Cure rate was higher and patients were more satisfied with sphincterotomy.
Chronic anal fissure usually is treated with nitroglycerin ointment, botulinum toxin (Botox) injection, or lateral internal sphincterotomy. All three treatments decrease anal sphincter pressure and improve anal blood flow. Lateral internal sphincterotomy has the highest cure rate but has been associated with postoperative incontinence in retrospective studies.
Now, researchers report 6-year follow-up results from a randomized controlled trial in which 82 patients received thrice-daily nitroglycerin ointment (0.25%) or underwent lateral internal sphincterotomy. Participants were enrolled from February 1997 through October 1998. Sixty-two percent of patients (27 in the nitroglycerin arm and 24 in the sphincterotomy arm) responded to a telephone survey in 2004 about treatment outcomes.
Recurrent fissure symptoms were less likely to have occurred in the sphincterotomy arm than in the nitroglycerin arm (0% vs. 41%; P=0.0004), and sphincterotomy patients were less likely to have required additional surgical treatment (0% vs. 59%; P<0.0001). The sphincterotomy patients were more likely to say that they were "moderately" or "very" satisfied with treatment (100% vs. 56%; P=0.04) and that they would use the same therapy again (92% vs. 63%; P=0.02). Fecal incontinence scores were similar in the two groups.
Comment: Provided that a surgeon who is skilled in lateral internal sphincterotomy is available, few downsides to this procedure exist. Initial use of topical nitroglycerin or Botox injection still is reasonable, but, given these data, repeated courses of medical therapy probably are not the best choice for patients with recurrent or persistent chronic fissure.
— Douglas K. Rex, MD
Published in Journal Watch Gastroenterology June 29, 2007
Citation(s):
Brown CJ et al. Lateral internal sphincterotomy is superior to topical nitroglycerin for healing chronic anal fissure and does not compromise long-term fecal continence: Six-year follow-up of a multicenter, randomized, controlled trial. Dis Colon Rectum 2007 Apr; 50:442-8.
Saturday, June 30, 2007
Sunday, June 24, 2007
Estrogen Therapy Associated with Lower Levels of Coronary-Artery Calcification
Physicians First Watch June 21, 2007
Estrogen therapy in younger postmenopausal women is associated with less coronary-artery calcification, reports a study in the New England Journal of Medicine.
Researchers studied some 1000 women from the Women's Health Initiative who were aged 50 to 59 at randomization, had previously undergone hysterectomy, and received conjugated equine estrogens or placebo for a mean of 7.4 years. Some 1.3 years after the trial was stopped (because of alarm over the number of cardiovascular events across all age ranges) and thus 8.7 years after randomization, the women underwent CT of the heart.
The mean calcium score was 83.1 for women on estrogens and 123.1 for those on placebo — a statistically significant difference.
The authors write that their results provide support "for the hypothesis that estrogen therapy may have cardioprotective effects in younger women." However, editorialists emphasize — as the authors do — that estrogens should not be used to prevent CVD
Estrogen therapy in younger postmenopausal women is associated with less coronary-artery calcification, reports a study in the New England Journal of Medicine.
Researchers studied some 1000 women from the Women's Health Initiative who were aged 50 to 59 at randomization, had previously undergone hysterectomy, and received conjugated equine estrogens or placebo for a mean of 7.4 years. Some 1.3 years after the trial was stopped (because of alarm over the number of cardiovascular events across all age ranges) and thus 8.7 years after randomization, the women underwent CT of the heart.
The mean calcium score was 83.1 for women on estrogens and 123.1 for those on placebo — a statistically significant difference.
The authors write that their results provide support "for the hypothesis that estrogen therapy may have cardioprotective effects in younger women." However, editorialists emphasize — as the authors do — that estrogens should not be used to prevent CVD
ACIP Recommendations on Varicella Immunization
The CDC's Advisory Committee on Immunization Practices has issued its recommendations for preventing varicella.
The recommendations, published as a supplement to MMWR, include the following highlights:
• Children should receive two doses of the vaccine, one between 12 and 15 months of age, and the other between the ages of 4 and 6.
• Healthy adults and adolescents without evidence of immunity should receive two doses, 4 to 8 weeks apart.
• A second dose is recommended for all those who have received only a single previous dose.
Full recommendations are available on the CDC's website.
The recommendations, published as a supplement to MMWR, include the following highlights:
• Children should receive two doses of the vaccine, one between 12 and 15 months of age, and the other between the ages of 4 and 6.
• Healthy adults and adolescents without evidence of immunity should receive two doses, 4 to 8 weeks apart.
• A second dose is recommended for all those who have received only a single previous dose.
Full recommendations are available on the CDC's website.
Lowering Blood Pressure Improves Diastolic Function, Regardless of Regimen
Reductions in blood pressure lead to improved diastolic function — regardless of the antihypertensive drugs used — reports a study in Lancet.
Researchers sought to determine whether the angiotensin-receptor blocker valsartan would be more effective than other antihypertensives at improving diastolic function. They randomized nearly 400 patients with hypertension and evidence of diastolic dysfunction to receive either the ARB or placebo. The patients also received other classes of antihypertensive agents to lower blood pressure to below 135/80 mm Hg.
After 38 weeks, tissue Doppler imaging showed improved diastolic function in both valsartan and placebo recipients, but there was no significant difference between the groups.
Authors of an accompanying commentary note that valsartan might have an advantage in patients with more advanced left ventricular remodeling. Nevertheless, they add, "the good news is that lowering blood pressure improves diastolic function, irrespective of the antihypertensive regimen used."
Researchers sought to determine whether the angiotensin-receptor blocker valsartan would be more effective than other antihypertensives at improving diastolic function. They randomized nearly 400 patients with hypertension and evidence of diastolic dysfunction to receive either the ARB or placebo. The patients also received other classes of antihypertensive agents to lower blood pressure to below 135/80 mm Hg.
After 38 weeks, tissue Doppler imaging showed improved diastolic function in both valsartan and placebo recipients, but there was no significant difference between the groups.
Authors of an accompanying commentary note that valsartan might have an advantage in patients with more advanced left ventricular remodeling. Nevertheless, they add, "the good news is that lowering blood pressure improves diastolic function, irrespective of the antihypertensive regimen used."
FDA Approves First Drug for Fibromyalgia
The FDA has approved pregabalin (Lyrica) for treating fibromyalgia.
The drug is the first treatment for the condition; it was approved in 2004 for use in diabetic peripheral neuropathy and postherpetic neuralgia. The expanded approval was based on two double-blind controlled trials involving about 1800 patients. Lyrica "reduces pain and improves daily functions for some patients," according to the FDA. The agency says that the drug's mechanism is unknown.
The manufacturer, Pfizer, has agreed to study use of the drug in children and breast-feeding women, according to the FDA.
The most common side effects are mild-to-moderate dizziness and sleepiness.
The drug is the first treatment for the condition; it was approved in 2004 for use in diabetic peripheral neuropathy and postherpetic neuralgia. The expanded approval was based on two double-blind controlled trials involving about 1800 patients. Lyrica "reduces pain and improves daily functions for some patients," according to the FDA. The agency says that the drug's mechanism is unknown.
The manufacturer, Pfizer, has agreed to study use of the drug in children and breast-feeding women, according to the FDA.
The most common side effects are mild-to-moderate dizziness and sleepiness.
Lab Screening in Children with Suspected Inflammatory Bowel Disease
When clinical suspicion is high, normal screening lab values have limited value.
Primary care clinicians often perform screening laboratory tests when they suspect that a child might have inflammatory bowel disease (IBD). Investigators evaluated the screening utility of hemoglobin values, platelet counts, erythrocyte sedimentation rate (ESR), and albumin levels using prospectively collected data from a multisite registry of 526 children (mean age, 11.6 years) who were newly diagnosed with IBD (392 with Crohn disease; 134 with ulcerative colitis).
All four tests were normal in 30% of children with mild disease (21% of patients with Crohn disease and 54% of those with ulcerative colitis), compared with only 4% of children with moderate or severe IBD. Of the four tests, ESR was the least likely to be normal (defined as <20 mm/hour), regardless of disease severity. For example, among children with moderate or severe IBD, 18% had normal ESRs, 24% had normal hemoglobin levels, 43% had normal platelet counts, and 50% had normal albumin levels. Hematochezia was the most common presenting feature in children with mild IBD.
Comment: These results indicate that the four IBD screening tests assessed have limited value. I wish the authors had performed more sophisticated analyses, such as calculating sensitivity for different combinations of laboratory values, because early identification of children with IBD is important. The authors note that new laboratory markers, such as antibodies against neutrophils or microbial antigens, and antiglycan antibodies, might hold greater promise.
— Howard Bauchner, MD
Published in Journal Watch Pediatrics and Adolescent Medicine June 13, 2007
Citation(s):
Mack DR et al. Laboratory values for children with newly diagnosed inflammatory bowel disease. Pediatrics 2007 Jun; 119:1113-9.
Primary care clinicians often perform screening laboratory tests when they suspect that a child might have inflammatory bowel disease (IBD). Investigators evaluated the screening utility of hemoglobin values, platelet counts, erythrocyte sedimentation rate (ESR), and albumin levels using prospectively collected data from a multisite registry of 526 children (mean age, 11.6 years) who were newly diagnosed with IBD (392 with Crohn disease; 134 with ulcerative colitis).
All four tests were normal in 30% of children with mild disease (21% of patients with Crohn disease and 54% of those with ulcerative colitis), compared with only 4% of children with moderate or severe IBD. Of the four tests, ESR was the least likely to be normal (defined as <20 mm/hour), regardless of disease severity. For example, among children with moderate or severe IBD, 18% had normal ESRs, 24% had normal hemoglobin levels, 43% had normal platelet counts, and 50% had normal albumin levels. Hematochezia was the most common presenting feature in children with mild IBD.
Comment: These results indicate that the four IBD screening tests assessed have limited value. I wish the authors had performed more sophisticated analyses, such as calculating sensitivity for different combinations of laboratory values, because early identification of children with IBD is important. The authors note that new laboratory markers, such as antibodies against neutrophils or microbial antigens, and antiglycan antibodies, might hold greater promise.
— Howard Bauchner, MD
Published in Journal Watch Pediatrics and Adolescent Medicine June 13, 2007
Citation(s):
Mack DR et al. Laboratory values for children with newly diagnosed inflammatory bowel disease. Pediatrics 2007 Jun; 119:1113-9.
Effect of Soy Intake on Blood Pressure and Lipids
In hypertensive women who added soy to their diets, blood pressure decreased.
Dietary soy is one of several factors that might explain the lower incidence of coronary heart disease in Asian countries than in Western countries. In a randomized, crossover trial, 60 healthy postmenopausal women followed the National Cholesterol Education Program (NCEP) diet or the NCEP diet with 25 g of soy protein supplied as one half cup of unsalted soy nuts (i.e., roasted soy beans) daily while maintaining an equivalent total protein content. Each phase was continued for 8 weeks, and researchers assessed the effect of the diets upon lipids and blood pressure (BP). Patients with systolic BP 165 mm Hg or diastolic BP of 100 mm Hg were excluded from the trial.
Mean BP was lower with soy than without, both among hypertensive women (137/82 vs. 152/88 mm Hg) and normotensive women (110/67 vs. 116/69 mm Hg). The soy diet was significantly lower in total and saturated fat than the control diet. Nonetheless, among normotensive women, total, LDL, and HDL cholesterol levels did not differ across diets. Among hypertensive women, LDL decreased by 11%; total and HDL cholesterol levels did not differ significantly.
Comment: In this small randomized crossover trial, adding soy protein to a diet showed impressive reductions in blood pressure; the magnitude of this effect was surprising and certainly requires confirmation. In contrast, the effect upon lipids was limited.
— Jamaluddin Moloo, MD, MPH
Published in Journal Watch General Medicine June 14, 2007
Citation(s):
Welty FK et al. Effect of soy nuts on blood pressure and lipid levels in hypertensive, prehypertensive, and normotensive postmenopausal women. Arch Intern Med 2007 May 28; 167:1060-7.
Dietary soy is one of several factors that might explain the lower incidence of coronary heart disease in Asian countries than in Western countries. In a randomized, crossover trial, 60 healthy postmenopausal women followed the National Cholesterol Education Program (NCEP) diet or the NCEP diet with 25 g of soy protein supplied as one half cup of unsalted soy nuts (i.e., roasted soy beans) daily while maintaining an equivalent total protein content. Each phase was continued for 8 weeks, and researchers assessed the effect of the diets upon lipids and blood pressure (BP). Patients with systolic BP 165 mm Hg or diastolic BP of 100 mm Hg were excluded from the trial.
Mean BP was lower with soy than without, both among hypertensive women (137/82 vs. 152/88 mm Hg) and normotensive women (110/67 vs. 116/69 mm Hg). The soy diet was significantly lower in total and saturated fat than the control diet. Nonetheless, among normotensive women, total, LDL, and HDL cholesterol levels did not differ across diets. Among hypertensive women, LDL decreased by 11%; total and HDL cholesterol levels did not differ significantly.
Comment: In this small randomized crossover trial, adding soy protein to a diet showed impressive reductions in blood pressure; the magnitude of this effect was surprising and certainly requires confirmation. In contrast, the effect upon lipids was limited.
— Jamaluddin Moloo, MD, MPH
Published in Journal Watch General Medicine June 14, 2007
Citation(s):
Welty FK et al. Effect of soy nuts on blood pressure and lipid levels in hypertensive, prehypertensive, and normotensive postmenopausal women. Arch Intern Med 2007 May 28; 167:1060-7.
Friday, June 15, 2007
Calcium and Vitamin D Intake and Risk for Breast Cancer
Higher calcium and vitamin D intake showed modest benefit in premenopausal women.
Animal experiments and observational human studies suggest that calcium and vitamin D may decrease risk for breast cancer. Researchers prospectively assessed this relation among 10,000 premenopausal and 20,000 postmenopausal women enrolled in the Women’s Health Study. Calcium and vitamin D intake was determined from self-reported questionnaires about food and vitamin supplement intake.
During a mean follow-up of 10 years, the overall incidence of invasive breast cancer was 2.6% among premenopausal women and 3.6% among postmenopausal women. The hazard ratio for developing invasive breast cancer was 0.61 for premenopausal women at the highest versus lowest quintiles of calcium intake and 0.65 for vitamin D intake. No relation was found between calcium and vitamin D intake and risk for invasive breast cancer among postmenopausal women.
Comment: In this large, prospective study, a higher intake of calcium and vitamin D was associated with a lower risk for invasive breast cancer among premenopausal but not postmenopausal women. Although the hazard ratios appear relatively large, the absolute risk reduction was modest. Limitations of this study include ascertainment of calcium and vitamin D intake only once at baseline and the possibility that unmeasured confounding variables explain the findings in this nonrandomized assessment of diet.
— Jamaluddin Moloo, MD, MPH
Published in Journal Watch General Medicine June 14, 2007
Citation(s):
Lin J et al. Intakes of calcium and vitamin D and breast cancer risk in women. Arch Intern Med 2007 May 28; 167:1050-9
Animal experiments and observational human studies suggest that calcium and vitamin D may decrease risk for breast cancer. Researchers prospectively assessed this relation among 10,000 premenopausal and 20,000 postmenopausal women enrolled in the Women’s Health Study. Calcium and vitamin D intake was determined from self-reported questionnaires about food and vitamin supplement intake.
During a mean follow-up of 10 years, the overall incidence of invasive breast cancer was 2.6% among premenopausal women and 3.6% among postmenopausal women. The hazard ratio for developing invasive breast cancer was 0.61 for premenopausal women at the highest versus lowest quintiles of calcium intake and 0.65 for vitamin D intake. No relation was found between calcium and vitamin D intake and risk for invasive breast cancer among postmenopausal women.
Comment: In this large, prospective study, a higher intake of calcium and vitamin D was associated with a lower risk for invasive breast cancer among premenopausal but not postmenopausal women. Although the hazard ratios appear relatively large, the absolute risk reduction was modest. Limitations of this study include ascertainment of calcium and vitamin D intake only once at baseline and the possibility that unmeasured confounding variables explain the findings in this nonrandomized assessment of diet.
— Jamaluddin Moloo, MD, MPH
Published in Journal Watch General Medicine June 14, 2007
Citation(s):
Lin J et al. Intakes of calcium and vitamin D and breast cancer risk in women. Arch Intern Med 2007 May 28; 167:1050-9
Monday, June 11, 2007
FDA Approves Extended-Release Zyflo
The FDA has approved an extended-release formulation of the asthma drug, Zyflo (zileuton), the manufacturer announced.
The leukotriene synthesis inhibitor is approved for the prevention and chronic treatment of asthma in patients ages 12 and older and will be marketed as Zyflo CR, beginning in the fall. The recommended dosage is two 600-mg tablets twice a day.
Zyflo CR is contraindicated in patients with active liver disease or elevated liver enzymes. The manufacturer reminds physicians to measure patients' liver enzyme levels before beginning treatment and at regular intervals thereafter.
JW June 2007
The leukotriene synthesis inhibitor is approved for the prevention and chronic treatment of asthma in patients ages 12 and older and will be marketed as Zyflo CR, beginning in the fall. The recommended dosage is two 600-mg tablets twice a day.
Zyflo CR is contraindicated in patients with active liver disease or elevated liver enzymes. The manufacturer reminds physicians to measure patients' liver enzyme levels before beginning treatment and at regular intervals thereafter.
JW June 2007
Reducing the Intensity of Treatment in Mild Asthma
Two randomized trials demonstrate the feasibility of step-down therapy in patients whose asthma is well controlled.
Many patients with mild asthma take standard daily doses of inhaled corticosteroids indefinitely. Two new industry-supported, placebo-controlled, randomized trials — each with about 500 participants whose mild asthma was controlled with twice-daily inhaled steroids — show that "step-down" therapy may be reasonable for such patients.
One study compared twice-daily inhaled steroid therapy with once-daily oral or inhaled alternatives. Patients received one of three treatments: inhaled fluticasone (Flovent Diskus, 100 µg), twice daily; combined fluticasone/salmeterol (Advair Diskus, 100/50 µg), once daily in the evening; or oral montelukast (Singulair), once daily. At 16 weeks, treatment failure (an endpoint that included several clinical and spirometric outcomes) had occurred in 20% of patients in each inhaled-therapy group and in 30% of montelukast patients, a significant difference. This difference reflected primarily spirometric outcomes, and not differences in need for systemic steroids or urgent asthma care.
The second study examined the relatively novel idea that as-needed inhaled steroids might be as effective as daily maintenance therapy. Patients received one of four treatments: twice-daily inhaled beclomethasone (250 µg) with as-needed albuterol; twice-daily combined beclomethasone/albuterol, with as-needed albuterol; the same beclomethasone/albuterol combination, but only as needed; and as-needed albuterol only. At 6 months, the primary outcome — morning peak expiratory flow rate — was similar in the twice-daily beclomethasone and the as-needed beclomethasone/albuterol groups, and was significantly higher in both groups than in the as-needed albuterol group. Both twice-daily beclomethasone and as-needed beclomethasone/albuterol were associated with fewer exacerbations than as-needed albuterol.
Comment: These important trials demonstrate the feasibility of step-down therapy in patients whose mild persistent asthma is well controlled with standard twice-daily inhaled corticosteroids. An objective of this research is to minimize cumulative lifetime exposure to inhaled steroids, which may have systemic effects after years of use. The first trial shows that once-daily montelukast or a once-daily combination of an inhaled steroid plus salmeterol are both reasonable alternatives (although treatment failures occurred somewhat more frequently with montelukast). In the second trial, symptom-driven inhaled corticosteroids worked as well as daily therapy in patients with mild asthma.
— Allan S. Brett, MD
Published in Journal Watch General Medicine May 16, 2007
http://content.nejm.org/cgi/content/full/356/20/2040
Many patients with mild asthma take standard daily doses of inhaled corticosteroids indefinitely. Two new industry-supported, placebo-controlled, randomized trials — each with about 500 participants whose mild asthma was controlled with twice-daily inhaled steroids — show that "step-down" therapy may be reasonable for such patients.
One study compared twice-daily inhaled steroid therapy with once-daily oral or inhaled alternatives. Patients received one of three treatments: inhaled fluticasone (Flovent Diskus, 100 µg), twice daily; combined fluticasone/salmeterol (Advair Diskus, 100/50 µg), once daily in the evening; or oral montelukast (Singulair), once daily. At 16 weeks, treatment failure (an endpoint that included several clinical and spirometric outcomes) had occurred in 20% of patients in each inhaled-therapy group and in 30% of montelukast patients, a significant difference. This difference reflected primarily spirometric outcomes, and not differences in need for systemic steroids or urgent asthma care.
The second study examined the relatively novel idea that as-needed inhaled steroids might be as effective as daily maintenance therapy. Patients received one of four treatments: twice-daily inhaled beclomethasone (250 µg) with as-needed albuterol; twice-daily combined beclomethasone/albuterol, with as-needed albuterol; the same beclomethasone/albuterol combination, but only as needed; and as-needed albuterol only. At 6 months, the primary outcome — morning peak expiratory flow rate — was similar in the twice-daily beclomethasone and the as-needed beclomethasone/albuterol groups, and was significantly higher in both groups than in the as-needed albuterol group. Both twice-daily beclomethasone and as-needed beclomethasone/albuterol were associated with fewer exacerbations than as-needed albuterol.
Comment: These important trials demonstrate the feasibility of step-down therapy in patients whose mild persistent asthma is well controlled with standard twice-daily inhaled corticosteroids. An objective of this research is to minimize cumulative lifetime exposure to inhaled steroids, which may have systemic effects after years of use. The first trial shows that once-daily montelukast or a once-daily combination of an inhaled steroid plus salmeterol are both reasonable alternatives (although treatment failures occurred somewhat more frequently with montelukast). In the second trial, symptom-driven inhaled corticosteroids worked as well as daily therapy in patients with mild asthma.
— Allan S. Brett, MD
Published in Journal Watch General Medicine May 16, 2007
http://content.nejm.org/cgi/content/full/356/20/2040
FDA Approves 7-Day Glucose Monitoring System
The FDA has approved a new continuous glucose monitoring system that doubles the time between sensor replacements, making the system more convenient for patients with diabetes.
The agency says that the percutaneous STS-7 system was found to be "safe and effective for detecting trends and tracking patterns of glucose levels in adults" in tests conducted in 72 patients at five clinical sites. The probe measures glucose levels every 5 minutes and has an alarm that can be set to warn of hypo- or hyperglycemia. Patients must replace the sensor weekly; an earlier, 3-day version received FDA approval in March of last year.
FDA Announcement: http://www.fda.gov/bbs/topics/NEWS/2007/NEW01647.html
The agency says that the percutaneous STS-7 system was found to be "safe and effective for detecting trends and tracking patterns of glucose levels in adults" in tests conducted in 72 patients at five clinical sites. The probe measures glucose levels every 5 minutes and has an alarm that can be set to warn of hypo- or hyperglycemia. Patients must replace the sensor weekly; an earlier, 3-day version received FDA approval in March of last year.
FDA Announcement: http://www.fda.gov/bbs/topics/NEWS/2007/NEW01647.html
Newborn Screening for Cystic Fibrosis Is Cost-Effective
Newborn Screening for Cystic Fibrosis Is Cost-Effective
The cost of screening is offset by lower treatment costs.
Newborn screening for cystic fibrosis (CF) is gaining acceptance. Investigators in the U.K. used a national registry to assess the cost-benefit of newborn CF screening. They compared estimated yearly treatment costs for 184 CF patients who were diagnosed by newborn screening and 950 CF patients who were diagnosed based on clinical symptoms at ages 1 to 9 years in 2002.
The treatment cost was 400% less for CF children diagnosed by newborn screening than for those diagnosed clinically (mean cost, US$7228 vs. US$12,008). The cost was 500% less for children diagnosed using homozygous F508 newborn screening compared with those diagnosed clinically. After adjustments for age and Pseudomonas infections, clinically diagnosed children had higher treatment costs per patient than children diagnosed by newborn screening, regardless of whether screening was based on the F508 mutation. The authors estimated that the cost savings associated with newborn screening would substantially offset the costs of instituting a national CF screening program in the U.K.
Comment: These data are important from both a policy and a clinical viewpoint. Diagnosis of CF by newborn screening is cost-effective. Early diagnosis of CF offers the opportunity for anticipatory management, reduced infections, improved nutrition, and as this study shows, lower treatment costs. Once all newborns are screened for CF, clinical outcomes should continue to improve.
— F. Bruder Stapleton, MD
Published in Journal Watch Pediatrics and Adolescent Medicine June 6, 2007
Citation(s):
Sims EJ et al. Economic implications of newborn screening for cystic fibrosis: A cost of illness retrospective cohort study. Lancet 2007 Apr 7; 369:1187-95.
The cost of screening is offset by lower treatment costs.
Newborn screening for cystic fibrosis (CF) is gaining acceptance. Investigators in the U.K. used a national registry to assess the cost-benefit of newborn CF screening. They compared estimated yearly treatment costs for 184 CF patients who were diagnosed by newborn screening and 950 CF patients who were diagnosed based on clinical symptoms at ages 1 to 9 years in 2002.
The treatment cost was 400% less for CF children diagnosed by newborn screening than for those diagnosed clinically (mean cost, US$7228 vs. US$12,008). The cost was 500% less for children diagnosed using homozygous F508 newborn screening compared with those diagnosed clinically. After adjustments for age and Pseudomonas infections, clinically diagnosed children had higher treatment costs per patient than children diagnosed by newborn screening, regardless of whether screening was based on the F508 mutation. The authors estimated that the cost savings associated with newborn screening would substantially offset the costs of instituting a national CF screening program in the U.K.
Comment: These data are important from both a policy and a clinical viewpoint. Diagnosis of CF by newborn screening is cost-effective. Early diagnosis of CF offers the opportunity for anticipatory management, reduced infections, improved nutrition, and as this study shows, lower treatment costs. Once all newborns are screened for CF, clinical outcomes should continue to improve.
— F. Bruder Stapleton, MD
Published in Journal Watch Pediatrics and Adolescent Medicine June 6, 2007
Citation(s):
Sims EJ et al. Economic implications of newborn screening for cystic fibrosis: A cost of illness retrospective cohort study. Lancet 2007 Apr 7; 369:1187-95.
caffeine for apnea in premies
Caffeine for Apnea — Why Check the Level?
Summary and Comment | Subscription Required
Routine monitoring of plasma caffeine levels in premature infants is unnecessary.
By Cornelius W. Van Niel, MD
June 6, 2007
Covering: Natarajan G et al. Pediatrics 2007 May 119:936-40
Summary and Comment | Subscription Required
Routine monitoring of plasma caffeine levels in premature infants is unnecessary.
By Cornelius W. Van Niel, MD
June 6, 2007
Covering: Natarajan G et al. Pediatrics 2007 May 119:936-40
vaginal atrophy NAM recs June 2007
?I don't see a distinction between persons w/ and w/o uterus...
Practice Watch
Treating Vaginal Atrophy with Local Estrogen
NAMS guidelines state that therapy choice should be individualized based on clinical experience and patient preference.
Unlike vasomotor symptoms, the vaginal atrophy accompanying postmenopausal estrogen loss worsens rather than abates with time. Up to 40% of postmenopausal women experience vaginal dryness, vulvovaginal irritation and itching, or dyspareunia, although only about 25% of symptomatic women seek medical help. Localized estrogen delivered by vaginal cream, tablet, or ring is approved for use in North America and can alleviate symptoms without the adverse effects of systemic hormone therapy. The North American Menopause Society (NAMS) has published a position paper on the use of these modalities, based on available evidence. Highlights of the guidelines include the following:
Management goals are to relieve symptoms and reverse anatomic and physiologic changes associated with diminished estrogen levels.
Nonhormonal lubricants and moisturizers should be used as first-line approaches; symptoms that do not respond to these measures may require hormonal therapy.
Evidence supports the use of low-dose local estrogen as effective and well tolerated, with limited systemic absorption.
All U.S.-approved products — estradiol and conjugated estrogen vaginal creams, the estradiol vaginal ring, and the estradiol vaginal tablet — are equally effective at labeled doses. Progestogen need not be prescribed with these low-dose local estrogens.
Vaginal estrogen therapy should be continued as long as troublesome symptoms persist.
Women at high risk for endometrial cancer who use higher doses of vaginal estrogen or who experience spotting or breakthrough bleeding may need endometrial evaluation. Data are insufficient to recommend annual endometrial evaluation for asymptomatic vaginal estrogen users.
Vaginal atrophy in women with non–hormone-dependent cancers can be treated with vaginal estrogen. Therapy for women with histories of hormone-dependent cancer should be individualized, based on the women’s preferences in consultation with their oncologists.
Comment: Symptomatic vaginal atrophy can significantly impair sexual function and intimacy. Women who have been reluctant to use and clinicians who have hesitated to prescribe local vaginal estrogens because of concern about systemic absorption should be encouraged by these findings and recommendations. Because most symptomatic women do not seek medical assistance, clinicians should offer information about vaginal atrophy symptoms and treatments in their menopause counseling and should address this condition with periodic examinations if genital atrophy is identified.
— Diane E. Judge, APN/CNP
Published in Journal Watch Women's Health June 7, 2007
Citation(s):
The role of local vaginal estrogen for treatment of vaginal atrophy in postmenopausal women: 2007
Practice Watch
Treating Vaginal Atrophy with Local Estrogen
NAMS guidelines state that therapy choice should be individualized based on clinical experience and patient preference.
Unlike vasomotor symptoms, the vaginal atrophy accompanying postmenopausal estrogen loss worsens rather than abates with time. Up to 40% of postmenopausal women experience vaginal dryness, vulvovaginal irritation and itching, or dyspareunia, although only about 25% of symptomatic women seek medical help. Localized estrogen delivered by vaginal cream, tablet, or ring is approved for use in North America and can alleviate symptoms without the adverse effects of systemic hormone therapy. The North American Menopause Society (NAMS) has published a position paper on the use of these modalities, based on available evidence. Highlights of the guidelines include the following:
Management goals are to relieve symptoms and reverse anatomic and physiologic changes associated with diminished estrogen levels.
Nonhormonal lubricants and moisturizers should be used as first-line approaches; symptoms that do not respond to these measures may require hormonal therapy.
Evidence supports the use of low-dose local estrogen as effective and well tolerated, with limited systemic absorption.
All U.S.-approved products — estradiol and conjugated estrogen vaginal creams, the estradiol vaginal ring, and the estradiol vaginal tablet — are equally effective at labeled doses. Progestogen need not be prescribed with these low-dose local estrogens.
Vaginal estrogen therapy should be continued as long as troublesome symptoms persist.
Women at high risk for endometrial cancer who use higher doses of vaginal estrogen or who experience spotting or breakthrough bleeding may need endometrial evaluation. Data are insufficient to recommend annual endometrial evaluation for asymptomatic vaginal estrogen users.
Vaginal atrophy in women with non–hormone-dependent cancers can be treated with vaginal estrogen. Therapy for women with histories of hormone-dependent cancer should be individualized, based on the women’s preferences in consultation with their oncologists.
Comment: Symptomatic vaginal atrophy can significantly impair sexual function and intimacy. Women who have been reluctant to use and clinicians who have hesitated to prescribe local vaginal estrogens because of concern about systemic absorption should be encouraged by these findings and recommendations. Because most symptomatic women do not seek medical assistance, clinicians should offer information about vaginal atrophy symptoms and treatments in their menopause counseling and should address this condition with periodic examinations if genital atrophy is identified.
— Diane E. Judge, APN/CNP
Published in Journal Watch Women's Health June 7, 2007
Citation(s):
The role of local vaginal estrogen for treatment of vaginal atrophy in postmenopausal women: 2007
Concussion recommendations -- CDC June 2007
free tool kit including patient handout and field triage guide.
www.cdc.gov/ncipc/tbi/physicians_tool_kit.htm
Physician's First Watch for June 8, 2007
www.cdc.gov/ncipc/tbi/physicians_tool_kit.htm
Physician's First Watch for June 8, 2007
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