SYDNEY, Australia, Feb. 18 — The e-mail has triumphed in a small randomized trial of communications between a surgeon here and patients awaiting elective thyroid or parathyroid procedures.

Under the rules established for the back-and-forth emails, the patients liked the approach, the surgeon found it efficient and convenient, and the lawyers kept their distance.

“There are clearly major advantages associated with the use of e-mail as a means of communication between surgeon and patient,” Leigh Delbridge, M.D., of the University of Sydney and Royal North Shore Hospital, and colleagues reported in the February issue of the Archives of Surgery.

“It avoids interruptions to office routine by avoiding the need to answer telephone calls from patients at all times of the day or having to engage in ‘phone tag’ if calls are answered at the end of the day’s work.

“E-mail responses can also be written undisturbed, with appropriate thought being given to the reply, ensuring that it is composed and accurate, something not readily achieved with a hurried telephone conversation.

“Copies of e-mails kept in the file provide clear and indisputable evidence of the responses provided, an invaluable resource should litigation ensue.

“Many of the responses in this study also demonstrated that many patients ‘open up’ when using e-mail communication and often ask questions or raise personal issues that they may have felt inhibited about in a face-to-face consultation.”

From the patients’ standpoint, “we demonstrated that making e-mail access available to patients after their initial preoperative consultation significantly increased the level of patient communication without any detectable downside.

“This study now confirms that, in the setting of a prospective randomized controlled clinical trial, patients encouraged to use e-mail access have significantly increased the level of preoperation interaction, without any reduction in measured satisfaction outcomes.”

In the controlled randomized study of 100 patients having thyroid or parathyroid surgery by the same surgeon, altogether, 22 e-mailed their surgeon requesting general information, recovery information, or reassurance, Dr. Delbridge and colleagues reported.

In the study, 50 patients (mean age 45.1, 40 women) were randomly assigned to receive an information sheet including the surgeon’s e-mail address and a statement informing them that e-mail was the surgeon’s preferred method of communication.

Another 50 patients (mean age 48.2, 42 women), received an information sheet without the surgeon’s e-mail address. However, all patients received an appointment card and Web site information that contained the surgeon’s e-mail address.

In this study, 81% of all the patients had ready access to e-mail and the Internet.

Overall, 26 of 100 patients initiated additional perioperative communication by any means. Nineteen (38%) were in the e-mail group, and seven (14%) used information on the standard sheet (P

LITTLE FALLS, N.J., May 7 — A combination of dietary counseling and probiotic supplements helped reduce obesity in women who had given birth, a randomized trial showed.

Women who received the combination treatment starting in the first trimester had a significantly lower percentage of body fat one year after delivery than those who received dietary counseling alone or no treatment (27.9% versus 28.9% and 30.4%, P=0.018), according to Kirsi Laitinen, Ph.D., of the University of Turku in Finland.

Inclusion of probiotics also reduced the rate of abdominal obesity (25% versus 42.9% and 40.4%), a difference that was statistically significant six months after delivery (P=0.023) but not at one year, she reported at the European Congress on Obesity in Amsterdam.

Although many factors contribute to obesity, she said, “probiotics could bring something new that is practical, safe, and potentially successful” as a treatment for obesity.

Dr. Laitinen and colleagues explored the effectiveness of probiotic supplementation in preventing obesity in pregnant women because pregnancy is one of the key factors promoting weight gain in women.

They randomized 256 pregnant women to one of three groups during their first trimester: dietary counseling plus placebo capsules, dietary counseling plus probiotic supplementation, or no advice plus placebo capsules.

The two groups that received nutritional counseling were also given some healthy foods, including spreads and salad dressings containing mono- and polyunsaturated fats and fiber-enriched pasta and breakfast cereal.

The probiotic supplements contained Lactobacillus rhamnosus GG and Bifidobacterium lactis. Supplementation continued for up to six months after delivery or until women stopped exclusive breastfeeding.

Dietary counseling resulted in lower intake of saturated fats and higher intake of mono- and polyunsaturated fats compared with controls, but energy intake was similar between groups.

The women who received probiotic supplementation were less likely to be abdominally obese.

Dr. Laitinen said the beneficial effects probably involved changes in the composition of the gut flora, which are different in obese compared with lean individuals.

Probiotics “can change the microbiota in a way that the energy harvest and storage, as well as the inflammation which is present in obesity, can be changed and this might have beneficial effects,” Dr. Laitinen said.

This study and previous studies have shown that probiotic supplementation does not have adverse effects on the mother or child, she said.

There was no information yet on the health outcomes of the children, but she said the mothers and children would continue to be followed to address this issue.

She acknowledged that the study was limited because the analyses did not control for prepregnancy weight.

The study was funded by the Social Insurance Institution of Finland, the Academy of Finland, and the Sigrid Juselius Foundation.

Dr. Laitinen reported no conflicts of interest.

Primary source: European Congress on Obesity

Source reference:
Laitinen K, et al “Dietary counseling and probiotic intervention initiated in early pregnancy modifies maternal adiposity over 12 months postpartum” ECO 2009; Abstract 1264.

GOLDEN, Colo., Feb 6 – A health-care rating company here said today that patients treated at hospitals that receive its top ranking have a 27% lower risk of dying during their hospital stay.

Moreover, according to HealthGrades, which compiles quality report cards on hospitals and doctors and sells those reports to consumers, patients treated at its top-ranked hospitals also have a 14% lower risk of complications.

HealthGrades used the Medicare discharge records from 2002, 2003 and 2004 to rank hospitals based on overall performance of risk-adjusted outcomes associated with 26 common Medicare inpatient procedures and diagnoses.

According to the HealthGrades annual Hospital Quality and Clinical Excellence Study, only 277 of 5,122 acute care hospitals ranked this year were designated as “Distinguished Hospitals for Clinical Excellence,” a designation reserved for hospitals that score in the top 5% of HealthGrades’ ranking system.

The report claimed that if all patients with any of the 26 conditions studied had been treated at these top-ranked hospitals from 2002 to 2004, there may have been 152,966 lives saved and 21,896 patients may have avoided a major post-operative complication.

The 26 conditions studied included atrial fibrillation, back and neck surgery (spinal fusion), bowel obstruction, carotid endarterectomy, chronic obstructive pulmonary disease, coronary artery bypass surgery, diabetic ketoacidosis and coma, heart attack, heart failure, hip fracture repair, prostatectomy, sepsis, stroke, total hip replacement, and valve replacement surgery.

According to the report, the five areas in which the top ranked hospitals achieved the greatest reduction in mortality were:

Diabetic ketoacidosis and coma, which was 35% lower.
Pancreatitis, which was 32% lower.
Community-acquired pneumonia, which was 31% lower.
Heart failure, which was 29% lower.
Coronary artery bypass surgery, which was also 29% lower.

Samantha Collier, M.D., who is HealthGrades’ vice-president of medical affairs, said the report this year points out “a clear and profound divergence between the best hospitals and all others.”

Moreover, she characterized the divide between the top ranked hospitals and the majority of U.S. hospitals as a growing “quality chasm.” She urged “all consumers, if possible, to do their homework before checking into a hospital.”

Primary source: HealthGrades

Source reference:
HealthGrades Fourth Annual Hospital Quality and Clinical Excellence Study February 2006.

SAN FRANCISCO — Bowling alleys, dance studios, and other places people exert themselves outside the gym shouldn’t be overlooked in rolling out automated external defibrillators, researchers warned.

In a population-based database, 8.7% of all sudden cardiac arrests occurred during dancing and another 4.0% occurred while bowling, Richard L. Page, MD, of the University of Wisconsin School of Medicine and Public Health in Madison, and colleagues found.

But the chance of survival was substantially higher than expected for these cases lumped together with others involving exercise in indoor public spaces, the group reported here at the Heart Rhythm Society meeting.

The 50% rate of survival to hospital discharge for those whose arrest occurred in buildings related to traditional exercise or other forms of exertion contrasted with 36% among those whose sudden cardiac arrest occurred in exercise-unrelated buildings (P=0.001).

Some states already require exercise facilities to have AEDs on hand, since exercise can be a trigger for sudden cardiac arrest in patients with an underlying susceptibility, noted Page, who is a past president of the HRS.

“There’s been a focus on the health club,” he told MedPage Today. “Yes, we should have them at fitness clubs, but we should also have them at the nontraditional exercise facilities.”

Organized dance and other “alternative exercise” can be quite strenuous, especially for individuals who aren’t physically fit, he pointed out.

His group examined a database for every sudden cardiac arrest that occurred from 1996 through 2008 in indoor public locations in the Seattle metropolitan area.

During this period, 150 sudden cardiac arrests occurred in some kind of an exercise facility (including ice rinks, indoor paintball centers, ski or golf clubhouses, pool table areas at bars, martial arts schools, and other atypical facilities) and 810 occurred in other buildings.

Activities at the time of sudden cardiac arrest included: Basketball for 16% Dancing for 8.7% “Working out” for 8.7% Walking or running on a treadmill for 8.0% Tennis for 4.7% Bowling for 4.0% Swimming for 4.0% Weight-lifting for 4.0%

Reasons for the higher survival rate among sudden cardiac arrests that occurred in exercise facilities overall may have been the greater use of CPR for those cases compared with arrests at exercise-unrelated buildings (77% versus 55%, P=0.001) and double the rate of AED use (16% versus 7%, P=0.001).

Other factors were younger age (55 versus 60, P=0.007), more cases being witnessed (90% versus 77%, P=0.001), and more arrests involving ventricular tachycardia or ventricular fibrillation (83% versus 59%, P=0.001).

Selection bias may also have played a role, as individuals feeling well enough to exercise may be a healthier and more physically fit group, Page noted.

He cautioned that the study was limited by lack of a denominator for exercise facilities, which precluded determination of relative risk among sites.

Also, the higher-than-typical survival rates for sudden cardiac arrest may not be replicable in other areas, since the Seattle area has a well-organized resuscitative response with “remarkably short EMS response times,” Page noted.

Page reported having no conflicts of interest to disclose.

Vitamin D alone won’t reduce fracture risk, but scarfing it down with calcium will, researchers say.
Taking the nutrients together decreased overall fracture risk by 8%, and hip fracture risk by 16%, Bo Abrahamsen, MD, PhD, of Copenhagen University Hospital in Denmark, and colleagues reported online in BMJ.
“Calcium and vitamin D together are effective in reducing risk of all fractures and hip fractures, whereas we can’t show anything like that for vitamin D on its own,” Abrahamsen told MedPage Today.
Much previous research has focused on whether vitamin D can reduce fracture risk alone or in combination with calcium. Abrahamsen and colleagues used the raw data from many of those studies for their assessment.
They pooled data from seven randomized controlled trials, totaling 68,517 patients whose mean age was 69.9 years. Just under 15% were men.

They found that using vitamin D with calcium reduced both overall fracture risk (HR 0.92, 95% CI 0.86 to 0.99, P=0.025) and hip fracture risk (HR 0.84, 95% CI 0.70 to 1.01, P=0.07) compared with no treatment.

Vitamin D alone in daily doses of 10 mcg or 20 mcg had no significant effects on fracture risk, compared with placebo.

“The data all point toward the importance of giving calcium with your vitamin D,” Abrahamsen said. “But we would very much welcome studies where larger doses of vitamin D were tried out on their own.”

Until someone conducts higher-dose trials, he said, “We can’t exclude that maybe vitamin D would be OK on its own if you took enough of it.”

“But in these relatively modest doses,” he added, “we can only show an effect if you take calcium as well.”

Whether calcium is more important in preventing fractures than was previously recognized remains to be determined, the researchers wrote.

Abrahamsen noted that the team did not compare vitamin D alone with vitamin D plus calcium head-to-head.

They did, however, look for possible interactions between the nutrients and prior fractures, and found that the effects of calcium and vitamin D in combination were completely independent.

“In this analysis, it doesn’t seem to be important whether patients had prior fractures or not,” Abrahamsen said. “It works equally well in patients with a prior fracture or patients taking calcium and vitamin D as primary prevention. . . . [This ] shows the fact that you had a prior fracture doesn’t mean you won’t benefit from calcium and vitamin D.”

Since the results are consistent with three recent meta-analyses, Abrahamsen and colleagues recommend a dose of 10 mcg of vitamin D combined with 1,000 mg of calcium. In high-risk patients, they said this should be supplemented by bisphosphonates or other antiosteoporotic drugs.

In an accompanying editorial, Opinder Sahota, MD, of Queen’s Medical Center in Nottingham, England, wrote that vitamin D may increase muscle strength, thereby reducing the risk of falls to prevent fractures.

Sahota noted that while the evidence is “still confusing, there is growing consensus that combined calcium and vitamin D is more effective than vitamin D alone in reducing nonvertebral fractures.”

Abrahamsen reported relationships with Novartis, Amgen, Nycomed, Eli Lilly, Procter & Gamble.

Co-authors reported relationships with Merck, Procter & Gamble, Roche, Eli Lilly, Shire, ProStrakan, Servier, Celltech, Alliance for Better Bone Health, Merch Sharp & Dohme, GlaxoSmithKline, Pfizer, sanofi-aventis, and Osteologix.

Sahota reported no disclosures.

Obesity may be the leading risk factor for an enlarged left atrium as patients get older, researchers said.

Being obese was associated with nearly two and a half times the risk of left atrial enlargement, Heribert Schunkert, MD, of the University of Lubeck in Germany, and colleagues reported in the Nov. 17 issue of the Journal of the American College of Cardiology.

Hypertension was also associated with more than a twofold increased risk of having an enlarged left atrium.

But in linear regression models, the effect of obesity “was almost twice the effect of hypertension,” the researchers said.

They explained that obesity and arterial hypertension cause a variety of structural and functional cardiac changes that may affect left atrial size.

While left atrial enlargement is a risk factor for atrial fibrillation, stroke, and death, they said, little is known about determinants of left atrium size in the general population.

So they looked at a subgroup of the prospective MONICA 3S study of 1,212 German patients ages 25 to 74 who were enrolled between October 1994 and June 1995.

Left atrial enlargement was determined by an echocardiography at baseline and again after 10 years. At baseline, the prevalence of left atrial enlargement was 9.8%.

Overall, the researchers found strong associations between left atrium size and obesity, arterial hypertension, and age.

Prevalence of left atrial enlargement was lowest in the normal-weight and normotensive group (2.5% for men, 3.2% for women).

Normal-weight patients who had hypertension had a significantly higher prevalence of left atrial enlargement (15.2% for men, 11% for women), as did obese patients who were normotensive (12.2% for men and 13.6% for women).

The highest prevalence was observed among obese patients who had hypertension (15.7% for men, 30.5% for women).

In adjusted prevalence models, both obesity and hypertension were predictors of the condition (OR 2.4 and OR 2.2, respectively).

But in adjusted incidence models, obesity was associated with nearly a threefold increased risk, while the odds ratio for hypertension fell to just above one.

Looking at adjusted mean values, patients who were obese and had hypertension had the highest rates of left atrial enlargement (30.0 ml/m). They also had the highest increase in enlargement and the highest incidence of the disease on follow-up, the researchers said.

They also said the results suggest that left atrial enlargement in obese and hypertensive patients may be tied to different pathophysiological mechanisms.

In hypertensive patients, cardiac adaptations may result from pressure overload of the left atrium that is primarily related to impaired filling, secondary to concentric hypertrophy, the researchers said.

Obese patients, on the other hand, may have left-atrial dilation as a result of hemodynamic alterations like increased intravascular volume and increased cardiac output. These changes may lead to left atrium volume overload, they said.

Given the increasing prevalence of obesity, they said, early interventions — especially in young obese patients — are “essential to prevent premature onset of cardiac remodeling.”

They noted that it’s unclear, however, to what extent weight maintenance or moderate weight loss has beneficial effects resulting in regression of left atrial enlargement.

The study was limited by not being able to assess other biological fluctuations that may have occurred over the 10 years.

The study was supported by the German Heart Failure Network, the Federal Ministry of Education and Research, the Deutsch Forschungsgemeinschaft, the Bundesministerium fur Forschung and Technologie, the Medical Faculty at the University of Lubeck, and the European Union-sponsored project Cardiogenics.

The researchers reported no conflicts of interest.

NEW YORK — Even as the U.S. dollar sags, many Americans are still heading overseas for bargains on elective cosmetic procedures and other surgical care they could not afford otherwise.

In some cases, they are also seeking experimental therapy unavailable in the U.S., such as last-ditch stem-cell-infusion therapy for myocardial ischemia. They may also be trying to jump to the head of the line for an organ transplant.

The scope of so-called medical tourism depends on how it is defined. It could be as mundane as simply crossing the border by car for simple dental work. It could mean elaborate highly planned excursions to Malaysia, Thailand, Singapore, India, Argentina, Brazil, Costa Rica, El Salvador, Turkey, and other destinations.

Watch: Clinical Presentation:Suphachai Chaithiraphan, M.D.

PARIS, Dec. 19 — Children exposed to extensive phototherapy to treat neonatal jaundice had twice as many moles at age nine as controls, found a small case-control study.

The mean nevus count was 3.5 (0.05; median 3.0) per child in the exposed group versus 1.45 (1.99; median 1.0) in the control group (P=0.02 for mean, P=0.01 for median), said Emmanuelle Matichard, M.D., of Bichat-Claude Bernard Hospital here, and colleagues.

“When the analysis was limited to nevus size 2 to 5 mm, the difference was more significant (P=0.006 for median and P=0.008 for mean),” the authors reported in the December issue of Archives of Dermatology.

Moreover, when nevi risks such as skin type, fair hair and light eye were considered, “the link between phototherapy and nevi 2 to 5 mm and 2 mm or larger remained significant (respectively P?‰¤0.001 and P=0.003).”

Higher numbers of acquired nevi are associated with an increased risk of melanoma, but that association was based on the acquisition of nevi by fair-skinned individuals exposed to sunlight. The association between melanoma risk and the acquisition of nevi as a result of phototherapy is not known, the authors explained.

But they concluded that children “who receive phototherapy must be targeted for prevention and surveillance.”

Regardless of these findings, “neonatal phototherapy remains the treatment of choice for neonatal hyperbilirubinemia.”

The study enrolled 58 children born in 1994 and 1995. Eighteen of the children received blue light therapy for treatment of jaundice during the first days following birth. These cases were matched with 40 children born during the same period who did not develop jaundice and who were not exposed to blue light therapy.

Neither group included children with tan or black skin, and the sunlight exposure was similar for both groups.

A single dermatologist performed a complete clinical examination of each child and melanocytic nevus was defined as a brown to black macule or papule. Freckles and caf?© au lait macules were excluded from the nevus count.

The nevi were also measured and categorized by size: < 2 mm (lentigo simples; 2-5 mm; and >5 mm).

All children had at least one melanocytic nevus, but when lentigo simplex was excluded from the count only 37 children had nevi and the mean nevus count decreased to 2.09 (SD 2.53) per child versus 28.5 (SD 15.33) per child when lentigo simplex were included.

The study also confirmed that sun exposure “especially during vacations, is strongly associated with total nevus count” and the association was most significant for nevi of 2 mm to 5 mm (P=0.005 for mean).

An unexpected finding was that history of one or more severe sunburns was not a risk factor for nevus development.

The findings raise the possibility that bilirubin is a photosensitizer, which would explain “why neonatal intensive phototherapy seem to associated with nevus count in this study and why this risk factor has not been identified until now,” they wrote.

Another possible explanation is that the characteristics of neonatal skin — reduced enzymatic activity, low metabolic detoxification, greater penetrability, and incompletely activated immunologic defense — may increase photosensitivity.

The authors caution, however, that the “small group sizes limit the power of the results” in this study. Another limitation was the failure to calculate the number of nevi per square meter of body surface, which would have allowed the authors to obtain more comparable data from other studies.

The authors reported no financial disclosures.

Primary source: Archives of Dermatology

Source reference:
Matichard E et al “Effect of Neonatal Phototherapy on Melanocytic Nevus Count in Children” Arch Dermatol 2006; 142:1599-1604.

Besides preventing clinical adverse events, cardiac resynchronization therapy with defibrillator (CRT-D) also improves health status in patients with mild congestive heart failure (CHF), according to a small, multicenter study.

One year after CRT-D implantation, New York Heart Association (NYHA) functional class II patients (mild CHF) reported significant improvement across three of eight health status domains: role physical functioning, social functioning, and vitality (P<0.001 for all), according to Susanne Pedersen, PhD, from Tilburg University, in Tilburg, the Netherlands, and colleagues.

Overall, those with class II heart failure improved in six of eight health status domains at 12 months compared with only two improved domains for those with class III heart failure, after adjusting for demographic and clinical factors, according to the study published online in the American Journal of Cardiology.

Researchers noted that studies involving class III and IV heart failure patients with CRT-D inevitably showed positive benefit, while studies with patients with less severe heart failure have demonstrated no health benefit.

“An explanation could be that mildly symptomatic patients have less room for improvement or that the follow-up time should be longer than the six months used in the latter studies to be able to demonstrate a benefit,” they wrote.

Pedersen and colleagues therefore sought to compare the changes in health status between those with class II and class III CHF at 12 months post-CRT-D implantation.

They utilized a set of standardized and validated questionnaires (the SF-36 Health Survey) to assess health status at baseline and 12 months.

The SF-36 comprises 36 items, divided into eight subscales: physical functioning, role physical functioning, bodily pain, general health, social functioning, role emotional functioning, mental health, and vitality.

Scores were converted between 0 and 100, with a higher score representing better function.

A total cohort of 169 patients (25% women) completed the survey at baseline and follow-up: 54 NYHA class II (20% women) and 115 NYHA class III patients (27% women).

Changes in health status between the two groups were similar after adjusting for baseline health status.

However, after adjusting for demographic and clinical factors, the researchers found that the NYHA class II patients fared better after CRT-D than the NYHA class III patients, particularly in general health and social functioning.

“NYHA functional class II patients scored on average 10.15 points higher on general health (SE 3.31, P=0.003) and 10.64 points higher on social functioning (SE 3.74, P=0.005) at 12 months after implantation compared to the NYHA functional class III patients,” they wrote.

The team also found that the use of psychotropic medication was associated with significantly less improvement in their study group, while a prolonged QRS duration equal to or greater than 150 ms was associated with more improvement.

The latter benefit “emphasizes that CRT-D is particularly effective in patients with significant inter- or intraventricular conduction delays,” researchers wrote.

In addition, defibrillator shocks during follow-up were not associated with a change in health status domain scores.

The researchers observed that a limitation of their study was that it did not control for CRT-D response or nonresponse because of a lack of information on NYHA class change, left ventricular ejection fraction, and QRS duration during the follow-up period.

In addition, they noted the limitation of a small sample size of patients with class II heart failure and the use of a generic rather than a disease-specific measure of health status.

“The present study suggests that mildly symptomatic CHF patients might also benefit from [CRT-D] in terms of improved health status,” the authors wrote. “The results of the present study show that it is important to look at the dimensions of health status separately, because using an overall score of health status may mask differences between subgroups on different dimensions of health status.”

The study was funded by grants from the Scientific Research and the Health Research and Development Organizations in the Netherlands.

Pedersen has received consultancy or speakers’ fees from Cameron Health Corporation, Medtronic, St. Jude Medical, and sanofi aventis.

Co-authors reported receiving speakers’ fees, research grants, and/or consultancy fees from multiple companies including Sorin Group, Boston Scientific, Biotronik, and St. Jude Medical.

CHICAGO, June 1 — In this exclusive live broadcast, researchers review the latest advances in polyp detection, colorectal cancer risk assessment and timing of follow-up preventive colonoscopy, and new thinking on sedation during colonoscopy.