Morning Break: Deadbeat Patients, Fish in the Gullet?

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Published: Mar 20, 2014

Business owners who claim that forcing them to provide health insurance that covers contraception violates their religious freedom will get their day in court -- Supreme Court -- next Tuesday when the "Supremes" hear oral arguments on that issue. Kaiser Health News in collaboration with The Daily Beast preview talking points.

An ACA rule could put doctors on the hook for patients who don't pay their insurance premiums. Read MedPage Today's coverage of the AMA's advice to doctors on how to handle such patients.

A New England Journal of Medicine editorial Wednesday called for the Senate to confirm Vivek Murthy, MD as the next surgeon general despite his comments about gun control.

Since laughter is the best medicine, here's your Rx today: Dr. Grumpy relates what not to say to a blind patient.

If anyone has ever told you they felt it in their gut that dark chocolate is good for you, unfortunately, they are sort of right.

WHO says only one-quarter of patients globally with multidrug-resistant TB are diagnosed, but a new initiative is improving the odds.

People are passionate about food, as CNN.com learned from the dozens of responses to a story about the "correct" way to cook quinoa.

A nurse's conviction for encouraging suicides was overturned by the Minnesota Supreme Court Wednesday, ruling unconstitutional parts of a law making it a crime to encourage or advise suicide, Reuters reported.

In case you ever need to remove a live fish from a patient's throat, here's how.

GlaxoSmithKline's MAGE-A3 cancer vaccine disappointed again, this time in a phase III trial for non-small cell lung cancer. Last fall, it fell short as a melanoma treatment.

An op/ed on SGR asks: "Is this anyway to treat America's doctors?" by MedPage Today reader Brian Joondeph, MD.

What's the evidence for evidence-based medicine? asks a blogger at BMJ.

Leana Wen, MD, profiles The Ten Types of ER Patients.

William Heisel looks at what happens after doctors are disciplined by state medical boards.

Who had richer parents, doctors or artists? asks NPR.

The A4 Alzheimer's chemoprevention trial team lays out the plan and rationale in this essay in Science Translational Medicine (sub req'd).

Health reform is literally changing the way medical practices are built.

IBM's Watson will help match glioblastoma patients with optimal treatment as part of a study run by the New York Genome Center.

Morning Break is a daily guide to what's new and interesting on the Web for healthcare professionals, powered by the MedPage Today community. Got a tip? Send it to us:   MPT_editorial@everydayhealthinc.com.

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Certain Rheumatoid Arthritis Drugs May Also Protect Patients' Hearts, Studies Find

SATURDAY, Oct. 26 (HealthDay News) -- Drugs that people with rheumatoid arthritis use to help ease the symptoms of the disease might also help ward off heart trouble, two new studies find.

Researchers in Sweden found that so-called "biologic" drugs, known as tumor necrosis factor inhibitors, or anti-TNFs, slightly reduce the risk for acute coronary syndrome -- a condition that includes angina and heart attack in which blood supply to the heart muscle is suddenly blocked.

In another study, British scientists also found taking these drugs was associated with a lower risk for heart attack in patients with rheumatoid arthritis.

The findings were to be presented Saturday at the American College of Rheumatology's annual meeting in San Diego. Findings presented at medical meetings are typically considered preliminary until published in a peer-reviewed journal.

The roughly 1.3 million Americans affected by the rheumatoid arthritis, a disease that occurs when the immune system mistakenly begins to attack the joints, often suffer from pain, stiffness, swelling, and have trouble moving and using many of their joints. The condition, which is twice as common among women, can also cause inflammation in the organs.

One expert said heart problems were also an issue for many patients.

"It has been known that patients with rheumatoid arthritis have a greater risk of developing heart disease than those without," said Dr. Kenneth Ong, acting chief of cardiology at The Brooklyn Hospital Center in New York City. "This risk seems to extend in many forms of cardiovascular disorders, among which the most notable is coronary artery disease, but also includes heart failure, peripheral artery disease and possibly stroke."

For the past decade, anti-TNF drugs have been used around the world to treat rheumatoid arthritis as well as other inflammatory conditions. These pricey medications -- prescribed under brand names such as Remicade, Enbrel, Humira, Cimzia and Simponi -- have been shown to reduce inflammation.

In the first study, the Swedish team compared rates of heart disease among patients with rheumatoid arthritis taking anti-TNFs with patients not using the drugs and people in the general population, to see if the medications could also cut the risk for heart issues.

The study involved a group of more than 7,700 patients in Sweden with rheumatoid arthritis who had never been diagnosed with heart disease. They began taking anti-TNFs between 2001 and 2010. Of this group, about 76 percent were women averaging about 57 years of age. The researchers compared these patients to a group of more than 23,000 similar people who also had rheumatoid arthritis but had never taken anti-TNFs, as well as a group of more than 38,500 similar people randomly selected from the general population in Sweden.

The researchers classified exposure to the drugs into three categories: those who were "actively" on the drugs; those with "short-term exposure" who took the medication for up to two years; and those who had "ever" taken the medication at some point.

The study revealed the prevalence of heart events was slightly lower among patients with rheumatoid arthritis who were actively taking anti-TNFs than people with rheumatoid arthritis who had never taken this type of medication. Patients actively taking anti-TNFs were 50 percent more likely to have angina or heart attacks than the general population, while patients who had never taken these medications were more than twice as likely to have these heart events.

After taking other factors into account, such as how long the patients had rheumatoid arthritis, other diseases affecting the patients and socio-economic status, the researchers found that patients actively on the drugs had a 27 percent lower risk for angina/heart attack than patients who had never taken such a drug.

"This nationwide study adds to the evidence that use of TNF inhibitors for rheumatoid arthritis also has an impact on cardiovascular [illness]," study author Dr. Lotta Ljung, a senior consultant in rheumatology at Umea University Hospital, said in a news release issued by the meeting organizers.

However, she stressed that it's not clear whether the drugs themselves caused the lowering of heart risks, or whether an easing of rheumatoid arthritis was the underlying cause of better heart health.

A second study conducted by researchers in the UK examined the effects of anti-TNF drugs on patients' risk for heart attacks. The researchers compared use of these drugs among patients with rheumatoid arthritis to patients taking more traditional drugs, known as non-biologic disease-modifying antirheumatic drugs (DMARDs).

Using The British Society for Rheumatology Biologics Register, which contains information compiled between 2001 and 2008 on more than 20,000 patients in the UK, the researchers examined the rate of heart attacks among nearly 14,300 people with rheumatoid arthritis. They also considered whether the severity of heart attacks was in any way affected by treatment with TNF inhibitors.

The researchers also used data from two previous British studies. One examined the safety of biologic drugs, the other examined heart attack-related hospitalizations in England and Wales.

"Better control of inflammation with biologic therapy might reduce not only the rate of heart attacks, but potentially also affect the size of [heart attacks]," reasoned study co-author Dr. William Dixon a rheumatologist with Arthritis Research UK's Epidemiology Unit at the University of Manchester.

The study showed that patients taking anti-TNF drugs were at lower risk for heart attack than patients taking traditional DMARDs. However, use of the biologic drugs did not affect the severity of heart attacks, the British team found.

In the news release, Dixon said that "rheumatologists can be reassured that treatment of active rheumatoid arthritis with anti-TNF therapy may lead not just to an improvement in joint symptoms, but also a reduction in the rate of [heart attacks] in the medium term."

His team pointed out, however, that patients with rheumatoid arthritis generally have an increased risk of heart attacks. So, even though anti-TNFs may help curb the risk for heart attacks they do not eliminate it. The U.K. group conclude that patients with rheumatoid arthritis who taking biologic drugs still need to take steps to cut their risk for heart disease.

One expert not connected to the studies agreed.

"Given that these studies demonstrate the increased risk of cardiovascular disease in rheumatoid arthritis, patients should try to mitigate other known cardiovascular risk factors by not smoking and maintaining a healthy diet and weight," said Dr. Diane Horowitz, a rheumatologist at North Shore University Hospital in Manhasset, N.Y., and Long Island Jewish Medical Center in New Hyde Park, N.Y.

For his part, Ong said it makes "sense that drugs that reduce inflammation in rheumatoid arthritis could reduce some of the risk of developing heart disease in these same patients."

But he added that the studies also raise intriguing questions, such as whether or not the heart-healthy benefits of anti-TNFs last beyond the time of treatment, whether the benefit extends equally to men and women and whether these results extend to patients who do not require hospitalization for heart issues.

Cost was another issue, Ong said. "Anti-TNF drugs are among the most expensive medications developed for the treatment of rheumatoid arthritis," he said. "I understand that it is not the first line of treatment for rheumatoid arthritis [but] if these initial results are verified by subsequent studies, the cost of treating rheumatoid arthritis may skyrocket."

-- Mary Elizabeth Dallas
Copyright © 2013 HealthDay. All rights reserved. SOURCE: Kenneth Ong, M.D, acting chief, cardiology, The Brooklyn Hospital Center, New York City; Diane Horowitz, M.D., rheumatologist, North Shore University Hospital, Manhasset, N.Y., and Long Island Jewish Medical Center, New Hyde Park, N.Y.; American College of Rheumatology, news release, 2013

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Fibromyalgia Might Be Harder on Younger Patients, Study Finds

SATURDAY, Oct. 26 (HealthDay News) -- Young and middle-aged fibromyalgia patients report worse symptoms and poorer quality of life than older patients, a new study reveals.

Fibromyalgia is characterized by symptoms such as musculoskeletal pain and tenderness, fatigue, and sleep and memory problems. The disorder, which most often affects women, has no known causes and few effective treatments.

The study included 978 fibromyalgia patients who were divided into three age groups: 39 and younger, 50 to 59, and 60 and older. The younger and middle-aged patients were more likely to be employed, unmarried, smokers, have a higher education level and lower body-mass index (BMI), a measure of body fat that takes height and weight into account.

They were also more likely to have a history of abuse and to have had fibromyalgia symptoms for a shorter length of time than older patients, the study authors said.

"Among the three age groups of young, middle-aged and older, symptom severity and quality of life differs," study senior author Dr. Terry Oh, a physical medicine and rehabilitation physician at the Mayo Clinic in Rochester, Minn., said in a clinic news release.

The findings were surprising, because older people generally have poorer quality of life and physical health than younger people, Oh said.

The researcher noted that female fibromyalgia patients in all three age groups reported a lower quality of life than average U.S. women, and that the difference between their physical health and that of the average woman was more significant than mental health differences, particularly in young patients.

The study was to be presented this week at the American College of Rheumatology annual meeting, in San Diego.

In other Mayo studies presented at the meeting, researchers found that about 7 percent of fibromyalgia patients have inflammatory rheumatic conditions and that these patients don't respond as well to treatment as those without rheumatic diseases, and that fibromyalgia patients may also have skin-related symptoms such as excessive sweating, burning and other sensations.

Because the studies were presented at a medical meeting, the data and conclusions should be viewed as preliminary until published in a peer-reviewed journal.

-- Robert Preidt
Copyright © 2013 HealthDay. All rights reserved. SOURCE: Mayo Clinic, news release, Oct. 26, 2013

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Current Colon Cancer Screening Guidelines Might Miss Some Patients

FRIDAY, Oct. 25 (HealthDay News) -- Current U.S. colon cancer screening guidelines may result in 10 percent of colon cancers being missed in people with a family history of colon polyps that can lead to cancer, a new study suggests.

"The biggest surprise was the percentage of missed cancers under the current guidelines. We figured there would be a few percent, but 10 percent is a large number," study author Dr. N. Jewel Samadder, of the Huntsman Cancer Institute at the University of Utah, said in a university news release.

Colorectal cancer is the third most common cancer in the United States and the second deadliest.

Samadder's team looked at data from nearly 127,000 people, aged 50- to 80, who underwent colonoscopy in Utah between 1995 and 2009. They found that first-degree relatives -- parents, siblings, children -- of people with adenomas (polyps linked to cancer) or advanced adenomas had a 35 percent to 70 percent increased risk of developing colon cancer than relatives of patients without these growths.

Second-degree relatives (aunts, uncles, grandparents) and third-degree relatives (cousins, nieces, nephews, great-grandparents) of people with adenomas were also at increased risk for colon cancer, according to the study published online Oct. 25 in the journal Cancer.

"We expected to see increased risk in first-degree relatives, but we weren't sure the risk would also be higher for more distant relatives in multiple generations," Samadder said.

Current national guidelines for colon cancer screening recommend colonoscopy every 10 years starting at age 50 for the general population. But first-degree relatives of people diagnosed with either colorectal cancer or advanced adenomas before age 60 should have a colonoscopy every five years beginning at age 40, according to the guidelines.

However, screening recommendations for second- and third-degree relatives of people diagnosed before age 60 are the same as for the general public.

So, the new findings "raise the issue of whether some level of more aggressive screening should be considered, not only for first-degree relatives of patients with polyps diagnosed at or below age 60, but also for those first-degree relatives of patients diagnosed above age 60," Samadder said.

One expert not connected to the study said the findings may be important, but it's often difficult to assess a patient's family history when it comes to colon cancer.

"This information is important not only to specialists who treat colon and rectal and cancer but all primary care providers who recommend screening programs for their patients," said Dr. Jerald Wishner, director of colorectal surgery at Northern Westchester Hospital in Mount KIsco, NY.

However, he added that, "It will be difficult to apply this information in everyday clinical practice. I regularly see patients who know their relatives have had surgery for cancer don't know the type. Finding out if their relatives have had adenomas or advanced adenomas will be very difficult. This will be further complicated as we seek information about second or third degree relatives."

-- Robert Preidt
Copyright © 2013 HealthDay. All rights reserved. SOURCES: Jerald Wishner, M.D., director, colorectal surgery, Northern Westchester Hospital, Mount Kisco, N.Y; University of Utah, news release, Oct. 22, 2013

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Many Lupus Patients Forgo Needed Medication, Study Finds

By Amy Norton
HealthDay Reporter

SATURDAY Oct. 26 (HealthDay News) -- Many poorer patients with the autoimmune disease lupus don't take their medications as prescribed, a new U.S. study suggests.

Researchers found that lupus patients on Medicaid -- the public health insurance program for the poor -- were often not sticking with their prescriptions. Over six months, patients picked up enough medication to cover only 31 percent to 57 percent of those days.

The findings are concerning, experts say, not only because lupus drugs can help send symptoms into remission, but because they may also stave off some of the long-term consequences of the disease.

"It's alarming," said lead researcher Dr. Jinoos Yazdany, of the University of California, San Francisco. "These medications have a proven track record of improving patients' outcomes."

The study used pharmacy claims data, so it's not possible to say why people were not taking their medication as prescribed, Yazdany said.

But money could be one factor. Medicaid covers the drugs, Yazdany noted, but even a small co-pay could be a barrier for low-income patients.

Drug side effects could be another issue, Yazdany said, as could a lack of education about the medications. "Some people may not be fully aware of the benefits of these drugs," she said.

Yazdany is scheduled to present the findings Saturday, at the American College of Rheumatology's annual meeting in San Diego.

The most common form of lupus is systemic lupus erythematosus (SLE). In SLE, the immune system attacks the body's own tissue, damaging the skin, joints, heart, lungs, kidneys and brain.

The disease mostly strikes women, usually starting in their 20s or 30s.

Lupus drugs include immune-system suppressors, such as cyclophosphamide (Cytoxan) and tacrolimus (Prograf), and anti-malaria drugs, such as hydroxychloroquine (Plaquenil), which can ease the fatigue, joint pain and skin rash seen in lupus.

Part of the goal is to control symptom flare-ups, including fatigue, fever, joint pain and skin rash. But the drugs can also reduce organ damage that can lead to kidney failure and heart disease.

The study included 23,187 Medicaid patients, mostly women, who were prescribed at least one drug for lupus. Yazdany's team used pharmacy claims to gauge whether patients were sticking with their prescribed regimen.

In general, patients lacked medication for a substantial proportion of the six months. But black, Hispanic and Native American patients were less compliant than white and Asian patients -- with only enough medication to cover a little more than half of the time period. And people living in the Midwest were less compliant than residents of other regions.

Overall, fewer than one-third of all patients had enough medication to cover at least 80 percent of the study period.

Dr. Cristina Drenkard, an assistant professor at Emory School of Medicine in Atlanta, said this finding is "very concerning."

Low-income minorities with lupus are known to fare worse than their white counterparts, and the reasons are probably many, noted Drenkard, whose research focuses on lupus. But it's likely that lesser adherence to drug regimens is one reason, she said.

Drenkard and her colleagues recently published a small study looking at whether a "self-management" program could help low-income black women with lupus. And they found that women who attended workshops at a public clinic were feeling better and doing a better job of taking their medication and generally managing their disease.

"We think self-management support like this is important for people with SLE," Drenkard said.

Still, a program like that would be only one part of the solution, these experts added.

"We need more research to understand what the barriers are to drug adherence, from the patient point of view," Yazdany said.

Another study to be reported at the same meeting underscores the importance of sticking with prescriptions. Researchers found that among more than 1,700 lupus patients in 11 countries, those taking anti-malaria drugs were less likely to show damage to their kidneys, heart or other organs over six years.

Do lupus patients with private insurance do a better job of sticking with their medications? It's not clear, said Yazdany. With Medicaid, there are state databases to comb through, but there is no similar way to study lupus patients with private insurance on a national level.

For now, Yazdany said it's important for all lupus patients to bring any medication concerns to their doctor. If side effects are an issue, she said, your doctor may be able to adjust the dose or switch the medication.

"We have more [drug] options available now than we used to," Yazdany said. "So there's a good chance that something else will work for you."

Data and conclusions presented at meetings are typically considered preliminary until published in a peer-reviewed medical journal.

Copyright © 2013 HealthDay. All rights reserved. SOURCES: Jinoos Yazdany, M.D., MPH, assistant professor, University of California, San Francisco; Cristina Drenkard, M.D., Ph.D., assistant professor, medicine, Emory School of Medicine, Atlanta; Oct. 26, 2013, presentation, American College of Rheumatology annual meeting, San Diego

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HIV Patients Get a Mental Lift From Exercise, Study Finds

FRIDAY, Aug. 16 (HealthDay News) -- Regular exercise can give a brain boost to people with HIV, according to a new study.

Trouble with memory and thinking, something doctors call "neurocognitive impairment," affects nearly half of people infected with HIV, the virus that causes AIDS. It can interfere with the ability to do daily tasks such as handling finances, driving and taking medication as scheduled, experts say.

However, the new study suggests that exercise "may reduce or potentially prevent neurocognitive impairment in HIV-infected persons," according to a team led by Dr. David Moore of the University of California, San Diego.

Their study included 335 people with HIV who were asked how much they exercised. They also underwent testing to assess seven brain functions commonly affected by HIV: verbal fluency, working memory, speed of information processing, learning, recall, executive function and motor function.

Those who got regular exercise were half as likely to show signs of impaired mental function as those who did not exercise, according to the study published in the August issue of the Journal of NeuroVirology.

The major benefit of exercise in people with HIV seems to be the reduction of risk factors that can affect the brain such as high blood pressure and abnormally high levels of fats in the blood, Moore said.

The findings add to previous research showing a link between exercise and brain health in people with HIV.

"Physical exercise, together with other modifiable lifestyle factors such as education, social engagement, cognitive [mental] stimulation and diet could be fruitful interventions to support people living with HIV," Moore said in a journal news release.

-- Robert Preidt
Copyright © 2013 HealthDay. All rights reserved. SOURCE: Journal of NeuroVirology, news release, Aug. 13, 2013

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Skin Cancer Patients Not Avoiding Sun, Study Suggests

WEDNESDAY, Oct. 2 (HealthDay News) -- Some people with melanoma aren't cautious about sun exposure, a small new study suggests, even though ultraviolet (UV) radiation from the sun is a major cause of skin cancer.

Researchers looked at 20 patients with malignant melanoma -- the most deadly type of skin cancer -- and a comparison group of 20 people without melanoma, all of whom carried portable UV-dose-detection devices and kept sun exposure diaries to measure their exposure to UV radiation.

Patients' overall daily UV radiation exposure rose 25 percent from the first to second summer after their melanoma diagnosis, and increased 33 percent from the first to the third summer, found the study published online Oct. 2 in the journal JAMA Dermatology.

The patients' UV exposure was also higher on vacation days and when they traveled to other countries, said Dr. Luise Winkel Idorn, of Bispebjerg Hospital and the University of Copenhagen in Denmark, and colleagues.

In comparison, people without melanoma had steady levels of UV radiation exposure, according to a journal news release.

-- Robert Preidt
Copyright © 2013 HealthDay. All rights reserved. SOURCE: JAMA Dermatology, news release, Oct. 2, 2013

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