Archive for the ‘New England Journal of Medicine’ Category

Health Reform and Changes in Health Insurance Coverage in 2014

August 13, 2014 Comments off

Health Reform and Changes in Health Insurance Coverage in 2014
Source: New England Journal of Medicine

In this analysis of nationally representative survey data from January 2012 through June 2014, we found a significant decline in the uninsured rate among nonelderly adults that coincided with the initial open-enrollment period under the ACA. These changes remained highly significant after adjustment for potential confounders such as employment, demographic characteristics, and income. As compared with the baseline trend, the uninsured rate declined by 5.2 percentage points by the second quarter of 2014, a 26% relative decline from the 2012–2013 period. Combined with 2014 Census estimates of 198 million adults 18 to 64 years of age,19 this corresponds to 10.3 million adults gaining coverage, although depending on the model and confidence intervals, our sensitivity analyses imply a wide range from 7.3 to 17.2 million adults.

The pattern of coverage gains was consistent with the effects of the ACA, with major gains for persons likely to be eligible for expanded Medicaid on the basis of their income and state of residence but smaller and nonsignificant changes for low-income adults in states without Medicaid expansion. Coverage gains were significant both in states with Medicaid expansion and in those without Medicaid expansion for persons with incomes between 139% and 400% of the federal poverty level, which is consistent with tax subsidies under the ACA for private insurance in this income range, regardless of state decisions regarding Medicaid expansion. Absolute gains were largest among young adults and Hispanics, two groups with high uninsured rates at baseline. State-level estimates of coverage gains were significantly associated with official HHS enrollment statistics, showing that each percentage point of the state population enrolling via the marketplaces was associated with a half-point decline in the uninsured rate. Nonetheless, the inherent lack of a control group precludes a causal interpretation for these findings, and other unmeasured factors may have contributed to these changes.

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Drug Safety in the Digital Age

July 2, 2014 Comments off

Drug Safety in the Digital Age
Source: New England Journal of Medicine

In this digital age, engaging with new media offers an unparalleled opportunity for medical and public health professionals to find information they need and to interactively reach out to patients and their support networks. One domain where these capabilities may have far-reaching effects that are currently undefined is drug safety. As the volume of health-related information on the Internet has grown, important questions have emerged. How are messages from regulators — for example, warnings against using a drug in a specific patient population — diffused digitally? And are the messages still accurate when they reach the general population?

Despite debates over its credibility, Wikipedia is reportedly the most frequently consulted online health care resource globally: Wikipedia pages typically appear among the top few Google search results and are among the references most likely to be checked by Internet users. We therefore evaluated Google searches and Wikipedia page views for each drug in our sample. We also examined the content of Wikipedia pages, looking specifically for references to safety warnings. To control for secular trends, we examined results from a 120-day window around the date of the announcement (from 60 days before the announcement to 60 days after it) and constructed a baseline period for comparison that ran from 60 days to 10 days before the period of interest began.

We identified safety warnings for 22 prescription drugs that are indicated for a range of clinical conditions, including primary hypertension, chronic myelogenous leukemia, and hepatitis C. Collectively, these drugs triggered 13 million searches on Google and 5 million Wikipedia page views annually during the study period. FDA safety warnings were associated with an 82% increase, on average, in Google searches for the drugs during the week after the announcement and a 175% increase in views of Wikipedia pages for the drugs on the day of the announcement, as compared with baseline trends.

Did users find accurate information on the drugs’ safety? We found that 41% of Wikipedia pages pertaining to the drugs with new safety warnings were updated within 2 weeks after the warning was issued with information provided in the FDA announcements. The Wikipedia pages for drugs that were intended for treatment of highly prevalent diseases (affecting more than 1 million people in the United States) were more likely to be updated quickly (58% were updated within 2 weeks) than were those for drugs designed to treat less-prevalent conditions (20% were updated within 2 weeks, P=0.03; see Fig. S2 in the Supplementary Appendix).

Overall, 23% of Wikipedia pages were updated more than 2 weeks after the FDA warning was issued (average, 42 days), and 36% of pages remained unchanged more than 1 year later (as of January 2014). For example, the FDA issued a safety communication on January 13, 2012, that brentuximab vedotin (Adcetris), used to treat Hodgkin’s lymphoma and systemic anaplastic large-cell lymphoma, had been linked to two cases of progressive multifocal leukoencephalopathy. As a result, the FDA placed a new black-box warning about this risk on the drug label, a move that was followed by a 50% increase in Google searches for the drug during the ensuing week and a 141% increase in views of the drug’s Wikipedia page. However, there was still no mention of the new black-box warning on Wikipedia 2 years later, a discrepancy that substantiates concerns raised by previous studies over the reliability of online drug information.

Distracted Driving and Risk of Road Crashes among Novice and Experienced Drivers

January 14, 2014 Comments off

Distracted Driving and Risk of Road Crashes among Novice and Experienced Drivers
Source: New England Journal of Medicine

Among novice drivers, dialing or reaching for a cell phone, texting, reaching for an object other than a cell phone, looking at a roadside object such as a vehicle in a previous crash, and eating were all associated with a significantly increased risk of a crash or near-crash. Among experienced drivers, only cell-phone dialing was associated with an increased risk.

How Medicaid affects adult health — Study: Health insurance helps lower-income Americans avoid depression, diabetes, major financial shocks

January 10, 2014 Comments off

How Medicaid affects adult health — Study: Health insurance helps lower-income Americans avoid depression, diabetes, major financial shocks
Source: New England Journal of Medicine (via MIT)

Enrollment in Medicaid helps lower-income Americans overcome depression, get proper treatment for diabetes, and avoid catastrophic medical bills, but does not appear to reduce the prevalence of diabetes, high blood pressure and high cholesterol, according to a new study with a unique approach to analyzing one of America’s major health-insurance programs.

The study, a randomized evaluation comparing health outcomes among more than 12,000 people in Oregon, employs the same research approach as a clinical trial, but applies it in a way that provides a window into the health outcomes of poor Americans who have been given the opportunity to get health insurance.

“What we found was that Medicaid significantly increased the probability of being diagnosed with diabetes, and being on diabetes medication,” says Amy Finkelstein, the Ford Professor of Economics at MIT and, along with Katherine Baicker of Harvard University’s School of Public Health, the principal investigator for the study. “We find decreases in rates of depression, and we continue to find reduced financial hardship. However, we were unable to detect a decline in the incidence of diabetes, high blood pressure, or high cholesterol.”

Health Care Spending — A Giant Slain or Sleeping?

December 26, 2013 Comments off

Health Care Spending — A Giant Slain or Sleeping?
Source: New England Journal of Medicine

The health care system is confronting a shocking surprise: slow growth in cost. According to U.S. government actuaries, real spending for health care increased a scant 0.8% per person in 2012, slightly less than the real gross domestic product (GDP) per capita. In contrast, since 1960, spending has increased an average of 2.3 percentage points more than GDP growth. The yearly gap between increases in health spending and GDP growth explains why national health expenditures jumped from 5% of the GDP in 1960 to 18% in 2011.

The recent moderation in spending is good news for payers of the health care bill, but analysts are divided about what to make of it. On the one hand, some believe that the Great Recession of 2007–2009 and the nation’s very slow recovery can explain ebbing increases in health care costs. Writing recently in the Journal, Fuchs described how — with rare exceptions — trends in health spending have always tracked with trends in the general economy. The implication is that health care costs will probably surge as the economy recovers.

On the other hand, some analysts (including one of us) believe that the slowdown exceeds what trends in the GDP would predict and that the past may no longer be prologue. They theorize that public and private efforts to control health spending, including features of the Affordable Care Act (ACA), may finally be working.

The purpose of this report is to explore this debate about national health expenditures and to understand its implications. We start by reviewing historic trends in health care spending and efforts to control them. We then probe further the rationales for seeing the recent slowdown as either temporary or likely to endure. We conclude by discussing possible consequences and policy responses should either the optimistic or the pessimistic scenario prevail.

Association of Nut Consumption with Total and Cause-Specific Mortality

November 21, 2013 Comments off

Association of Nut Consumption with Total and Cause-Specific Mortality
Source: New England Journal of Medicine

In two large prospective U.S. cohorts, we found a significant, dose-dependent inverse association between nut consumption and total mortality, after adjusting for potential confounders. As compared with participants who did not eat nuts, those who consumed nuts seven or more times per week had a 20% lower death rate. Inverse associations were observed for most major causes of death, including heart disease, cancer, and respiratory diseases. Results were similar for peanuts and tree nuts, and the inverse association persisted across all subgroups.

Note: Supported by grants from the National Institutes of Health (UM1 CA167552, P01 CA055075, P01 CA87969, R01 HL60712, R01 CA124908, P50 CA127003, and 1U54 CA155626-01) and the International Tree Nut Council Nutrition Research and Education Foundation.

Talking with Patients about Other Clinicians’ Errors

November 1, 2013 Comments off

Talking with Patients about Other Clinicians’ Errors
Source: New England Journal of Medicine

Although a consensus has been reached regarding the ethical duty to communicate openly with patients who have been harmed by medical errors, physicians struggle to fulfill this responsibility. One particular challenge is that although the literature assumes the physician providing the disclosure also committed the error, health care today is delivered by complex groups of clinicians across multiple care settings. In addition, safety experts emphasize the role that system breakdowns play in adverse events. Thus, many decisions about discussing errors with patients involve situations in which other clinicians were primarily responsible for the error.

Confronting the apparent error of a colleague raises challenging questions about whether an error occurred, how the error arose, which professionals carry what responsibilities, and how to talk with the patient about the event. Existing guidelines emphasize the overall importance of disclosing errors, but (with the exception of the case study of the American College of Physicians Ethics and Human Rights Committee)16 they offer little guidance on disclosing others’ mistakes; this lack of guidance heightens clinicians’ uncertainty about what to do. Consequently, patients may be told little about these events, and opportunities to build trust, ensure that learning occurs after errors, and avoid litigation may be lost.

We convened a working group of experts in patient safety, medical malpractice insurance and litigation, error disclosure, patient–provider communication, professionalism, bioethics, and health policy. After the meeting, a subgroup of attendees collaborated to refine these concepts and draft this manuscript. Below, we describe recommendations that extend existing guidelines for clinicians and institutions on communicating with patients about colleagues’ harmful errors.

The Public and the Conflict over Future Medicare Spending

September 12, 2013 Comments off

The Public and the Conflict over Future Medicare Spending
Source: New England Journal of Medicine

Two recent government reports show substantial short-term improvements in the financial outlook for Medicare and in the federal budget deficit. However, these forecasts also suggest the need for further action brought about by a worsening of the financial situation after 2015 as the number of Medicare recipients increases from 52 million to 73 million in the decade following. This issue is likely to receive considerable attention in the upcoming debate about the federal budget deficit and the national debt.

As we reported in the Journal in 2011, there has been little public support for major policy changes aimed at reducing Medicare spending to lower the federal deficit. This article goes further and seeks to document the underlying beliefs that may shape the public response to future efforts to substantially slow projected Medicare spending. Our thesis is that there exists today a wide gap in beliefs between experts on the financial state of Medicare and the public at large. Because of the potential electoral consequences, these differences in perception are likely to have ramifications for policymakers addressing this issue.

Zolpidem and Driving Impairment — Identifying Persons at Risk

August 9, 2013 Comments off

Zolpidem and Driving Impairment — Identifying Persons at Risk
Source: New England Journal of Medicine

Zolpidem (Ambien, Sanofi) is the most widely used prescription drug for insomnia and one of the most commonly used drugs in the United States. Treatment of insomnia, which has important effects on patients’ quality of life, may also have larger public health benefits. In its 2006 report, the Institute of Medicine (IOM) Committee on Sleep Medicine and Research concluded that sleep deprivation and sleep disorders represent an unaddressed public health problem that has substantial health consequences and leads to high health care costs.1 The IOM noted that one of every five serious injuries from driving accidents can be attributed to driver sleepiness. Numerous sleep drugs are available for treating insomnia and are also used to reduce next-day somnolence. But it is widely recognized that these drugs themselves can sometimes contribute to next-day somnolence, depending on such factors as drug dose, dosage form, and individual patient characteristics.

Controlled Trial of Psychotherapy for Congolese Survivors of Sexual Violence

June 7, 2013 Comments off

Controlled Trial of Psychotherapy for Congolese Survivors of Sexual Violence
Source: New England Journal of Medicine

Mental health problems such as depression, anxiety, and post-traumatic stress disorder (PTSD) are common in survivors of sexual violence. In high-income countries, there are effective treatments for trauma related to sexual violence, but these treatments have not been adequately tested in low-income, conflict-affected countries with few mental health professionals and low literacy rates. The few studies of effectiveness have had methodologic limitations, including a lack of controls and high attrition rates.

Eastern Democratic Republic of Congo is a low-income, conflict-affected region in which political and economic instability are ongoing problems and nearly 40% of women have experienced sexual violence. The development of effective mental health services has important implications for the recovery of sexual-violence survivors in the Democratic Republic of Congo and similar countries.

We evaluated an adaptation of group cognitive processing therapy provided by community-based paraprofessionals (psychosocial assistants), supervised by psychosocial staff at a nongovernmental organization (NGO) and by clinical experts based in the United States. Cognitive processing therapy has shown efficacy in high-income countries, with effects lasting for 5 or more years. We evaluated the benefits of adding this therapy to services offered by workers trained only in case management and individual supportive counseling.

Targeted versus Universal Decolonization to Prevent ICU Infection

May 30, 2013 Comments off

Targeted versus Universal Decolonization to Prevent ICU Infection

Source: New England Journal of Medicine

Health care–associated infection is a leading cause of preventable illness and death and often results from colonizing bacteria that overcome body defenses. Among the pathogens causing health care–associated infection, methicillin-resistant Staphylococcus aureus (MRSA) has been given priority as a target of reduction efforts because of its virulence and disease spectrum, multidrug-resistant profile, and increasing prevalence in health care settings, particularly among patients in the intensive care unit (ICU). Hospitals commonly screen patients in the ICU for nasal carriage of MRSA and use contact precautions with carriers. Nine states mandate such screening.

Decolonization has been used to reduce transmission and prevent disease in S. aureus carriers, primarily carriers of methicillin-resistant strains but also carriers of methicillin-sensitive ones. aureus, including both methicillin-resistant and methicillin-susceptible strains, accounts for more health care–associated infections than any other pathogen. It is the most common cause of ventilator-associated pneumonia and surgical-site infection and the second most common cause of central-catheter–associated bloodstream infection. Decolonization commonly involves a multiday regimen of intranasal mupirocin and chlorhexidine bathing.

There is debate about whether decolonization should be used and, if so, whether to target high-risk pathogens or patient populations that are susceptible to infection from many pathogens. In particular, the broad antimicrobial activity of chlorhexidine makes it attractive for preventing health care–associated infection from many pathogens. Several studies have shown that daily chlorhexidine bathing of all patients in the ICU can reduce MRSA acquisition, the concentration of bacteria on the body surface, and bloodstream infection from all pathogens. A comparative-effectiveness trial is needed to determine what type of decolonization strategy works best to reduce MRSA and other pathogens in ICUs. In addition, it is important to know whether decolonization can be effective in routine ICU care. We conducted a cluster-randomized, pragmatic, comparative-effectiveness trial in adult ICUs to compare targeted and universal decolonization with one another and with MRSA screening and contact precautions alone.

See: MRSA Study Slashes Deadly Infections in Sickest Hospital Patients (Science Daily)

Outcomes of Medical Emergencies on Commercial Airline Flights

May 30, 2013 Comments off

Outcomes of Medical Emergencies on Commercial Airline Flights

Source: New England Journal of Medicine

Commercial airlines serve approximately 2.75 billion passengers worldwide annually. When in-flight medical emergencies occur, access to care is limited. Physicians and other medical professionals are often called on to assist when traveling, despite limited training or experience with these situations. Airlines partner with health care institutions to deliver real-time medical advice from an emergency call center to airline personnel, in an effort to improve the quality of care provided to passengers.

There is limited information on the incidence and characteristics of in-flight medical emergencies. Although previous studies of these events have characterized the incidence, categories of symptoms, rates of aircraft diversion, and resources accessed, many have used information obtained from single airlines and have lacked information on patient outcomes.

We conducted a study of in-flight medical emergencies involving large commercial airlines, characterizing on-board assistance provided by flight crews and other passengers and identifying the outcomes of these events, including ambulance transport to a hospital and hospital admission. On the basis of our findings, we suggest a practical approach to the initial management of common in-flight medical emergencies for medical personnel who may be called on to render aid.

See: ‘Is There a Doctor On Board?’ Travelers Play Valuable Role Assisting Crew in Common Medical Emergencies on Flights (University of Pittsburgh, School of the Health Sciences]

Preliminary Report: Epidemiology of the Avian Influenza A (H7N9) Outbreak in China

April 25, 2013 Comments off

Preliminary Report: Epidemiology of the Avian Influenza A (H7N9) Outbreak in China
Source: New England Journal of Medicine

The first identified cases of human infection with a novel influenza A (H7N9) virus occurred in eastern China during February and March 2013 and were characterized by rapidly progressive pneumonia, respiratory failure, acute respiratory distress syndrome (ARDS), and fatal outcomes.1 We analyzed available data from field investigations to characterize the descriptive epidemiology of laboratory-confirmed cases of avian influenza A (H7N9) virus infection in humans reported to the Chinese Center for Disease Control and Prevention (China CDC) as of April 17, 2013. In this report, we summarize the preliminary findings of case investigations and follow-up monitoring of close contacts of persons with confirmed cases of H7N9 virus infection who have been identified to date. This is an ongoing investigation.

A Behavioral Weight-Loss Intervention in Persons with Serious Mental Illness

April 17, 2013 Comments off

A Behavioral Weight-Loss Intervention in Persons with Serious Mental Illness
Source: New England Journal of Medicine

Overweight and obesity are epidemic among persons with serious mental illness, yet weight-loss trials systematically exclude this vulnerable population. Lifestyle interventions require adaptation in this group because psychiatric symptoms and cognitive impairment are highly prevalent. Our objective was to determine the effectiveness of an 18-month tailored behavioral weight-loss intervention in adults with serious mental illness.

We recruited overweight or obese adults from 10 community psychiatric rehabilitation outpatient programs and randomly assigned them to an intervention or a control group. Participants in the intervention group received tailored group and individual weight-management sessions and group exercise sessions. Weight change was assessed at 6, 12, and 18 months.

Of 291 participants who underwent randomization, 58.1% had schizophrenia or a schizoaffective disorder, 22.0% had bipolar disorder, and 12.0% had major depression. At baseline, the mean body-mass index (the weight in kilograms divided by the square of the height in meters) was 36.3, and the mean weight was 102.7 kg (225.9 lb). Data on weight at 18 months were obtained from 279 participants. Weight loss in the intervention group increased progressively over the 18-month study period and differed significantly from the control group at each follow-up visit. At 18 months, the mean between-group difference in weight (change in intervention group minus change in control group) was −3.2 kg (−7.0 lb, P=0.002); 37.8% of the participants in the intervention group lost 5% or more of their initial weight, as compared with 22.7% of those in the control group (P=0.009). There were no significant between-group differences in adverse events.

A behavioral weight-loss intervention significantly reduced weight over a period of 18 months in overweight and obese adults with serious mental illness. Given the epidemic of obesity and weight-related disease among persons with serious mental illness, our findings support implementation of targeted behavioral weight-loss interventions in this high-risk population. (Funded by the National Institute of Mental Health; ACHIEVE number, NCT00902694.)

Monetary Costs of Dementia in the United States

April 5, 2013 Comments off

Monetary Costs of Dementia in the United States
Source: New England Journal of Medicine

We used nationally representative data to document comprehensively the incremental increase in costs attributable to dementia that arise from market transactions for goods and services as well as the costs of unpaid caregiving. We found that dementia leads to total annual societal costs of $41,000 to $56,000 per case, with a total cost of $159 billion to $215 billion nationwide in 2010. Our calculations suggest that the aging of the U.S. population will result in an increase of nearly 80% in total societal costs per adult by 2040.

The main component of the costs attributable to dementia is the cost for institutional and home-based long-term care rather than the costs of medical services — the sum of the costs for nursing home care and formal and informal home care represent 75 to 84% of attributable costs. Our estimate places dementia among the diseases that are the most costly to society. The cost for dementia care purchased in the marketplace ($109 billion) was similar to estimates of the direct health care expenditures for heart disease ($96 billion in 2008, or $102 billion in 2010 dollars) and significantly higher than the direct health care expenditures for cancer ($72 billion in 2008, or $77 billion in 2010 dollars). These costs do not include the costs of informal care, which are likely to be larger for dementia than for heart disease or cancer.

Although the costs attributable to dementia reported here are large, they are considerably smaller than those reported by the Alzheimer’s Association, which has estimated that in 2010 the monetary costs alone were $172 billion (2010 dollars) as compared with our estimate of $109 billion. There are several reasons for this higher estimate. It is likely that the cost per case reported by the Alzheimer’s Association is higher because it was estimated on the basis of a sample from a more severely impaired population (persons identified in the Medicare Current Beneficiary Survey as having dementia). The higher cost is also based on a significantly larger estimate of the prevalence of dementia. The national prevalence of dementia used by the Alzheimer’s Association is derived from a study of three Chicago neighborhoods. The diagnostic criteria for dementia used in that study did not require the presence of a limitation in ADLs or IADLs (a criterion that was used in ADAMS), a factor that probably led to the substantially higher estimate of the prevalence of dementia in the Chicago study. Finally, the cost estimate from the Alzheimer’s Association was not adjusted for the costs of coexisting conditions.

Globalization, Climate Change, and Human Health

April 4, 2013 Comments off

Globalization, Climate Change, and Human Health
Source: New England Journal of Medicine

he global scale, interconnectedness, and economic intensity of contemporary human activity are historically unprecedented, as are many of the consequent environmental and social changes. These global changes fundamentally influence patterns of human health, international health care, and public health activities. They constitute a syndrome, not a set of separate changes, that reflects the interrelated pressures, stresses, and tensions arising from an overly large world population, the pervasive and increasingly systemic environmental impact of many economic activities, urbanization, the spread of consumerism, and the widening gap between rich and poor both within and between countries.

In recent decades, international connectivity has increased on many fronts, including the flow of information, movements of people, trading patterns, the flow of capital, regulatory systems, and cultural diffusion. These exponential increases in demographic, economic, commercial, and environmental indexes have been labeled the Great Acceleration. Remarkably, the resultant environmental effects are now altering major components of the Earth system. The current geologic epoch is being called the Anthropocene (successor to the Holocene epoch) in recognition of the global force that Homo sapiens has become, pushing or distorting Earth’s great natural global systems beyond boundaries considered to be safe for continued human social and biologic well-being. The loss of biodiversity, the greatly amplified global circulation of bioactive nitrogen compounds, and human-induced climate change have already reached levels that are apparently unsafe.

These changes pose fundamental threats to human well-being and health. For example, a positive relationship has been observed between regional trends in climate (rising temperatures and declining rainfall) and childhood stunting in Kenya since 1975, indicating that as projected warming and drying continue to occur along with population growth, food yields and nutritional health will be impaired. These human-induced climatic changes often act in concert with environmental, demographic, and social stressors that variously influence regional food yields, nutrition, and health. Furthermore, at the current level of global connectedness and interdependence, the environmental impact of human activity has a wider geographic range, although its influence may be offset somewhat by more effective global alerts and more rapid distribution of food aid. The extreme heat and wildfires in western Russia in the summer of 2010 destroyed one third of that country’s wheat yield, and the subsequent ban on exported grain contributed to a rise in the price of wheat worldwide, exacerbating hunger in Russia (where flour prices increased by 20%) and in low-income urban populations in countries such as Pakistan and Egypt. On the economic front, the recent global financial crisis has underscored the domino-like interdependence of national economies.

Primary Prevention of Cardiovascular Disease with a Mediterranean Diet

April 4, 2013 Comments off

Primary Prevention of Cardiovascular Disease with a Mediterranean Diet
Source: New England Journal of Medicine

The risk of stroke was reduced significantly in the two Mediterranean-diet groups. This is consistent with epidemiologic studies that showed an inverse association between the Mediterranean diet or olive-oil consumption and incident stroke.

Our results compare favorably with those of the Women’s Health Initiative Dietary Modification Trial, wherein a low-fat dietary approach resulted in no cardiovascular benefit.35 Salient components of the Mediterranean diet reportedly associated with better survival include moderate consumption of ethanol (mostly from wine), low consumption of meat and meat products, and high consumption of vegetables, fruits, nuts, legumes, fish, and olive oil. 36,37 Perhaps there is a synergy among the nutrient-rich foods included in the Mediterranean diet that fosters favorable changes in intermediate pathways of cardiometabolic risk, such as blood lipids, insulin sensitivity, resistance to oxidation, inflammation, and vasoreactivity.

Surgery versus Physical Therapy for a Meniscal Tear and Osteoarthritis

March 22, 2013 Comments off

Surgery versus Physical Therapy for a Meniscal Tear and Osteoarthritis
Source: New England Journal of Medicine

Symptomatic, radiographically confirmed osteoarthritis of the knee affects more than 9 million people in the United States.1 Meniscal tears are also highly prevalent, with imaging evidence of a meniscal tear observed in 35% of persons older than 50 years of age; two thirds of these tears are asymptomatic.2 Meniscal damage is especially prevalent among persons with osteoarthritis3,4 and is frequently treated surgically with arthroscopic partial meniscectomy. This procedure, in which the surgeon trims the torn meniscus back to a stable rim, is performed for a range of indications in more than 465,000 persons annually in the United States.5

The high prevalence of meniscal tears in patients with osteoarthritis of the knee and the observation that these lesions are often asymptomatic challenge the ability of clinicians to determine whether symptoms are caused by the tear, osteoarthritis, or both. Clinicians who suspect that the tear is symptomatic may refer the patient to a surgeon for arthroscopic partial meniscectomy. The role of arthroscopic surgery in patients with osteoarthritis has been studied in two randomized, controlled trials over the past decade. One trial6 compared arthroscopic débridement and lavage with a sham surgical procedure, and the other7 compared arthroscopic débridement with a nonoperative regimen. Neither trial showed a statistically significant or clinically important difference between the arthroscopic and nonoperative groups with respect to functional improvement or pain relief over a period of 24 months.6,7

These landmark trials established that arthroscopic treatment was not superior to the other interventions in the treatment of knee osteoarthritis, but they did not focus on management of a symptomatic meniscal tear, which is a frequent indication for knee arthroscopy in patients with osteoarthritis of the knee. The efficacy of arthroscopic partial meniscectomy in symptomatic patients with a meniscal tear and osteoarthritis has been evaluated, to our knowledge, in only one randomized, controlled trial, which was a single-center study involving 90 patients.8,9 This study did not show a significant difference in pain relief or functional status between arthroscopic partial meniscectomy plus a physical-therapy regimen and physical therapy alone. Given the frequency and cost of arthroscopic partial meniscectomy and the paucity of data, we designed the Meniscal Tear in Osteoarthritis Research (METEOR) trial to assess the efficacy of arthroscopic partial meniscectomy as compared with a standardized physical-therapy regimen for symptomatic patients with a meniscal tear and concomitant mild-to-moderate osteoarthritis.

Protecting Patient Privacy and Data Security

March 14, 2013 Comments off

Protecting Patient Privacy and Data Security

Source: New England Journal of Medicine

On December 4, 2012, two Australian radio DJs called London’s King Edward VII’s Hospital, identified themselves, in fake British accents, as Queen Elizabeth and Prince Charles, and asked about a celebrity patient who had been admitted for pregnancy complications. A nurse, filling in at the reception desk in the early morning hours, answered the phone and, without attempting to verify the callers’ identities, transferred them to the duty nurse caring for the Duchess of Cambridge. The duty nurse then provided them with confidential patient information.1 The Australian DJs broadcast the phone call, considering it a humorous prank, but as the world knows, it had disastrous consequences.

How confident are U.S. hospitals, nursing homes, and physicians’ offices that their staff would appropriately deny patient information to an unknown caller?

50-Year Trends in Smoking-Related Mortality in the United States

January 25, 2013 Comments off

50-Year Trends in Smoking-Related Mortality in the United States

Source: New England Journal of Medicine

The disease risks from cigarette smoking increased over most of the 20th century in the United States as successive generations of first male and then female smokers began smoking at progressively earlier ages. American men began smoking manufactured cigarettes early in the 20th century; by the 1930s, the average age at initiation fell below 18 years.1,2 Relatively few women smoked regularly before World War II; their average age at initiation continued to decrease through the 1960s. Women were not included in the earliest prospective epidemiologic studies in the 1950s,3-5 since mortality from lung cancer among women was not yet increasing in the general population.6 The landmark 1964 U.S. Surgeon General’s Report concluded only that “cigarette smoking is causally related to lung cancer in men.”7 Neither sex had yet experienced the full effects of smoking from adolescence throughout adulthood.

The first large, prospective study of smoking and mortality involving both women and men was Cancer Prevention Study I (CPS I), initiated by the American Cancer Society (ACS) in 1959.8,9 The relative risk of death from lung cancer during the first 6 years of follow-up among current smokers, as compared with persons who had never smoked, was 2.69 (95% confidence interval [CI], 2.14 to 3.37) for women and 11.35 (95% CI, 9.10 to 14.15) for men.10 In 1982, the ACS initiated the second Cancer Prevention Study (CPS II), which included nearly 1.2 million men and women nationwide.11 During the intervening 20 to 25 years, the relative risk of death from lung cancer had increased to 11.94 (95% CI, 9.99 to 14.26) for female smokers and to 22.36 (95% CI, 17.77 to 28.13) for male smokers.10,12

Several factors may have altered the health risks incurred by smokers. Smoking patterns have changed. Women who began smoking in the 1950s or thereafter have smoked more like men than they did in previous generations (i.e., starting at an earlier age and smoking more heavily).1 Daily cigarette consumption peaked during the 1970s among male smokers and during the 1980s among female smokers13; smoking prevalence in the two groups has since decreased in parallel. Contemporary smokers have spent much of their lives smoking filtered cigarettes made of blended tobacco.2,14 Women have more difficulty quitting than men; thus, for both current and former female smokers, the number of years of smoking has increased. Male and female smokers today are less educated and less affluent than smokers were 20 to 40 years ago.15 Since the 1950s, there has been a more rapid proportional decrease in the background risk of death from cardiovascular conditions among persons who have never smoked than among smokers.16,17

We calculated death rates and the relative risks associated with active cigarette smoking and smoking cessation during three time periods — 1959–1965, 1982–1988, and 2000–2010 — using data from the two historical ACS cohorts (CPS I and CPS II) and pooled data from five contemporary cohort studies in the United States.18-23 A central question is whether the hazards for women are now approaching those for men as their lifetime smoking behaviors have become increasingly similar.

See: Smokers Who Quit Before Age 40 Have Lifespan Almost as Long as People Who Never Smoked (Science Daily)


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