Physician's First Watch: Archives

Advanced Dementia's Course

The final stages of dementia are characterized by pneumonia, fevers, eating problems, and extremely high mortality, according to a prospective observational study in the New England Journal of Medicine.

Researchers followed over 300 patients with advanced dementia (and their healthcare proxies). Almost a quarter died within 6 months, and half within the course of the 18-month study. Infections and eating problems were common, heralding high mortality: the adjusted 6-month mortality rate for those suffering at least one episode of pneumonia was 47%; for a febrile episode, 44%; and for eating problems, 39%.

In the last 3 months of life, about 40% experienced burdensome interventions (e.g., parenteral therapy, hospitalizations, and tube feedings). Patients whose proxies believed their patients had less than 6 months to live were much less likely to undergo such interventions.

The authors write: "These findings can be used to inform families and care providers that infections and eating problems should be expected and that their occurrence often indicates that the end of life is near."

LINK(S):

NEJM article (Free abstract; full text requires subscription)

NEJM editorial (Subscription required)

Journal Watch General Medicine summary (Free)

Published in Physician's First Watch October 15, 2009

Abdominal Aortic Aneurysm: Short-Term Outcomes After Endovascular vs. Open Repair

Endovascular repair of abdominal aortic aneurysms carries a lower likelihood of perioperative death than open repair — a mortality advantage that disappears by the 2-year mark — according to an interim report of a 9-year study in JAMA.

Researchers randomized nearly 900 patients (aged 49 or older) from Veterans Affairs hospitals to either endovascular or open repair.

Mortality during hospitalization or at 30 days was significantly lower with the endovascular approach; however, at the 2-year mark, mortality did not differ significantly between the groups. In addition, the groups did not differ in self-reported measures of health-related quality of life or in the incidence of erectile dysfunction at 2 years.

LINK(S):

JAMA article (Free)

Previous Physician's First Watch coverage of endovascular repair of abdominal aortic aneurysms (Free)

Published in Physician's First Watch October 14, 2009

Cosleeping Linked to SIDS, Alcohol Also a Factor

Roughly half of infants who die of SIDS were sleeping with a parent during their last sleep, reports BMJ.

Researchers analyzed the sleeping situations of 80 SIDS infants up to age 2 years in southwest England and two groups of controls: a randomly selected group of families and a group of families with SIDS risk factors (e.g., maternal smoking, larger families, younger mothers, mothers in lower social classes).

Of the SIDS infants, 54% were cosleeping with a parent on their bed or sofa during their last sleep, compared with roughly 20% in both control groups. Parental drug and alcohol use within the past 24 hours combined with cosleeping was also more common in the SIDS group.

An editorialist says: "All health professionals should advise parents that the safest place for an infant to sleep is in [an infant bed] beside the parents' bed in the first 6 months of life."

LINK(S):

BMJ article (Free)

BMJ editorial (Subscription required)

Published in Physician's First Watch October 14, 2009

High-Intensity Exercise Reduces Fatigue in Patients Undergoing Chemotherapy

Patients undergoing chemotherapy experience less fatigue when they participate in an exercise regimen that includes high-intensity activity, BMJ reports online.

Nearly 300 adults undergoing chemotherapy for cancer at two Danish hospitals were randomized to either group exercise plus conventional care, or conventional care alone for 6 weeks. In the exercise group, patients participated in high-intensity exercise (4.5 hours weekly, including cardiovascular and resistance training), relaxation, massage, body awareness, and restorative training, for a total of 9 hours a week.

At 6 weeks, patients in the exercise group saw significant improvements in fatigue, relative to those in the control group. Exercise patients also had significant improvements in physical and emotional well-being, aerobic capacity, and muscular strength.

The authors conclude that the types of exercises used are "feasible, safe, and beneficial to various patients with cancer during chemotherapy, even patients with advanced disease."

LINK(S):

BMJ article (Free)

Published in Physician's First Watch October 14, 2009

Minimally Invasive vs. Open Radical Prostatectomy

Minimally invasive radical prostatectomy accounts for nearly half of all radical prostatectomies in the U.S., yet the procedure is associated with higher rates of some complications, according to a JAMA study.

Researchers linked federal databases to examine outcomes in some 8800 older men who underwent radical prostatectomy between 2003 and 2007. They found that the percentage of minimally invasive procedures — robot-assisted or not — increased from roughly 9% in 2003 to over 40% by 2007.

Men undergoing minimally invasive procedures were generally at a higher socioeconomic level than those undergoing the older retropubic approach; they also had shorter hospital stays and were less likely to require transfusions or have respiratory complications. However, the minimally invasive approach led to higher rates of urinary incontinence and erectile dysfunction.

The authors say their results may reflect society's infatuation with a new technology that increased costs and had yet to "realize marketed or potential benefits during early adoption."

LINK(S):

JAMA article (Free abstract; full text requires subscription)

Published in Physician's First Watch October 14, 2009

Clinicians Cautioned Against Using Zanamivir Inhalation Powder in Mechanical Ventilators

One patient has died after being given zanamivir (Relenza) inhalation powder that was solubilized and delivered through mechanical ventilation, the FDA reports.

The patient, a pregnant woman living outside the U.S., was given the drug via nebulizer for 3 days. She died after the ventilator became obstructed by apparent "stickiness caused by lactose" in the inhalation powder, according to the manufacturer.

The manufacturer and the FDA remind clinicians that the drug is not meant to be "reconstituted in any liquid formulation and is not recommended for use in any nebulizer or mechanical ventilator." Zanamivir is indicated for prophylaxis and treatment of influenza A and B.

LINK(S):

FDA alert (Free)

Manufacturer letter to healthcare professionals (Free PDF)

Published in Physician's First Watch October 13, 2009

Intimate Partner Violence Linked to Increased Risk for Medical and Psychosocial Diagnoses

Women who've recently experienced intimate partner violence (IPV) are more likely to have mental, musculoskeletal, reproductive, and other diagnoses, reports Archives of Internal Medicine.

Some 3600 randomly selected women from a U.S. health plan completed telephone surveys about IPV. Eight percent reported IPV within the past year; their medical records from the previous year were then compared with those of women who had never experienced IPV.

In age-adjusted analyses, recent IPV was associated with increased risk for numerous diagnoses, including:

• musculoskeletal conditions (e.g., low back pain, acute sprains);
  
• psychosocial problems (e.g., anxiety, substance use, depression);
  
• reproductive diagnoses (e.g., vaginitis, menstrual disorders);
  
• lacerations;
  
• sexually transmitted infections.
  

The authors say their findings suggest that certain diagnoses, including those listed above, "may be important indicators for screening women for IPV."

LINK(S):

Archives of Internal Medicine article (Free abstract; full text requires subscription)

Published in Physician's First Watch October 13, 2009

Breast Tenderness After Starting Combination Hormone Therapy May Indicate Higher Breast Cancer Risk

Postmenopausal women who experience new-onset breast tenderness after starting combination hormone therapy may face increased risk for breast cancer, according to an Archives of Internal Medicine study.

Researchers examined data on some 17,000 Women's Health Initiative participants who were randomized to receive estrogen-progestin or placebo daily. In the hormone group, women with new-onset breast tenderness at 12 months were about 50% more likely to be diagnosed with breast cancer during 5.6 years' follow-up, relative to those without tenderness. (There was no such association among placebo recipients.)

The sensitivity and specificity of breast tenderness for predicting cancer risk were 41% and 64%, respectively — which, the authors say, are similar to values for the Gail model.

The authors note that hormone-induced elevations in serum estrone and estrone sulfate might lead to increased breast tenderness and heightened cancer risk. They add that their findings "should be considered by ... prescribing physicians to inform decisions regarding continued combined hormone therapy."

LINK(S):

Archives of Internal Medicine article (Free)

Published in Physician's First Watch October 13, 2009

H1N1 Update: CDC Releases 2009 H1N1 Vaccine Schedules

Children aged 6 months through 9 years should receive two doses of 2009 H1N1 vaccine roughly 4 weeks apart, the CDC announced in MMWR.

The report details the differing age-range approvals for the manufacturers:

• CSL's vaccine is approved for use in people 18 years and older (one dose, IM);
  
• Novartis', for ages 4 and up (one dose, IM, except for children under 10, who get two);
  
• Sanofi Pasteur's, for ages above 6 months (one dose, IM, except for children under 10);
  
• MedImmune's, for ages 2 to 49 (one dose, intranasally, except for children under 10).
  

The injectable formulations are adjuvant-free and contain inactivated virus; the intranasal formulation contains live attenuated virus and shouldn't be administered to children under 2, adults over 49, pregnant women, people with medical conditions that put them at higher risk for flu complications, and children under 5 who've had a wheezing episode within a year. All the vaccines contain egg protein, and the article's table provides details on those containing mercury.

LINK(S):

MMWR article (Free)

ACIP recommendations on vaccine priority groups (One-time registration required)

NEJM/Journal Watch H1N1 Influenza Center (Free)

Published in Physician's First Watch October 9, 2009

Herpes Zoster Linked to Increased Risk for Stroke

A patient's risk for stroke increases during the year after a herpes zoster attack, according to a retrospective study published online in Stroke.

Using a national database, researchers in Taiwan examined the incidence of stroke in some 7800 adults who had herpes zoster attacks and 23,000 matched controls. During 1 year of follow-up, stroke occurred in 1.7% of zoster patients and 1.3% of controls (adjusted hazard ratio, 1.3). Patients with zoster and ophthalmic complications were at especially high risk (adjusted HR, 4.3).

The association between zoster and stroke was limited to patients aged 45 and older.

The authors write: "Although varicella zoster virus vasculopathy is a well-documented complication ... it does not fully account for the unexpectedly high risk of stroke in these patients."

LINK(S):

Stroke article (Free abstract; full text requires subscription)

Published in Physician's First Watch October 9, 2009