has helped raise $31.5 million for the ALS Association over the past year, more than 16 times what it raised the previous year, the organization said on Wednesday.

    More than 5,600 people are diagnosed each year with ALS, a progressive neurodegenerative disease that attacks nerve cells and pathways in the brain and spinal cord, eventually paralyzing patients, according to the organization.

    A 2012 study found that National Football League players were at greater risk than the general population of dying of neurodegenerative diseases.

Oncology Articles

  • Robotic prostate removal tied to surgical changes, costs

    By Andrew M. Seaman

    NEW YORK (Reuters Health) - The introduction of robotic surgery for prostate cancer may have led to changes in the number of surgeons performing prostate removals and in the overall cost, according to a new study.

    With the technology being used more widely, fewer doctors are performing the procedure and the overall cost of prostate removal has gone up, researchers found.

    While studies examining the benefits and potential harms of robotic surgery have produced mixed results, the researchers write in BJU International that there is little information on how the innovation influenced prostate removal in the U.S.

    "We knew by anecdotal reports as well as the scientific literature that it had become relatively widespread but we didn't know how that had been done," said Dr. Steven Chang, the study's lead author from Harvard Medical School, Brigham and Women's Hospital and the Dana-Farber Cancer Institute in Boston.

    Robotic-assisted radical prostatectomy, which is the removal of the prostate with the help of a robot, began after U.S. regulators approved Intuitive Surgical, Inc.'s da Vinci Surgical System in 2000.

    Before that, surgeons would remove the prostate through a relatively large incision in so-called open surgery - or through a small incision with the help of a camera, in laparoscopic surgery.

    For the new study, the researchers used data on nearly 490,000 men who had their prostates removed between 2003 and 2010. Of those, 338,448 had open or laparoscopic surgery and 150,921 had robotic-assisted surgery.

    Overall, there was a dramatic increase in the number of prostate removals with the new technology. The proportion of surgeons doing at least half of their prostate removals with the robot increased from 0.7 percent in 2003 to about 42 percent by 2010.

    Surgeons who had been doing more than 24 prostate removals each year were the most likely to start using the new technology.

    The researchers also found that the number of surgeons performing prostate removals decreased during the study period from about 10,000 to 8,200.

    Chang said the finding that fewer surgeons are performing the procedure is likely because the ones who were only doing a few every year decided to stop altogether.

    "It was fairly obvious that the people who adopted this technology had a higher volume per year than people who did not adopt this technology," he said.

    "We have seen a concentration of da Vinci use among high volume surgeons, which we think is a positive for the healthcare system," said Dave Rosa, the executive vice president and chief scientific officer of Intuitive Surgical, Inc., in a statement emailed to Reuters Health.

    "Da Vinci use for radical prostatectomy has been shown to have clinical advantages over open prostatectomy in most of the dozens of comparative clinical studies published," Rosa added.

    The current study was not designed to analyze which type of surgery is safer or leads to fewer complications, Chang said.

    "I don't think anyone really knows that answer and I don't know if that study will ever be done," Dr. Jeff Karnes, who was not involved with the new study, told Reuters Health.

    When it comes to prostate removal, the surgeon's experience is likely more important than whether it's done with or without a robot, said Karnes, an urologist from the Mayo Clinic in Rochester, Minnesota.

    Chang and his colleagues also found that the introduction of the new technology was tied to an increase in overall U.S. spending on prostate removals.

    They write that the increase in cost is likely related to an increased number of prostate removals and increased cost for each procedure.

    Robotic-assisted prostate removals cost more than open surgeries throughout the study but the researchers found that the cost of the older surgical methods also increased toward the end of the study.

    They can't say, based on their data, why the cost of open or laparoscopic surgeries began to increase, but they suggest it may be due to slower surgeons continuing to use open surgeon or innovations in open surgery that drove the price up.

    Alternatively, Karnes said it could also be a result of riskier prostate removals, which take more time, needing open surgery.

    Intuitive Surgical, Inc.'s Rosa said a thorough study would take into account overall societal costs in an economic analysis. Those costs include how the patients faired after the procedure.

    "Costs can be calculated very differently in economic studies depending on the methodology used," he said.

    Chang said a goal in the future would be to do a more thorough cost analysis that includes more indirect costs.

    Overall, Karnes said he is not surprised by the results of the study.

    "We know that when a hospital acquires the technology the number of robot procedures go up in that hospital," he said.

    For patients faced with prostate removal, he said it's likely best to make a decision on open or robotic-assisted surgery based on the surgeon's experience and performance.

    SOURCE: http://bit.ly/1luyDMz BJU International, online August 26, 2014.

  • Medicaid payouts for office visits may influence cancer screening: study

    By Kathryn Doyle

    NEW YORK (Reuters Health) - In states where Medicaid pays doctors higher fees for office visits, Medicaid beneficiaries are more likely to be screened for breast, cervical or colorectal cancer, according to a new study.

    "States tend to vary in their reimbursement rates for different types of medical care services; some states may have low reimbursements for certain services and higher reimbursements for others," said lead author Dr. Michael T. Halpern of the Division of Health Services and Social Policy Research at RTI International at Washington, D.C.

    Medicaid, a health insurance program for low-income individuals, is jointly funded by the federal government and the individual states. Each state establishes its own coverage and reimbursement policies.

    Unexpectedly, states' reimbursement rates for specific screening tests weren't always associated with an increase in screening rates, Halpern and his team found.

    There is no reason to believe that reimbursing more for a certain test would lead to that test being used less, so there's probably something else going on to explain that relationship, which was specifically true for Pap tests, Halpern told Reuters Health by email.

    Researchers analyzed Medicaid data from 2007 for 46 states and the District of Columbia.

    In states with higher payments for office visits, cancer screenings were more common. But higher payments for the screenings themselves did not always mean the screenings were performed more often, according to results published in the journal Cancer.

    Nationwide, the median Medicaid reimbursement for an office visit is $37. (In other words, half the states pay doctors less than that.) The median Medicaid reimbursement was $24 for a Pap test, which can detect early cervical cancer, and $271 for a colonoscopy.

    These tests are all recommended for the age group of the people in the study, but since some of the tests are not recommended yearly and the study only includes data from 2007, it was not clear whether the Medicaid beneficiaries were receiving guideline-based screening, Halpern said.

    State by state, when screening test reimbursement rose by 20 percent, the odds of receiving a colonoscopy increased by 1.6 percent, the odds of getting a Pap test decreased by 0.8 percent, and a mammogram might be more or less likely depending on the type and location of the screening order.

    But when reimbursement for an office visit rose by 20 percent, so did screening rates, by 2 to 8 percent.

    "Many primary care physicians do not accept Medicaid patients or are able to provide care only to limited numbers of Medicaid beneficiaries, potentially due to low reimbursements for office visits," Halpern said. "By increasing Medicaid reimbursements for primary care physician office visits, more physicians may be able to provide care for Medicaid beneficiaries, thus increasing their likelihood of receive cancer screenings."

    For screenings like colonoscopy and mammography, the primary care doctor refers the patient to another provider for those tests, so the amount Medicaid reimburses for the tests generally doesn't have a financial benefit for the referring physician, he said.

    "The finding with higher Medicaid office fees is noteworthy, because it means that higher fees open physicians' doors to Medicaid patients and that is the first step to getting patients the care they need," said Stephen Zuckerman, senior fellow and co-director of the Health Policy Center of the Urban Institute. "Cancer screening is only on part of that."

    Doctors' time is limited, and economic incentives matter to them, Zuckerman told Reuters Health by email.

    "In a system with many payers, that means that it makes sense for physicians to see patients for whom they receive better compensation before they see other patients," he said.

    Fees are not the only incentives in scheduling patients, but they do play an important role, he said.

    "Since office visit fees have the most consistent relationship to receipt of cancer screening, it would be important to make sure those fees are sufficient to get Medicaid patients appropriate access to primary care services," Zuckerman said.

    SOURCE: http://bit.ly/1tOc4l9 Cancer, online August 25, 2014.

  • Prescription painkiller deaths fall in medical marijuana states

    By Kathryn Doyle

    NEW YORK (Reuters Health) - Researchers aren't sure why, but in the 23 U.S. states where medical marijuana has been legalized, deaths from opioid overdoses have decreased by almost 25 percent, according to a new analysis.

    "Most of the discussion on medical marijuana has been about its effect on individuals in terms of reducing pain or other symptoms," said lead author Dr. Marcus Bachhuber in an email to Reuters Health. "The unique contribution of our study is the finding that medical marijuana laws and policies may have a broader impact on public health."

    California, Oregon and Washington first legalized medical marijuana before 1999, with 10 more following suit between then and 2010, the time period of the analysis. Another 10 states and Washington, D.C. adopted similar laws since 2010.

    For the study, Bachhuber, of the Philadelphia Veterans Affairs Medical Center and the University of Pennsylvania, and his colleagues used state-level death certificate data for all 50 states between 1999 and 2010.

    In states with a medical marijuana law, overdose deaths from opioids like morphine, oxycodone and heroin decreased by an average of 20 percent after one year, 25 percent by two years and up to 33 percent by years five and six compared to what would have been expected, according to results in JAMA Internal Medicine.

    Meanwhile, opioid overdose deaths across the country increased dramatically, from 4,030 in 1999 to 16,651 in 2010, according to the Centers for Disease Control and Prevention (CDC). Three of every four of those deaths involved prescription pain medications.

    Of those who die from prescription opioid overdoses, 60 percent have a legitimate prescription from a single doctor, the CDC also reports.

    Medical marijuana, where legal, is most often approved for treating pain conditions, making it an option in addition to or instead of prescription painkillers, Bachhuber and his coauthors wrote.

    In Colorado, where recreational growth, possession and consumption of pot has been legal since 2012 and a buzzing industry for the first half of 2014, use among teens seems not to have increased (see Reuters story of July 29, 2014 here: http://reut.rs/1o040NI).

    Medical marijuana laws seem to be linked with higher rates of marijuana use among adults, Bachhuber said, but results are mixed for teens.

    But the full scope of risks, and benefits, of medical marijuana is still unknown, he said.

    "I think medical providers struggle in figuring out what conditions medical marijuana could be used for, who would benefit from it, how effective it is and who might have side effects; some doctors would even say there is no scientifically proven, valid, medical use of marijuana," Bachhuber said. "More studies about the risks and benefits of medical marijuana are needed to help guide us in clinical practice."

    Marie J. Hayes of the University of Maine in Orno co-wrote an accompanying commentary in the journal.

    "Generally healthcare providers feel very strongly that medical marijuana may not be the way to go," she told Reuters Health. "There is the risk of smoke, the worry about whether that is carcinogenic but people so far haven't been able to prove that."

    There may be a risk that legal medical marijuana will make the drug more accessible for kids and smoking may impair driving or carry other risks, she said.

    "But we're already developing Oxycontin and Vicodin and teens are getting their hands on it," she said.

    If legalizing medical marijuana does help tackle the problem of painkiller deaths, that will be very significant, she said.

    "Because opioid mortality is such a tremendously significant health crisis now, we have to do something and figure out what's going on," Hayes said.

    The efforts states currently make to combat these deaths, like prescription monitoring programs, have been relatively ineffectual, she said.

    "Everything we're doing is having no effect, except for in the states that have implemented medical marijuana laws," Hayes said.

    People who overdose on opioids likely became addicted to it and are also battling other psychological problems, she said. Marijuana, which is not itself without risks, is arguably less addictive and almost impossible to overdose on compared to opioids, Hayes said.

    Adults consuming marijuana don't show up in the emergency room with an overdose, she said. "But," she added, "we don't put it in Rite Aid because we're confused by it as a society."

    SOURCE: http://bit.ly/1pYZf8d JAMA Internal Medicine, August 25, 2014

  • Mammography false alarms linked with later tumor risk

    By Ronnie Cohen

    NEW YORK (Reuters Health) - Women whose screening mammograms produce false alarms have a heightened risk of being diagnosed with breast cancer years later, but the reason remains mysterious, researchers say.

    An increased risk of breast cancer among women with a "false positive" mammogram has been reported before. What's new about this study is that the authors tried to figure out how much, if any, of the extra risk is simply due to doctors missing the cancer the first time they investigated the worrisome mammogram findings.

    But mistakes from doctors missing cancers explained only a small percentage of the increased risk, according to lead author My von Euler-Chelpin, an epidemiologist from the University of Copenhagen in Denmark.

    She told Reuters Health in a telephone interview that she could not explain most of the increased risk of later breast cancer in women with false-positive mammograms. (A mammogram is considered false positive when it suggests possible breast cancer but additional screenings or a biopsy fails to find it.)

    Of more than 58,000 Danish women who had mammography between 1991 and 2005, her study identified 4,743 women with suspicious findings that were eventually declared negative.

    By 2008, 295 of those 4,743 women had been diagnosed with breast cancer, von Euler-Chelpin and colleagues reported in Cancer Epidemiology.

    Radiologists reread the original mammograms and found that doctors had actually missed the cancer in 72 of the 295 women, for a false-negative rate of 1.5 percent. Even after taking those missed cancers into account, however, the researchers found that women with false-positive mammograms were still 27 percent more likely to be diagnosed with breast cancer years later, compared to women with only negative test results.

    The risk was slightly higher in women who had surgical biopsies that turned out to be negative.

    Von Euler-Chelpin thinks a smaller percentage of American women would have an elevated risk for breast cancer after a false-positive test because the U.S. has a higher rate of false positives than Denmark. The risk of a false-positive test over 10 mammograms ranges from 58 percent to 77 percent in the U.S., while it is around 16 percent in Denmark, the study says.

    Dr. Michael Alvarado, a breast cancer surgeon from the University of California, San Francisco, agreed that the risk of being diagnosed with breast cancer after a false positive mammogram is probably lower in the U.S. than in Denmark.

    "It's hard to translate the data to the U.S. population because we have such a different screening program, we tend to biopsy everything, and we're much more aggressive," he told Reuters Health. Alvarado was not involved in the current study.

    "Is there some inherent biology of the breast that makes it suspicious and it puts you at higher risk? I don't think anyone knows what it is," he said.

    Alvarado wondered if women who get false-positive mammograms should be followed more closely by their doctors, or if false-positive patients should be screened differently.

    Von Euler-Chelpin told Reuters Health the excess rate of breast cancer among women who have had false-positive mammograms points to the need to personalize screening programs for women - and Dr. Karla Kerlikowske agreed.

    Kerlikowske, from the University of California, San Francisco, is developing a risk calculator app to guide women in deciding how often to get mammograms. The calculator considers a range of factors, including age, race, previous breast cancer, family history and breast density. Kerlikowske was not involved in the current study.

    Although having had a false-positive mammogram is associated with a woman's breast cancer risk, Kerlikowske points out that the actual risk of being diagnosed with breast cancer remains low.

    The average five-year breast cancer risk for a 50-year-old white woman with no prior family history of breast cancer is 1.25 percent, the calculator shows. It ranges from less than 1 percent, to 2.70 percent, depending upon breast density, for the same woman with a history of a prior breast biopsy, regardless of whether the biopsy was positive or negative.

    "The absolute risk is still small," Kerlikowske said. "To me, it just says, now you have this risk factor, and you have to consider it with other risk factors."

    Von Euler-Chelpin agrees.

    "This paper is one little step on the way of trying to identify high-risk groups," she said. "The goal is to find more personalized screening programs for women."

    The American Cancer Society recommends that women be screened for breast cancer every year they are in good health starting at age 40. But a growing number of researchers have questioned the benefits of annual mammograms, and since 2009 the government-backed United States Preventive Services Task Force has recommended that screening be done every two years and be generally restricted to women aged 50 to 74.

    Women in Denmark between the ages 50 to 69 are invited to have screening mammograms every other year, Von Euler-Chelpin said.

    Getting a mammogram every other year instead of annually did not increase the risk of advanced breast cancer in women ages 50 to 74, according to a study Kerlikowske published last year (see Reuters story of March 18, 2013 here: http://reut.rs/1w7CMuh).

    The recommendation to reduce the frequency and delay the start of mammography screening was based on research showing the risk of false-positive results - which needlessly expose women to the anguish of a possible breast cancer diagnosis and the ordeal of further testing - outweighed the benefits of detecting cancers earlier.

    SOURCE: http://bit.ly/1wALk81 Cancer Epidemiology, online July 14, 2014.

  • Fewer U.S. youth using sunscreen new study finds

    By David Beasley

    ATLANTA (Reuters) - Fewer U.S. teenagers are using sunscreen, even as skin cancer rates increase, a study found.

    The percentage of high school students using sunscreen dropped from 67.7% in 2001 to 56.1% in 2011, according to the study by researchers at William Paterson University in New Jersey and published August 21 in the publication Preventing Chronic Disease.

    The study analyzed survey data from high school students collected for the Centers for Disease Control and Prevention's Youth Risk Behavior Surveillance System.

    The drop in sunscreen use occurred as melanoma, the most dangerous form of skin cancer, increased 1.6% annually among men from 2001 to 2010 and 1.4% among women, the study said.

    "It's alarming," said Corey Basch, assistant professor of public heath at William Paterson and one of the study's authors. "Given that the rates of skin cancer and melanoma are going up, we would have liked to have seen sun protection measures also going up."

    The CDC recommends using sunscreen and avoiding tanning beds to avoid developing skin cancer.

    Avoiding over-exposure to the sun is particularly important during childhood and adolescence, the study said.

    The findings point to the need for a greater push to inform teenagers on the dangers of sun exposure, said Basch.

    "What we really need is to change the mindset that having this artificially tanned skin is attractive," she said.

    In Australia, a massive public information campaign called "Slip Slop Slap" included handing out free sunscreen at beaches and was effective in increasing sun protection, Basch said. Television ads showed beachgoers wearing hats and shirts.

    "Over time, it really transformed how people envisioned a beach day," Basch said. "It was no longer just frying yourself, so to speak, on a beach in a string bikini."

    While the use of sunscreen by teenagers is dropping in the United States, so is the use of indoor tanning devices, the study said.

    From 2009 to 2011, the percentage of respondents using tanning devices dropped from 15.6% to 13.3%, the study said. However, the decrease was so small that it is not considered significant, Basch said.

    SOURCE: http://1.usa.gov/1nfLiOx

    Prev Chronic Dis 2014.

Orthopedic Articles

  • Knee replacement may go poorly for people who think life isn't fair

    By Kathryn Doyle

    NEW YORK (Reuters Health) - People who tend to blame others for their suffering and think setbacks in their lives are irreparable tend to report more pain after knee replacement surgery, according to a new study.

    This is not the first time feelings of personal injustice have been tied to longer recovery times and increased disability after injury, the authors write.

    "Pain is a complex phenomenon that is influenced by biological, social, and psychological factors," said lead author Esther Yakobov, a doctoral student in clinical psychology at McGill University in Montreal.

    "Studies conducted with patients who suffer from chronic pain because of an injury demonstrated that individuals who judge their experience as unfair, focus on their losses, and blame others for their painful condition also tend to experience more pain and recover from their injuries slower than individuals who do not," she told Reuters Health by email.

    But those studies had been with victims of injuries, where externalizing blame is a bit easier than for degenerative conditions like osteoarthritis, she noted.

    For the new study, a group of 116 men and women with severe osteoarthritis, between ages 50 and 85 years old and scheduled for knee replacement surgery in Canada, first filled out questionnaires assessing perceived injustice, how much they think about or worry about pain and their fear of movement or re-injury.

    They rated their agreement with statements like, "It all seems so unfair" and "I am suffering because of someone else's negligence."

    With another clinical questionnaire the patients gauged their pain levels and physical functioning.

    After the knee replacement surgeries, which were all deemed successful, the patients rated their pain and function again at a one-year checkup.

    The more a patient agreed before surgery that life seems unfair and others are to blame for their problems, the more pain they reported experiencing one year after surgery. That was true even when age, sex, other health conditions and pre-surgery pain levels were accounted for, according to the results in the journal Pain.

    The more the patient thought about pain and felt helpless because of it before surgery, the more severe their disability during recovery seemed to be.

    "A decade ago, we reported that preoperative anxiety and depression influenced the outcome after surgery," said Dr. Victoria Brander, a physical medicine and rehabilitation specialist at Northwestern Orthopaedic Institute in Chicago.

    This new study adds to the effort to refine the concept, identifying specific psychological characteristics that serve as risk factors for complicated or painful recovery, Brander, who was not part of the new study, told Reuters Health by email.

    "All of these psychological factors point to the fact that patients who perceive themselves as helpless, those who are afraid, those who feel loss of control, have a more difficult time," Brander said.

    "The contrary is also true - patients who exhibit high levels of 'self-efficacy' (that is, patients who have a high degree of confidence in their own ability to achieve a goal) appear to do best after knee replacement," she said.

    Osteoarthritis, the wearing away of cartilage, joint lining, ligaments and bone in a joint, affects one third of people over age 65 in the U.S., according to the Centers for Disease Control and prevention.

    Knee replacement surgery can relieve pain and restore mobility, but about 20 percent of patients will have a problematic recovery or intense pain, based on previous research.

    How individuals perceive pain as just or unjust can vary widely between patients, and it can be influenced by many factors, so it's hard to say if having a more negative outlook is common or uncommon, Yabokov said.

    Researchers don't yet know if people with more negative outlooks only perceive their pain as worse than others or if their psychological state affects the physiology of healing and actually leads to more pain, she said.

    Nevertheless, findings like this suggest patients should be screened for their psychosocial outlook before surgery, she said.

    "This might suggest the usefulness of screening patients in terms of 'catastrophizing,' perceived injustice, fear of movement, and recovery expectancies before treatment or surgery," she said. "With this screening information, appropriate psychological intervention that targets specific risk factors of each patient can then be matched to patients' needs."

    SOURCE: http://bit.ly/1qOr9BB Pain, online July 25, 2014.

  • Knee replacement may go poorly for people who think life isn't fair

    By Kathryn Doyle

    NEW YORK (Reuters Health) - People who tend to blame others for their suffering and think setbacks in their lives are irreparable tend to report more pain after knee replacement surgery, according to a new study.

    This is not the first time feelings of personal injustice have been tied to longer recovery times and increased disability after injury, the authors write.

    "Pain is a complex phenomenon that is influenced by biological, social, and psychological factors," said lead author Esther Yakobov, a doctoral student in clinical psychology at McGill University in Montreal.

    "Studies conducted with patients who suffer from chronic pain because of an injury demonstrated that individuals who judge their experience as unfair, focus on their losses, and blame others for their painful condition also tend to experience more pain and recover from their injuries slower than individuals who do not," she told Reuters Health by email.

    But those studies had been with victims of injuries, where externalizing blame is a bit easier than for degenerative conditions like osteoarthritis, she noted.

    For the new study, a group of 116 men and women with severe osteoarthritis, between ages 50 and 85 years old and scheduled for knee replacement surgery in Canada, first filled out questionnaires assessing perceived injustice, how much they think about or worry about pain and their fear of movement or re-injury.

    They rated their agreement with statements like, "It all seems so unfair" and "I am suffering because of someone else's negligence."

    With another clinical questionnaire the patients gauged their pain levels and physical functioning.

    After the knee replacement surgeries, which were all deemed successful, the patients rated their pain and function again at a one-year checkup.

    The more a patient agreed before surgery that life seems unfair and others are to blame for their problems, the more pain they reported experiencing one year after surgery. That was true even when age, sex, other health conditions and pre-surgery pain levels were accounted for, according to the results in the journal Pain.

    The more the patient thought about pain and felt helpless because of it before surgery, the more severe their disability during recovery seemed to be.

    "A decade ago, we reported that preoperative anxiety and depression influenced the outcome after surgery," said Dr. Victoria Brander, a physical medicine and rehabilitation specialist at Northwestern Orthopaedic Institute in Chicago.

    This new study adds to the effort to refine the concept, identifying specific psychological characteristics that serve as risk factors for complicated or painful recovery, Brander, who was not part of the new study, told Reuters Health by email.

    "All of these psychological factors point to the fact that patients who perceive themselves as helpless, those who are afraid, those who feel loss of control, have a more difficult time," Brander said.

    "The contrary is also true - patients who exhibit high levels of 'self-efficacy' (that is, patients who have a high degree of confidence in their own ability to achieve a goal) appear to do best after knee replacement," she said.

    Osteoarthritis, the wearing away of cartilage, joint lining, ligaments and bone in a joint, affects one third of people over age 65 in the U.S., according to the Centers for Disease Control and prevention.

    Knee replacement surgery can relieve pain and restore mobility, but about 20 percent of patients will have a problematic recovery or intense pain, based on previous research.

    How individuals perceive pain as just or unjust can vary widely between patients, and it can be influenced by many factors, so it's hard to say if having a more negative outlook is common or uncommon, Yabokov said.

    Researchers don't yet know if people with more negative outlooks only perceive their pain as worse than others or if their psychological state affects the physiology of healing and actually leads to more pain, she said.

    Nevertheless, findings like this suggest patients should be screened for their psychosocial outlook before surgery, she said.

    "This might suggest the usefulness of screening patients in terms of 'catastrophizing,' perceived injustice, fear of movement, and recovery expectancies before treatment or surgery," she said. "With this screening information, appropriate psychological intervention that targets specific risk factors of each patient can then be matched to patients' needs."

    SOURCE: http://bit.ly/1qOr9BB Pain, online July 25, 2014.

  • Knee replacement may go poorly for people who think life isn't fair

    By Kathryn Doyle

    NEW YORK (Reuters Health) - People who tend to blame others for their suffering and think setbacks in their lives are irreparable tend to report more pain after knee replacement surgery, according to a new study.

    This is not the first time feelings of personal injustice have been tied to longer recovery times and increased disability after injury, the authors write.

    "Pain is a complex phenomenon that is influenced by biological, social, and psychological factors," said lead author Esther Yakobov, a doctoral student in clinical psychology at McGill University in Montreal.

    "Studies conducted with patients who suffer from chronic pain because of an injury demonstrated that individuals who judge their experience as unfair, focus on their losses, and blame others for their painful condition also tend to experience more pain and recover from their injuries slower than individuals who do not," she told Reuters Health by email.

    But those studies had been with victims of injuries, where externalizing blame is a bit easier than for degenerative conditions like osteoarthritis, she noted.

    For the new study, a group of 116 men and women with severe osteoarthritis, between ages 50 and 85 years old and scheduled for knee replacement surgery in Canada, first filled out questionnaires assessing perceived injustice, how much they think about or worry about pain and their fear of movement or re-injury.

    They rated their agreement with statements like, "It all seems so unfair" and "I am suffering because of someone else's negligence."

    With another clinical questionnaire the patients gauged their pain levels and physical functioning.

    After the knee replacement surgeries, which were all deemed successful, the patients rated their pain and function again at a one-year checkup.

    The more a patient agreed before surgery that life seems unfair and others are to blame for their problems, the more pain they reported experiencing one year after surgery. That was true even when age, sex, other health conditions and pre-surgery pain levels were accounted for, according to the results in the journal Pain.

    The more the patient thought about pain and felt helpless because of it before surgery, the more severe their disability during recovery seemed to be.

    "A decade ago, we reported that preoperative anxiety and depression influenced the outcome after surgery," said Dr. Victoria Brander, a physical medicine and rehabilitation specialist at Northwestern Orthopaedic Institute in Chicago.

    This new study adds to the effort to refine the concept, identifying specific psychological characteristics that serve as risk factors for complicated or painful recovery, Brander, who was not part of the new study, told Reuters Health by email.

    "All of these psychological factors point to the fact that patients who perceive themselves as helpless, those who are afraid, those who feel loss of control, have a more difficult time," Brander said.

    "The contrary is also true - patients who exhibit high levels of 'self-efficacy' (that is, patients who have a high degree of confidence in their own ability to achieve a goal) appear to do best after knee replacement," she said.

    Osteoarthritis, the wearing away of cartilage, joint lining, ligaments and bone in a joint, affects one third of people over age 65 in the U.S., according to the Centers for Disease Control and prevention.

    Knee replacement surgery can relieve pain and restore mobility, but about 20 percent of patients will have a problematic recovery or intense pain, based on previous research.

    How individuals perceive pain as just or unjust can vary widely between patients, and it can be influenced by many factors, so it's hard to say if having a more negative outlook is common or uncommon, Yabokov said.

    Researchers don't yet know if people with more negative outlooks only perceive their pain as worse than others or if their psychological state affects the physiology of healing and actually leads to more pain, she said.

    Nevertheless, findings like this suggest patients should be screened for their psychosocial outlook before surgery, she said.

    "This might suggest the usefulness of screening patients in terms of 'catastrophizing,' perceived injustice, fear of movement, and recovery expectancies before treatment or surgery," she said. "With this screening information, appropriate psychological intervention that targets specific risk factors of each patient can then be matched to patients' needs."

    SOURCE: http://bit.ly/1qOr9BB Pain, online July 25, 2014.

Transplant Articles

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Women’s Health Articles

  • Medicaid payouts for office visits may influence cancer screening: study

    By Kathryn Doyle

    NEW YORK (Reuters Health) - In states where Medicaid pays doctors higher fees for office visits, Medicaid beneficiaries are more likely to be screened for breast, cervical or colorectal cancer, according to a new study.

    "States tend to vary in their reimbursement rates for different types of medical care services; some states may have low reimbursements for certain services and higher reimbursements for others," said lead author Dr. Michael T. Halpern of the Division of Health Services and Social Policy Research at RTI International at Washington, D.C.

    Medicaid, a health insurance program for low-income individuals, is jointly funded by the federal government and the individual states. Each state establishes its own coverage and reimbursement policies.

    Unexpectedly, states' reimbursement rates for specific screening tests weren't always associated with an increase in screening rates, Halpern and his team found.

    There is no reason to believe that reimbursing more for a certain test would lead to that test being used less, so there's probably something else going on to explain that relationship, which was specifically true for Pap tests, Halpern told Reuters Health by email.

    Researchers analyzed Medicaid data from 2007 for 46 states and the District of Columbia.

    In states with higher payments for office visits, cancer screenings were more common. But higher payments for the screenings themselves did not always mean the screenings were performed more often, according to results published in the journal Cancer.

    Nationwide, the median Medicaid reimbursement for an office visit is $37. (In other words, half the states pay doctors less than that.) The median Medicaid reimbursement was $24 for a Pap test, which can detect early cervical cancer, and $271 for a colonoscopy.

    These tests are all recommended for the age group of the people in the study, but since some of the tests are not recommended yearly and the study only includes data from 2007, it was not clear whether the Medicaid beneficiaries were receiving guideline-based screening, Halpern said.

    State by state, when screening test reimbursement rose by 20 percent, the odds of receiving a colonoscopy increased by 1.6 percent, the odds of getting a Pap test decreased by 0.8 percent, and a mammogram might be more or less likely depending on the type and location of the screening order.

    But when reimbursement for an office visit rose by 20 percent, so did screening rates, by 2 to 8 percent.

    "Many primary care physicians do not accept Medicaid patients or are able to provide care only to limited numbers of Medicaid beneficiaries, potentially due to low reimbursements for office visits," Halpern said. "By increasing Medicaid reimbursements for primary care physician office visits, more physicians may be able to provide care for Medicaid beneficiaries, thus increasing their likelihood of receive cancer screenings."

    For screenings like colonoscopy and mammography, the primary care doctor refers the patient to another provider for those tests, so the amount Medicaid reimburses for the tests generally doesn't have a financial benefit for the referring physician, he said.

    "The finding with higher Medicaid office fees is noteworthy, because it means that higher fees open physicians' doors to Medicaid patients and that is the first step to getting patients the care they need," said Stephen Zuckerman, senior fellow and co-director of the Health Policy Center of the Urban Institute. "Cancer screening is only on part of that."

    Doctors' time is limited, and economic incentives matter to them, Zuckerman told Reuters Health by email.

    "In a system with many payers, that means that it makes sense for physicians to see patients for whom they receive better compensation before they see other patients," he said.

    Fees are not the only incentives in scheduling patients, but they do play an important role, he said.

    "Since office visit fees have the most consistent relationship to receipt of cancer screening, it would be important to make sure those fees are sufficient to get Medicaid patients appropriate access to primary care services," Zuckerman said.

    SOURCE: http://bit.ly/1tOc4l9 Cancer, online August 25, 2014.

  • After men, lesbians report the most orgasms during sex

    By Ronnie Cohen

    NEW YORK (Reuters Health) - Single lesbians report having orgasms more often than heterosexual women but both gay and straight men still come out on top of the climax chart, a new report says.

    Researchers at the Kinsey Institute for Research in Sex, Gender, and Reproduction at Indiana University in Bloomington analyzed responses from 2,850 single Americans to online questionnaires. The survey was sponsored by the online dating company Match.com, although participants were not drawn from users of the site.

    The men and women in the study ranged in age from 21 to more than 80 years old.

    Men reported having an orgasm during sex with a familiar partner 22.2 percent more often than women, the study found.

    But lesbian women said they reached climax during sex 13.1 percent more often than heterosexual women, according to the findings published in the Journal of Sexual Medicine.

    "Women's orgasms are less predictable than men's and they vary with sexual orientation and men's don't," lead researcher Justin Garcia told Reuters Health.

    In 1966, pioneering sex researchers Masters and Johnson suggested that straight men could learn a lot about how to guide their partners to orgasm from lesbian women, said Garcia, an Indiana University gender studies professor.

    Consequently, he told Reuters Health, his study's finding that lesbians have more orgasms than heterosexual women came as no surprise.

    "There are still pretty strong sexual double standards in America and they infiltrate the bedroom," he said.

    Nicole Prause, who studies human sexual behavior at the University of California, Los Angeles, agrees that sexual double standards that favor pleasuring men continue to prevail. But she questioned the validity of the current study's data on lesbians because she believes women often believe they are having an orgasm when in fact they are not.

    "I would be shocked if they're not over-counting," Prause told Reuters Health. She was not involved with the current study.

    "I don't think they're lying," she said. "I think they really believe they're having orgasm. If they're having fun, keep having fun. But there's a science issue that hasn't been addressed."

    When both men and women reach orgasm they have eight to 12 measurable contractions, Prause said. But researchers don't measure them.

    "How do women learn what an orgasm is?" she asked. "Your parents aren't talking to you about it. Where would you learn? I don't know. Maybe they're reporting orgasms just when they're having a pleasurable sensation."

    The authors of the current study say there is a dearth of data on rates of orgasm across sexual orientations.

    In the new study, single men reported experiencing orgasm during sex with a familiar partner on average 85.1 percent of the time, while women reported orgasm 62.9 percent of the time.

    Familiar partners exclude unfamiliar sexual "hookups," like those common among students on college campuses, Garcia said.

    "We know that in hookups, where men and women don't know their partners, the orgasm rates are lower," he said. It's also known that that orgasm rates are higher in men and women in committed relationships, he said.

    His data showed hardly any difference between the frequency of orgasm reported by heterosexual and gay men. Heterosexual men said they had an orgasm 85.5 percent of the time, and gay men reported orgasms 84.7 percent of the time.

    Heterosexual women reported orgasm during sex with a familiar partner 61.6 percent of the time, while homosexual women reported orgasm significantly more often - 74.7 percent of the time, the study found.

    The surprising finding for Garcia, he said, was among bisexual men and women. Compared to other men, bisexual men reported a lower, though not significantly, orgasm rate of 77.6 percent, the study found.

    Bisexual women also reported a lower rate - 58 percent - than other women.

    The reason for bisexuals' lower orgasm rates remains unclear, Garcia said. He said the data underscore the need for more information about the health of sexual minorities.

    Prause also would like to learn more about sexual minorities and orgasm. But she is skeptical about the usefulness of the current study's self-reported data.

    "I want to believe that women know their own bodies and I want to believe the lesbian effect is there. I'm glad they think they're having a better time," she said.

    Along with the disadvantage of using self-reported data, the study was also limited by the fact that participation required access to a computer. In addition, the authors note, they "did not include the categories of 'queer' or 'asexual' or a variety of other categories that more fully encompass people's sexual identities."

    Prause called for studies, like one she is doing in Pittsburgh, that actually measure orgasm contractions and check the validity of self-reports. Those studies are difficult to do, she said, because universities, including UCLA, are reluctant to allow people to reach orgasm in laboratories.

    "There's a very simple and straightforward way to measure the presence of orgasm," Prause said, "but no one's doing it."

    SOURCE: http://bit.ly/XFZHOi The Journal of Sexual Medicine, online August 18, 2014.

  • California lawmakers pass measure requiring testing of rape kits

    By Jennifer Chaussee

    (Reuters) - Amid ongoing efforts to address a backlog of unanalyzed rape kits that go untested throughout the country, California lawmakers passed a bill on Friday requiring law enforcement to process the evidence within a certain time frame.

    The bill next goes for a procedural approval in the state Assembly next week before heading to Governor Jerry Brown's desk for his signature. Brown vetoed a pilot program in 2011 that would have required certain counties to process their backlogged rape kits.

    But the latest measure, which takes a different approach by setting up a timeline for rape kit processing, received wide bipartisan support in Sacramento after several amendments extended the amount of time law enforcement would have to process the kits.

    The bill, which passed through the state Senate unanimously, would require hospitals to submit rape kits to forensic labs within five days of collecting the DNA evidence from a sexual assault victim.

    Law enforcement would have 20 days to do so. Once a forensic lab receives a rape kit, they would have 120 days to process it.

    "Testing this evidence gets the DNA from the crime into a national database, tells rape victims we care and helps ensure that rapists are caught and convicted," said state Assembly member Nancy Skinner, who authored the bill.

    Skinner's bill comes after an audit by a district attorney and local law enforcement officials found more than 1,900 unprocessed rape kits within the Bay Area's Alameda County alone.

    Rape kits holding DNA evidence that could help catch perpetrators are often left on storage shelves in police stations and labs due to funding shortages. It can cost between $1,200 and $1,500 to test a rape kit.

    California is not the first state to address backlogged rape kits statewide. Six other states have passed legislation requiring law enforcement to inventory backlogged kits. Of those states, Texas, Illinois and Colorado also require the tests to be submitted to crime labs within a certain time frame.

    In 2003, after New York City processed 17,000 backlogged rape kits, the city's arrest rate for rape went up by 30 percentage points, from 40 percent to 70 percent.

    Currently, there are an estimated 400,000 unprocessed rape kits in the United States, according to the sexual assault advocacy group End the Backlog, which lobbies for policies to expedite rape kit processing.

  • U.S. to propose birth control exception for religious companies -source

    By Caroline Humer

    (Reuters) - The Obama administration will ensure access to birth control coverage for employees of closely-held companies that object to contraception on religious grounds, proposing a new accommodation to health benefits mandated by the Affordable Care Act, a source familiar with the plan said on Friday.

    The move follows a Supreme Court ruling in June that allowed certain for-profit companies to refuse to cover contraceptives due to the religious beliefs of their owners.

    President Barack Obama's healthcare reform law requires companies to provide free birth control coverage as a preventive service included in their health plans.

    The U.S. Department of Health and Human Services had already provided an exception to non-profit groups with religious affiliations, such as certain universities or hospitals, in 2013. The exception requires insurers to cover the cost of birth control for employees of such organizations, separate from the benefits paid for by the employers.

    On Friday, it was expected to propose an extension of that rule to closely-held companies in rules published in the Federal Register, the source said.

    The rule is in direct response to the Supreme Court ruling in favor of Hobby Lobby Stores Ltd, a family-owned chain of craft stores, and Conestoga Wood Specialties Corp of Pennsylvania. The two companies combined employ nearly 14,000 people. The accommodation is expected to impact at nearly 50 additional companies who have filed similar lawsuits.

    At the time, the justices ruled that for-profit companies can make claims under a 1993 federal law called the Religious Freedom Restoration Act that was enacted to protect religious liberty. They had suggested that the government could extend the accommodation made for non-profit groups.

    HHS also proposed on Friday an interim rule for non-profits to lay out additional ways that these companies can provide notice to the government in writing of their religious objections to providing contraception coverage.

    The interim rule for non-profits is largely in response to a Supreme Court order in July, issued days after the Hobby Lobby ruling, that gave a temporary exemption to a Christian college in Illinois. It had said that the initial process for informing insurers of their religious standing also violated their beliefs.

  • Mammography false alarms linked with later tumor risk

    By Ronnie Cohen

    NEW YORK (Reuters Health) - Women whose screening mammograms produce false alarms have a heightened risk of being diagnosed with breast cancer years later, but the reason remains mysterious, researchers say.

    An increased risk of breast cancer among women with a "false positive" mammogram has been reported before. What's new about this study is that the authors tried to figure out how much, if any, of the extra risk is simply due to doctors missing the cancer the first time they investigated the worrisome mammogram findings.

    But mistakes from doctors missing cancers explained only a small percentage of the increased risk, according to lead author My von Euler-Chelpin, an epidemiologist from the University of Copenhagen in Denmark.

    She told Reuters Health in a telephone interview that she could not explain most of the increased risk of later breast cancer in women with false-positive mammograms. (A mammogram is considered false positive when it suggests possible breast cancer but additional screenings or a biopsy fails to find it.)

    Of more than 58,000 Danish women who had mammography between 1991 and 2005, her study identified 4,743 women with suspicious findings that were eventually declared negative.

    By 2008, 295 of those 4,743 women had been diagnosed with breast cancer, von Euler-Chelpin and colleagues reported in Cancer Epidemiology.

    Radiologists reread the original mammograms and found that doctors had actually missed the cancer in 72 of the 295 women, for a false-negative rate of 1.5 percent. Even after taking those missed cancers into account, however, the researchers found that women with false-positive mammograms were still 27 percent more likely to be diagnosed with breast cancer years later, compared to women with only negative test results.

    The risk was slightly higher in women who had surgical biopsies that turned out to be negative.

    Von Euler-Chelpin thinks a smaller percentage of American women would have an elevated risk for breast cancer after a false-positive test because the U.S. has a higher rate of false positives than Denmark. The risk of a false-positive test over 10 mammograms ranges from 58 percent to 77 percent in the U.S., while it is around 16 percent in Denmark, the study says.

    Dr. Michael Alvarado, a breast cancer surgeon from the University of California, San Francisco, agreed that the risk of being diagnosed with breast cancer after a false positive mammogram is probably lower in the U.S. than in Denmark.

    "It's hard to translate the data to the U.S. population because we have such a different screening program, we tend to biopsy everything, and we're much more aggressive," he told Reuters Health. Alvarado was not involved in the current study.

    "Is there some inherent biology of the breast that makes it suspicious and it puts you at higher risk? I don't think anyone knows what it is," he said.

    Alvarado wondered if women who get false-positive mammograms should be followed more closely by their doctors, or if false-positive patients should be screened differently.

    Von Euler-Chelpin told Reuters Health the excess rate of breast cancer among women who have had false-positive mammograms points to the need to personalize screening programs for women - and Dr. Karla Kerlikowske agreed.

    Kerlikowske, from the University of California, San Francisco, is developing a risk calculator app to guide women in deciding how often to get mammograms. The calculator considers a range of factors, including age, race, previous breast cancer, family history and breast density. Kerlikowske was not involved in the current study.

    Although having had a false-positive mammogram is associated with a woman's breast cancer risk, Kerlikowske points out that the actual risk of being diagnosed with breast cancer remains low.

    The average five-year breast cancer risk for a 50-year-old white woman with no prior family history of breast cancer is 1.25 percent, the calculator shows. It ranges from less than 1 percent, to 2.70 percent, depending upon breast density, for the same woman with a history of a prior breast biopsy, regardless of whether the biopsy was positive or negative.

    "The absolute risk is still small," Kerlikowske said. "To me, it just says, now you have this risk factor, and you have to consider it with other risk factors."

    Von Euler-Chelpin agrees.

    "This paper is one little step on the way of trying to identify high-risk groups," she said. "The goal is to find more personalized screening programs for women."

    The American Cancer Society recommends that women be screened for breast cancer every year they are in good health starting at age 40. But a growing number of researchers have questioned the benefits of annual mammograms, and since 2009 the government-backed United States Preventive Services Task Force has recommended that screening be done every two years and be generally restricted to women aged 50 to 74.

    Women in Denmark between the ages 50 to 69 are invited to have screening mammograms every other year, Von Euler-Chelpin said.

    Getting a mammogram every other year instead of annually did not increase the risk of advanced breast cancer in women ages 50 to 74, according to a study Kerlikowske published last year (see Reuters story of March 18, 2013 here: http://reut.rs/1w7CMuh).

    The recommendation to reduce the frequency and delay the start of mammography screening was based on research showing the risk of false-positive results - which needlessly expose women to the anguish of a possible breast cancer diagnosis and the ordeal of further testing - outweighed the benefits of detecting cancers earlier.

    SOURCE: http://bit.ly/1wALk81 Cancer Epidemiology, online July 14, 2014.