Thursday, May 19, 2011

Troponin Rise After PCI Signals Higher Mortality Risk

From Heartwire
Sue Hughes

May 17, 2011 (New York, New York) — Troponin elevations following elective PCI are associated with an increase in long-term mortality, according to a new meta-analysis. The authors suggest that more intensive treatment of patients with raised troponin levels post-PCI may lead to improved long-term outcomes.

The meta-analysis, published online May 13, 2011 in Catheterization and Cardiovascular Interventions, was conducted by a team led by Dr Dmitriy N Feldman (Weill Cornell Medical College, New York).

Feldman explained to heartwire that the issue of whether postprocedure troponin rises are associated with worse long-term outcomes has been the subject of controversy for many years.
He noted that troponins are more sensitive and specific markers of myocardial necrosis than creatine kinase and are essential in establishing diagnosis as well as predicting prognosis in patients with suspected ACS.
But their role in predicting prognosis in elective-PCI patients is not so well defined.

The authors point out that while large increases in creatine kinase after elective PCI are associated with an increase in in-hospital adverse cardiac events and reduced long-term survival, the association between troponin elevation after elective PCI and long-term cardiac events is not so well established.

To look at this issue further, they performed a meta-analysis of 22 studies, involving 22 353 patients, reporting on the prognostic impact of cardiac troponin T or troponin I elevation after elective PCI and published between 1998 and 2009.

Results showed that postprocedural troponin T was elevated in 26% of patients and troponin I was increased in 34% of patients. The long-term all-cause mortality in patients with raised troponins was significantly higher when compared with patients without troponin rises. In addition, the combination of all-cause mortality/MI was also higher.

Feldman said the reason for this association is not completely clear, but it is thought that patients who have these increases have a higher plaque burden and there is therefore a greater likelihood of plaque being dislodged during the PCI and traveling downstream to block small arterioles causing myocardial necrosis.
It may also be the result of resistance to aspirin and/or clopidogrel so platelets are more active and lodge in small vessels.

Asked what recommendations he would make on the basis of these new results, Feldman said ideally there should be a study showing that more aggressive treatment in patients with raised troponin levels improved outcomes, but such a study is not planned at present.

He noted that ACC/AHA guidelines recommend routine measurement of cardiac enzymes post-PCI (class 2A recommendation), but not all hospitals do this. Feldman commented to heartwire : "Our results suggest that there is value in measuring postprocedure troponin. This can identify higher-risk patients who need to be followed more closely and treated more aggressively." He added that patients with raised troponin following a previous PCI could be given more aggressive antithrombotic therapy if undergoing a subsequent procedure.

Cervical Cancer Screening Every 3 Years for Most Women

From Medscape Medical News
Roxanne Nelson

May 19, 2011 — A single test for the human papillomavirus (HPV) was found to be superior in predicting cervical cancer or high-grade cervical intraepithelial neoplasia than a single Pap test, according to a new study.

The results, which were highlighted at a press briefing held in advance of the annual meeting of the American Society of Clinical Oncology (ASCO), confirmed that for women with a negative HPV test and normal cytology, a 3-year follow-up appears to be safe and appropriate.

Women who tested negative for HPV had a 5-year cancer risk that was similar to those who tested negative for HPV and had normal cytology (3.8 vs 3.2 per 100,000 women per year; P = .8). This was half the cancer risk of women who had a negative result on Pap testing only (3.8 vs 7.5 per 100,000 women per year; P = .3).

Concurrent HPV testing and cervical cytology (cotesting) is an approved and promising alternative to cytology alone in women 30 years and older. Screening guidelines from organizations such as the American College of Obstetricians and Gynecologists and the American Cancer Society have endorsed the use of cotesting in this age group as a safe alternative to Pap testing alone.

Safety Data Lacking

However, the authors note that broad acceptance of cotesting has been hindered by a lack of evidence supporting its performance in routine clinical practice, especially related to the safety of 3-year screening intervals for women who test negative for HPV and have normal cytology results.

"Data are lacking on the safety of these guidelines in routine clinical practice," said lead author Hormuzd Katki, PhD, from the division of cancer epidemiology and genetics at the National Cancer Institute (NCI). "In particular, we need to know the actual cancer rates with cotesting, especially for women who test negative for HPV and have a normal Pap test."

Dr. Katki noted that his group at the NCI has been collaborating with Kaiser Permanente in Northern California, which began a cotesting program in 2003. In their study, Dr. Katki and colleagues obtained data on 331,818 women 30 years and older who enrolled in Kaiser's cotesting program from 2003 to 2005, and who were followed through 2009.

The women were categorized by their HPV and Pap test results at enrollment, explained Dr. Katki. "Then we estimated 5-year cumulative rates of cervical precancer and cancer."

5-Year Risk for Cancer/Precancer by Test Results
Test Results 5-Year Risk (%) Excess Risk (%)
HPV positive 7.6 7.4
HPV negative 0.2
Pap positive 4.7 4.3
Pap negative 0.4
HPV positive/Pap positive 12.0
HPV positive/Pap negative 6.0
HPV negative/Pap positive 0.9
HPV negative/Pap negative 0.2

Pap Test Not Obsolete

HPV testing identified more women who were at high risk for cervical cancer than Pap testing. "Women who tested HPV positive at enrollment had higher 5-year risks of developing cervical cancer or precancer than women with an abnormal Pap test at enrollment," said Dr. Katki, "and vice versa. Women who tested HPV negative had a lower risk of developing cancer or precancer" than those who had normal cytology results.

This shows that the HPV test is better able to separate those who are at high risk for cancer from those who are at low risk, he noted.

But Dr. Katki emphasized that the Pap test is not useless. Pap tests remain useful for triaging women with positive HPV tests, and can identify women with immediate disease.

Dr. Katki concluded that this study shows that a negative HPV test provides 5 years of an extremely low risk for cancer; the risk was not appreciably lowered by a negative Pap test. The data suggest that all women who test negative for HPV can safely extend their screening interval to at least 3 years.

"The data presented us with a strong hypothesis that will need to be tested in practice: Instead of doing cotesting, we could do HPV testing," and ask those with negative results to extend their screening interval to at least 3 years, Dr. Katki explained.

"Pap testing would then be reserved only for those in the HPV-positive population," he said. "In the Kaiser population, this would have reduced the number of Pap tests by 95% and could potentially retain all of the safety of cotesting."

Real-World Data

Comoderator George W. Sledge Jr, MD, president of ASCO, noted that he found this to be a "wonderful population-based study from a large real-world experience."

"It also tells us not just where we're going with cervical cancer, but perhaps with cancer screening in general," said Dr. Sledge, who is Ballve-Lantero Professor of Oncology and professor of pathology and laboratory medicine at the Indiana University School of Medicine, Indianapolis. "It is a switch from our classic approach of using now-ancient techniques of cytopathology to more molecular-based techniques that allow us to actually look at the specific cause of cancer in patients with cervical carcinoma."

Dr. Sledge noted that he "suspects that we'll see this again and again as we look at screening going forward for other diseases."

"This is going to be increasingly important — not just to medical oncologists, but also to all those who take care of these women," he said.

Annual Meeting of the American Society of Clinical Oncology. Abstract 1508. To be presented June 6, 2011.

Tuesday, May 10, 2011

Even Short-Term NSAID Use Risky in Cardiac Patients

From Medscape Medical News > Neurology

Megan Brooks

May 9, 2011 — In patients with prior myocardial infarction (MI), most nonsteroidal anti-inflammatory drugs (NSAIDs), even when taken for as little as 1 week, are associated with an increased risk for death and recurrent MI, new observational data indicate.

Use of NSAIDs was associated with a 45% increased risk for death or recurrent MI in the first 7 days of treatment and a 55% increased risk if treatment continued to 3 months. The findings were published online May 9 in Circulation.

"We found that short-term treatment with most NSAIDs was associated with increased and instantaneous cardiovascular risk," first author Anne-Marie Schjerning Olsen, MB, from Copenhagen University in Hellerup, Denmark, told Medscape Medical News.
Dr. Anne-Marie Schjerning Olsen

"Our results indicate that there is no apparent safe therapeutic window for NSAIDs in patients with prior MI and challenge the current recommendations of low-dose and short-term use of NSAIDs as being safe," she said.

Results 'Completely Consistent' With 2007 AHA Advisory

In a 2007 scientific statement, the American Heart Association (AHA) advised clinicians about the risks of NSAID use among patients with known cardiovascular disease or those at risk for ischemic heart disease and provided a stepped-care approach for use of these agents in this patient population.

Asked to comment on the new study, Elliott Antman, MD, from Brigham and Women's Hospital and Harvard Medical School in Boston, Massachusetts, and lead author of the 2007 advisory, said, "Essentially, what this paper shows is that there is a gradient of risk among NSAIDs; some are associated with more risk than others; none appear to be completely safe, and the researchers could not identify a period that appeared to be safe, no matter how short."

"This is completely consistent with the advice that we put forward in 2007, which is to use the safest drug, in the lowest dose required to control musculoskeletal symptoms, for the shortest period of time," Dr. Antman told Medscape Medical News.

"We do have to be practical here," Dr. Antman said, "because despite very best efforts with physical therapy and nonpharmacologic treatments, there are individuals who have severe, debilitating arthritis, lupus, or rheumatoid arthritis and we do have to have a treatment plan for those patients." The AHA's stepped-care approach provides such a plan, Dr. Antman noted.

First Time-to-Event Analysis

Using the Danish National Patient Registry, Dr. Olsen and colleagues identified 83,675 patients who were admitted to a hospital with a first MI between 1997 and 2006 and were discharged alive. Their average age was 68 years, and 63% were men.

At least 1 prescription claim for NSAID treatment after discharge was identified for 35,405 patients (42.3%), most commonly ibuprofen (23%) and diclofenac (13.4%). The most commonly prescribed selective cyclooxygenase (COX)-2 inhibitors were rofecoxib (4.7%) and celecoxib (4.8%).

During the observation period, 35,257 deaths or recurrent MIs (42.1%) were registered in the database. According to the investigators, the risk for death or recurrent MI was elevated at the beginning of NSAID treatment (hazard ratio [HR], 1.45; 95% confidence interval [CI], 1.29 - 1.62) and the risk persisted throughout treatment (HR after 90 days, 1.55; 95% CI, 1.46 - 1.64).

Particularly worrying was the fact that…diclofenac was associated with early and higher cardiovascular risk than…rofecoxib, which was withdrawn from the market in 2004 due to its unfavorable cardiovascular risk profile.

All NSAIDs, except naproxen, were associated with an increased risk for death or recurrent MI, with diclofenac having the highest risk (HR in the first week of treatment, 3.26; 95% CI, 2.57 - 3.86).

"Particularly worrying," Dr. Olsen told Medscape Medical News, "was the fact that the widely used nonselective NSAID diclofenac was associated with early and higher cardiovascular risk than the selective COX-2 inhibitor rofecoxib, which was withdrawn from the market in 2004 due to its unfavorable cardiovascular risk profile."

"The accumulating evidence suggests that we must limit NSAID use to the absolute minimum in patients with established cardiovascular disease," she added.

"If NSAID therapy is necessary for patients with known cardiovascular disease, the doctors should choose a more selective COX-1 inhibitor in minimum dose (eg, naproxen ≤ 500 mg daily or ibuprofen ≤ 1200 mg daily) for the shortest period of time," she added.

Dr. Antman said this paper provides a "good reminder" for clinicians and patients about the risks of NSAIDs in this patient population.

"Many of the drugs that we are talking about," he noted, "can be obtained over-the-counter, and it is the presumption of many patients that if it is a drug that they can get over-the-counter it must be 'safer.' Very often they don't report those medications to their physician when they go for an office visit."

The authors and Dr. Antman have reported no relevant financial relationships.

Circulation. Published online May 9, 2011. Abstract

Monday, May 9, 2011

AAP Issues Guidelines on Chaperone Use During Pediatric Exam

From Medscape Education Clinical Briefs
News Author: Laurie Barclay, MD
CME Author: Penny Murata, MD

April 27, 2011 — Using a chaperone during a pediatric physical examination should be a shared decision between the patient and pediatrician, according to the revised policy statement of the American Academy of Pediatrics (AAP) reported online April 25 and published in the May print issue of Pediatrics. The new guidelines, entitled "Use of Chaperones During the Physical Examination of the Pediatric Patient," highlight issues of patient comfort, privacy, and confidentiality.

"In the medical office setting, the physical examination of an infant, toddler, or child should always be performed in the presence of a parent or guardian," write Edward S. Curry, MD, FAAP, from the AAP Committee on Practice and Ambulatory Medicine, and colleagues.
"If a parent or guardian is unavailable or the parent's presence will interfere with the physical examination, such as in a possible case of abuse or parental mental health issues, a chaperone should be present during the physical examination.
If the patient is an adolescent or young adult and the examination requires inspection or palpation of anorectal or genital areas and/or the female breast, a chaperone is recommended."

In some states, the use of a chaperone during pediatric examinations is required by state regulations. In all cases, physicians should discuss in advance the scope, nature, and purpose of the physical examination to be performed with the pediatric patient, provided the child is old enough to understand, and/or his or her parent. Every effort should be made, such as using gowns or drapes to protect privacy, to relieve the physical or psychological discomfort of some examination procedures.

A nurse or medical assistant, rather than a friend or family member, is preferred as a chaperone during female breast, genital, or anorectal examinations, but offices are not required to have a chaperone.

Situations may arise in which a chaperone is not present because of patient preference or because a chaperone from the office is unavailable.

Situations in which a physician may request the presence of a chaperone may include evidence of mental health issues in the patient or parent; developmental issues; or the presence of anxiety, tension, or reluctance regarding the examination.

"For the rare situation in which the patient refuses an appropriate chaperone and the physician is concerned that providing the examination might result in false allegations or medicolegal risk, the physician is not obligated to provide further treatment," the statement authors write.

"...If a medical chaperone is indicated and the patient refuses, the patient or parent should be given alternatives, including seeking care elsewhere. Pediatricians should develop policy about the use of chaperones in the office or clinic setting and document in the medical record if they are unable to adhere to the policy or state medical board regulations."

Pediatrics. Published online April 25, 2011. Full text

Sunday, May 8, 2011

A1C Not Reliable for Diabetes Screening in Pediatric Population

From Reuters Health Information

By Bob Saunders

NEW YORK (Reuters Health) May 04 2011- Hemoglobin A1c (A1C) levels are not sensitive or specific enough to be used to identify children and adolescents with or at risk for diabetes, according to a report in Diabetes Care online April 22.

"Our results suggest that, although A1C could be used as a clinical tool to identify type 2 diabetes, along with fasting and 2-h glucose, the use of A1C alone to pinpoint prediabetes and type 2 diabetes is not recommended," stated Dr. Sonia Caprio in an email to Reuters Health.

She and her colleagues explain that the American Diabetes Association has recommended the use of A1C to diagnose diabetes and prediabetes, based on studies in adults.
With the increase in childhood obesity it has become critical to identify those conditions in young individuals, but little is known about the use of A1C for screening the pediatric population.

Dr. Caprio, at Yale University School of Medicine in New Haven, Connecticut, and colleagues therefore studied that strategy in a multiethnic group of 1156 obese children and adolescents.
All the subjects underwent an oral glucose tolerance test (OGTT) and measurement of their A1C.

Based on an A1C <5.7%, 77.2% were classified as normal; 21.4% with an A1C of 5.7-6.4% were considered at risk for diabetes; and 1.4% with A1C levels >6.5% were given a diagnosis of diabetes.

However, there was poor agreement between A1C and OGTT criteria in classifying subjects.

Based on the OGTT result, 27% of those in the normal A1C category had prediabetes, according to the report.
On the other hand, only 47% of those in the at-risk A1C group actually had OGTT values indicating prediabetes or diabetes.
In the highest A1C strata, 12.5% had a normal glucose tolerance test, 24% had prediabetes and 62% did have type 2 diabetes.

The researchers calculated that the best A1C level for identifying prediabetes was 5.5%, but this had only a specificity of 59.9% and sensitivity of 57.0%.
The optimal A1C threshold for identifying type 2 diabetes was 5.8%, yielding a specificity and sensitivity of 87.6% and 67.7%, respectively.

"Given the low sensitivity and specificity, the use of A1C by itself represents a poor diagnostic tool for prediabetes and type 2 diabetes in obese children and adolescents," Dr. Caprio and colleagues conclude.

"Our data are in agreement with those who reported using the National Health and Nutrition Examination Survey of 14,611 individuals aged 20 years, clearly showing that an A1C of 6.5% has a lower capacity to detect prediabetes and undiagnosed type 2 diabetes than the OGTT," added Dr. Caprio.

Asked if all obese youngsters should therefore be screened with an OGTT, she replied, "The OGTT should be performed in those obese children/adolescents with a strong family history of diabetes or gestational diabetes, signs of insulin resistance such as acanthosis nigricans, elevated triglycerides and fatty liver disease."

The authors of the report call for prospective studies to look at the utility of A1C measurements in children and adolescents for predicting diabetes-related comorbidities later in life.

SOURCE: http://bit.ly/j7W52u

Diabetes Care 2011.

Wednesday, May 4, 2011

The Overactive Bladder

From Therapeutic Advances in Urology
Posted: 03/11/2011; Ther Adv Urol. 2010;2(4):147-155

Richard Foon, MRCOG; Marcus J. Drake, MA, DM, FRCS (Urol)

Abstract

Urinary urgency and the associated symptoms which comprise overactive bladder are prevalent amongst the general population and adversely affect quality of life. Disease management consists of a sequential series of options starting with behavioural and lifestyle techniques, pharmacological management (antimuscarinics) and, in severe cases, surgical treatment (urinary diversion, neuromodulation, augmentation cystoplasty and detrusor myectomy).
There is increasing recognition of pathophysiological mechanisms in the urothelium, interstitial cells and afferent neurons allowing the importance of peripheral integrative interaction to be identified. The hierarchy of the central nervous system control adds additional complexity to understanding the oflower urinary tract function. Some newer methods of treatment include Botulinum toxin A intramural injections, oral beta-3 adrenergic agonists and rho-kinase inhibitors. The lack of a disease generating hypothesis, the lack of animal models for disease and the subjective nature of the central symptom (urgency) still pose considerable theoretical and scientific hurdles that need to be overcome in the treatment of this condition.
Introduction

Overactive bladder syndrome (OAB) is the presence of urinary urgency, usually with frequency and nocturia, in the absence of other causes of similar symptoms.
It is essential to consider urinary tract infection or pelvic malignancy as a potential cause. The following are definitions of some of the key terms [Abrams et al. 2002]:

1. Urgency: the complaint of a sudden compelling desire to pass urine, which is difficult to defer.
2. Detrusor overactivity (DO): a urodynamic observation characterized by involuntary detrusor contractions during the filling phase, which may be spontaneous or provoked (Figure 1).
3. Increased daytime frequency: a complaint by the patient who considers that he/she voids too often by day.
4. Nocturia: the complaint that the individual has to wake at night one or more times to void.

If there is associated urgency incontinence, the term 'OAB wet' can be used; if there is no urgency incontinence then the term 'OAB dry' is appropriate [Stewart et al. 2003].
Urgency is the symptom with greatest impact on quality of life [Coyne et al. 2008] and hence is one of the main issues with regards to the clinical management.
It is important to note that not all patients present with both frequency and urgency. In fact, frequency might in some people be a compensatory mechanism by which the bladder is prevented from filling to a volume where urgency occurs.
As a result some patients may present with minimal urgency, despite urgency being the defining symptom of OAB; they will, though, manifest frequent voiding of small volumes.

Lower urinary tract symptoms (LUTS) in general are highly prevalent [Coyne et al. 2009] while it is estimated that the prevalence of OAB is approximately 12%, increasing with age, and somewhat similar prevalence in males and females [Irwin et al. 2006]. As far as the financial cost is concerned, OAB has a significant impact, costing billions of euros for clinical, social and occupational management [Reeves et al. 2006].

rest of article - http://www.medscape.com/viewarticle/738698_8

Conclusions

Conservative management, supplemented by antimuscarinic drugs, should be instigated following simple evaluation. Where symptoms persist, urodynamic diagnosis is appropriate. A number of invasive treatments are available, but the evidence base is patchy and potential morbidity and cost can be substantial. Development of new treatments based on a growing wealth of experimental data is promising, but many challenges remain.

Negative Stress Test May Not Rule Out Acute Coronary Syndrome

From Medscape Emergency Medicine > Viewpoints Posted: 03/17/2011

Amal Mattu, MD

Introduction

Cardiac stress testing is an important element in risk stratification of patients and prediction of future cardiac events.
However, the utility of a recent negative stress test (ST) is limited when it is used to determine the risk for acute coronary syndrome (ACS) in a patient presenting to the emergency department with symptoms of angina.
Almost every experienced emergency physician has cared for patients with true ACS or even primary cardiac arrest despite having a recent negative ST.
Unfortunately, overreliance on negative tests, especially STs, is a common reason for misdiagnosis or delays in diagnosis in patients with ACS.
The study by Walker and colleagues has provided us with a nice reminder that negative STs are certainly not a guarantee of cardiac health.

Coronary Disease in Emergency Department Chest Pain Patients With Recent Negative Stress Testing

Walker J, Galuska M, Vega D
West J Emerg Med. 2010;11:384-388

The authors performed a retrospective chart review of adult patients who presented to their community-based teaching hospital with a chief complaint of chest pain and who had a negative or inconclusive most-recent ST within the preceding 3 years. Various types of STs were included (treadmill ECG study, treadmill echocardiogram, treadmill nuclear study, pharmacologic echocardiogram, pharmacologic nuclear study).
Patients were excluded if they had undergone cardiac catheterization or coronary artery bypass graft surgery between the time of their most recent ST and their emergency department visit.
Patients were then evaluated for significant coronary artery disease (CAD) within 30 days of the emergency department visit.
Significant CAD was defined as an acute myocardial infarction with positive cardiac biomarkers, subsequent positive ST (of any type), cardiac catheterization requiring intervention, coronary artery bypass graft surgery, or death as a result of medical cardiac arrest.

A total of 164 patients were evaluated; 34 (20.7%) of these patients had CAD. There was no significant difference between the patients with true negative ST vs inconclusive ST: 122 patients had negative ST, of which 25 (20.5%) had CAD, and 42 patients had inconclusive STs, of which 9 (21.4%) had CAD.
Of the 34 patients who had CAD, 16 (47.0%) had their most recent ST within 6 months of admission, and 8 (23.5%) had their most recent ST within 1 month of admission.

Viewpoint

The key takeaway point from this study is very simple and provides confirmation of the anecdotal experience of seasoned emergency physicians: a recent negative ST does not exclude ACS in patients presenting with anginal symptoms.
It is critical to remember that cardiac tests (ECGs, troponins, STs, and even coronary angiography) are useful for risk stratification, but no test is capable of stratifying a patient's risk to zero.
Patients presenting with a history of a present illness that is strongly suggestive of ACS should be treated conservatively with a repeat workup if necessary -- that recent negative ST should never obviate your concern!

Automated vs. Manual BP Monitoring for Systolic Hypertension

From Journal Watch > Journal Watch © 2011 Massachusetts Medical Society

Paul S. Mueller, MD, MPH, FACP

Posted: 03/14/2011;

Abstract
Automated blood pressure monitoring was more accurate.

Introduction

Office manual blood pressure (BP) monitoring is fraught with problems, including variable BP measuring skills among healthcare workers, "white-coat hypertension," and digit preference (readings ending in "0").
In this trial, Canadian investigators randomized 67 primary care practices to use either ongoing manual office BP monitoring (control) or automated office BP monitoring using the BpTRU device (intervention; after the BpTRU cuff is positioned properly, the patient is left alone, and the device automatically takes five BP readings and displays an average).
Awake ambulatory BP monitoring was the gold standard.

Overall, 555 patients with systolic hypertension participated in the study. Compared with manual office BP readings, automated office BP readings correlated more strongly with ambulatory BP monitoring.
For example, the mean manual office systolic BP after enrollment was 6.5 mm Hg higher than ambulatory BP, whereas mean automated office systolic BP was only 2.3 mm Hg higher than ambulatory BP; this difference was significant.
For diastolic BP, mean automated and manual office measurements were both about 4 mm Hg higher than ambulatory measurements. Another striking finding was a fall in automated systolic BP while the patient rested in the exam room:
Mean systolic BP fell from 147 to 133 mm Hg during a 10-minute period.

Comment

Automated BP monitoring (with multiple readings taken while the patient is resting) is more accurate than manual BP monitoring in primary care patients with systolic hypertension.
The results have obvious clinical implications, such as limiting unnecessary treatment. Indeed, several years ago, my institution systematically eliminated manual BP monitoring in favor of automated BP monitoring.