Physician's First Watch: Archives

HPV Vaccination for Boys Not Cost Effective

Vaccinating boys against human papillomavirus (HPV) is not likely to be cost effective on a population level, according to a BMJ analysis based on disease-simulation models.

When 12-year-old boys were added to a U.S.-based HPV vaccination program for girls, researchers estimated a cost of over $100,000 per quality-adjusted life year (QALY) gained for most scenarios.

The researchers conclude: "Including boys in an HPV vaccination programme generally exceeds conventional thresholds of good value for money."

LINK(S):

BMJ article (Free)

BMJ editorial (Subscription required)

Previous Physician's First Watch coverage of FDA advisory panel recommending HPV vaccine for boys (Free)

Published in Physician's First Watch October 9, 2009

A Third of Patients with Chronic Back Pain Recover Within a Year

A third of patients may completely recover from chronic lower back pain by 9 months, according to a BMJ study.

Researchers enrolled some 400 patients who presented to general practitioners, physiotherapists, or chiropractors soon after experiencing low back pain and who had persistent pain at 3 months. The patients were followed for 1 year. By 9 months, some 35% had fully recovered (i.e., they were pain-free, had no back-related disability, and had fully returned to work), and by 12 months, 41% had.

The following groups were at increased risk for delayed recovery: those with previous sick leave related to low back pain, high disability levels at enrollment, lower education levels, and a higher perceived risk for persistent pain.

LINK(S):

BMJ article (Free)

Published in Physician's First Watch October 8, 2009

H1N1 Update: No Resurgence — Yet — in Cities Hardest Hit Last Spring

Patients may ask about an article in this morning's New York Times that some cities are reporting near-normal levels of flu activity for this time of year. The cities were those hardest hit at the outset of the pandemic.

New York, which had widespread school closures in the spring, is reporting normal attendance, according to the Times. The same holds true for Boston and Philadelphia. One theory to explain the relative lack of flu in these cities — as opposed to the rest of the country where activity is widespread — is that the earlier outbreaks conferred enough "herd immunity" to protect them now. The theory was put forward by New York City's health commissioner at a national flu meeting last week.

Others aren't so sure. The Times quotes one CDC researcher who says it's "an interesting hypothesis, with biological plausibility," but that only time would tell whether it's accurate.

LINK(S):

New York Times story (Free)

CDC's summary of current flu activity (Free)

NEJM/Journal Watch H1N1 Influenza Center (Free)

Published in Physician's First Watch October 8, 2009

ICDs Offer No Survival Advantage Early After Myocardial Infarction

Using implantable cardioverter-defibrillators (ICDs) in high-risk patients early after myocardial infarction confers no survival advantage, reports the New England Journal of Medicine.

Researchers narrowed down a large group of patients from European centers who'd had an MI to some 900 patients at increased risk for death. The patients either had reduced ejection fractions and an increased heart rate, or had nonsustained ventricular tachycardia during Holter monitoring, or both. At an average of 2 weeks after MI, half were randomly allocated to receive ICDs in addition to the medical therapy received by controls.

After a mean 37 months' follow-up, ICD recipients showed no overall survival advantage. The ICD group had significantly fewer sudden cardiac deaths — an advantage offset by their significantly higher rate of nonsudden cardiac deaths.

In Journal Watch Cardiology, Dr. Mark S. Link speculates: "Perhaps complications of the procedure or adverse effects of ventricular pacing or ICD shocks on heart failure increase nonarrhythmic mortality."

LINK(S):

NEJM article (Free abstract; full text requires subscription)

NEJM editorial (Subscription required)

Journal Watch Cardiology summary (Your Journal Watch subscription required)

Published in Physician's First Watch October 8, 2009

Early Treatment with Glatiramer Acetate May Delay Clinically Definite MS

Early treatment with glatiramer acetate may delay the onset of clinically definite multiple sclerosis, according to an industry-funded study published online in Lancet.

Nearly 500 adults with clinically isolated syndrome (defined as one unifocal neurologic event plus at least two lesions 6 mm or larger on brain MRI) were randomized to receive daily injections of glatiramer acetate or placebo. During 3 years' follow-up, clinically definite MS was diagnosed significantly less often with glatiramer acetate than with placebo (25% vs. 43% of patients). The number needed to treat was 5.5.

The most common adverse events with active treatment were injection-site reactions.

The authors say their study "establishes glatiramer acetate as an option for patients with clinically isolated syndrome who choose to start treatment early to improve control of the underlying disease process."

LINK(S):

Lancet article (Free abstract; full text requires subscription)

Lancet comment (Subscription required)

Published in Physician's First Watch October 7, 2009

H1N1 Update: CDC Offers Reassurance on Vaccine Safety and Availability

The CDC addressed fears over 2009 H1N1 vaccine safety and availability at a press briefing Tuesday.

CDC Director Thomas Frieden addressed "three major concerns that people have" — that 2009 H1N1 is "just a mild illness"; that the vaccine may not be safe; and that it's already too late to be vaccinated.

Dr. Frieden countered with a reminder that 2009 H1N1 has killed many people and will likely kill more. Regarding safety, he said that the vaccine is made in the same way and in the same facilities as seasonal vaccines, which have an excellent safety record. And as to the futility of vaccination, he said, we "don't know what the rest of this long flu season is going to hold. We haven't had a flu season like this in at least 50 years."

He added: "We're very confident that there will be plenty of vaccine for everyone who wants to be vaccinated. It won't be available when everyone wants to be vaccinated."

LINK(S):

CDC news briefing transcript (Free)

NEJM/Journal Watch H1N1 Influenza Center (Free)

Published in Physician's First Watch October 7, 2009

H1N1 Update: Seasonal Flu Vaccine Seems to Offer Some Protection Against 2009 H1N1

Vaccination against seasonal strains of flu seems to offer some protection against 2009 H1N1 virus, particularly severe infections, according to a retrospective study published online in BMJ.

Researchers examined vaccination status in 60 laboratory-confirmed cases of 2009 H1N1 compared with that in 180 matched controls. All subjects were patients in a respiratory disease hospital in Mexico City during the early months of the pandemic. Cases had been admitted for influenza, and controls were treated for diseases other than influenza or pneumonia.

Cases were less likely than controls to have received the seasonal vaccine (13% vs. 29%). Among the cases, those who'd been vaccinated were less likely to die.

The authors urge caution in interpreting the results, which they say "in no way indicate that seasonal vaccine should replace vaccination against pandemic influenza."

LINK(S):

BMJ article (Free)

NEJM/Journal Watch H1N1 Influenza Center (Free)

Published in Physician's First Watch October 7, 2009

Sleep Deprivation, Alcohol Use Have Greater Deleterious Effects on Driving Ability in Patients with Sleep Apnea

Patients with obstructive sleep apnea (OSA) are more likely to experience simulated car crashes after partial sleep deprivation or low alcohol consumption compared with people without apnea, according to a driving simulator study in Annals of Internal Medicine.

Nearly 40 patients with OSA and 20 controls underwent a 90-minute driving task under three conditions: unrestricted sleep, partial sleep restriction (maximum 4 hours' sleep on 1 night), and low-dose alcohol consumption (blood alcohol target, 0.05 g/dL).

Patients with OSA had greater steering deviation under all three conditions than did controls. OSA patients were also more likely to have crashes — 10% after unrestricted sleep, 21% after alcohol consumption, and 32% after sleep deprivation (only one control had a crash).

The authors conclude that "it may be advisable" for patients with OSA "to avoid even legal doses of alcohol or sleep restriction before driving or performing other tasks in which safety is a factor."

LINK(S):

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

Published in Physician's First Watch October 6, 2009

Mediterranean Diet Associated with Reduced Risk for Depression

Adherence to a Mediterranean-style diet is associated with lower risk for developing depression, reports Archives of General Psychiatry.

Some 10,000 young adults in Spain completed food-frequency questionnaires to assess how well they followed a Mediterranean dietary pattern (i.e., high in fruits, vegetables, fish, nuts, cereal, and legumes; low in meat and whole-fat dairy; moderate alcohol intake; and high ratio of monounsaturated-to-saturated fatty acids).

After a median 4 years' follow-up, people in the top three quintiles of diet adherence had lower hazard ratios for incident self-reported depression than those in the lowest quintile. High consumption of fruits and nuts, legumes, and fish were each separately associated with lower depression risk.

The authors speculate that the observed effect may be explained by the diet's beneficial impact on endothelial function, which may, in turn, improve production of brain-derived neurotrophic factor — reported to be reduced in depression.

LINK(S):

Archives of General Psychiatry article (Free abstract; full text requires subscription)

Published in Physician's First Watch October 6, 2009

Automatic External Defibrillators Recalled Because of Memory Chip Failure

Philips is recalling roughly 5400 of its HeartStart FR2+ automated external defibrillators (AEDs) over concerns of a memory chip failure that could leave the devices inoperable, the FDA announced on Monday.

Four models, listed in the press release, are affected by the recall. The chip failure occurred in some devices during self-testing, not emergency use.

The company is working with customers to replace the affected AEDs. Customers may also check the Philips website to see whether their device is implicated in the recall.

LINK(S):

FDA safety alert (Free)

Manufacturer news release (Free)

Manufacturer product recall site (Free)

Published in Physician's First Watch October 6, 2009