All This Talk of Diabetes Mortality Is a Downer

By Sean Kelley

Last week I went to San Francisco for the American Diabetes Association’s Scientific Sessions, a huge annual gathering of endocrinologists, scientists, nurse educators, and pharmaceutical companies. The latest research on type 1 and type 2 diabetes was delivered, theories discussed, and news announced.

There was much discussion of uncomfortable subjects: neuropathy, nephropathy ,cardivascular disease, hypoglycemia , death. While not fatal itself, diabetes has lots of excellent ways to kill you through related conditions: stroke, heart disease, and kidney failure spring immediately to mind. Read More

Go Ahead, Email Your Doctor...As Long As It's Not Serious

A near-death experience taught me the perils of online communication with my patients
by Dena Rifkin, MD

I read a news item today reporting that only one in three U.S. doctors communicate with patients via email. We doctors were accused of lagging behind other professionals in online communication.

Well, I am one of the physicians already communicating with patients via email. Like everything else about the digital world, it has its benefits and its drawbacks. I fully agree that simple things, like prescription refills, routine lab reports, and so forth can be handled best by email—often, these do not even require the intervention of a physician.

It's when we get into questions about health problems that email can be problematic.

I returned from a holiday weekend at home to find an email from a patient waiting for me. It had been sent late on Friday night. "Dear Doctor," my patient wrote. "I am very worried." He went on to describe bleeding, fatigue, and weakness. He asked me to call him when convenient. Then he ended the message: "I hope you have a good holiday."

Three days had passed. My heart was racing as I called his home phone number. Fortunately, he was still alive, but he had not sought any other medical help. I sent him directly to the emergency room and he spent several days in the hospital recovering from a serious intestinal bleeding episode.

All of our patients are asked to sign a consent form before we communicate via email, and part of that consent involves agreeing not to use email for acute health problems requiring urgent attention, like this one. But it is so easy to send an email—much easier than calling the on-call physician or going to an emergency room. I've had other, less extreme encounters where patients emailed about issues that really needed to be addressed in person.

If you choose to email your own doctor, realize that these e-encounters are probably best reserved for administrative problems or minor updates to ongoing discussions (like telling the physician that a recent medication worked well or didn't work), rather than new medical problems. At the very least, you'll save your doctor a Monday morning heart attack like the one I nearly had.

Heart Failure Raises Risks After Non-Cardiac Surgeries

(HealthDay News) -- Older people with heart failure face heightened odds of complications and death after non-cardiac surgeries, according to the largest study ever conducted on the issue.

"We're trying to draw attention to this major problem," said lead researcher Dr. Adrian F. Hernandez, an assistant professor of medicine at Duke University in Durham, N.C.

Heart failure, the progressive loss of the heart's ability to pump blood, is widespread among older Americans, but it sometimes is overlooked as a risk factor when surgery is needed, he said.

"Most physicians focus on whether [older patients] have coronary artery disease or have a risk of heart attack," Hernandez said. "Heart failure is by far a more important risk factor, but it doesn't usually have greater weight when they want to identify patients at risk of complications or consider how they want to treat them after surgery."

Symptoms of heart failure include shortness of breath, fatigue and swelling of the legs.

Hernandez' group published the study in the April issue of Anesthesiology. They used Medicare data on more than 159,000 people undergoing major surgery not involving the heart, such as hip replacement operations. Past estimates have put the incidence of heart failure in the older population between 5 percent and 12 percent, but the new study found the condition in almost 20 percent of those having surgery.

The study divided the participants into three groups: those with heart failure, with or without coronary artery disease; those with only coronary artery disease; and those with neither condition.

Nearly 98 percent of all those who had surgery were discharged soon afterward from the hospital. But 17.1 percent of those with heart failure had to be re-hospitalized within 30 days, compared to 10.8 percent of those with coronary artery disease and just 8.1 percent of those with neither ailment.

In the month after a surgery, 1.6 percent of those with heart failure died, compared to 0.5 percent for those with coronary artery disease and 0.3 percent of those with neither condition, the study found.

Steps can be taken to reduce the toll, Hernandez said.

"The first thing is to check on what the conditions are that might influence the patients outcomes," he said. "We have to identify therapies that lower the risk of a poor outcome and assure that all patients, when they have surgery, are carefully monitored."

Close attention should be paid to be sure that symptoms of heart failure are kept to a minimum, Hernandez said. Medications such as beta blockers and diuretics can be used to keep heart failure under control, he added.

But he noted that it's not certain how effective such measures might be in reducing risks -- only a rigorous, controlled study could answer that question definitively.

"We are planning to do such studies, but our planning is still in the early stages," he said. "We still need to identify sponsors of such a study."

One expert applauded the new research.

The increase in surgery risk due to heart failure has been noted before, but "this is a big study that involves a lot of people. It solidifies that the risk is real, and the risk is substantial," said Dr. Robert Hobbs, a staff cardiologist at the Cleveland Clinic whose work covers heart failure and transplant medicine.

Measures that can be taken to reduce the risk include simply not performing surgery, if possible, on someone whose life might be endangered, Hobbs said. "If surgery is necessary for someone with heart failure, there should be targeted use of heart failure medications before the operation and an effort to avoid overloading the body with intravenous fluid during the procedure," he said.

"And we would certainly watch them more carefully in the postoperative period," Hobbs added.

More information
Learn about heart failure, its symptoms and treatment, from the U.S. Library of Medicine.

Know Suicide's Warning Signs

(HealthDay News) -- While many people view spring as a time of renewal and hope, the greatest number of suicides in the United States occur each year in April and May, notes the American College of Emergency Physicians.

It's not clear why suicide rates spike in the spring, said ACEP President Dr. Linda L. Lawrence. But "we do know that suicide is the 11th leading cause of death for all ages in the United States, with one suicide occurring every 16 minutes or about 11 suicides per 100,000 people," she said in a prepared statement.

"Moreover, suicide is the second leading cause of death among 25- to 34-year-olds and the third leading cause of death among 15- to 24-year-olds. Men take their own lives nearly four times more often than women, with men ages 75 and older having the highest rate of suicide, although over a lifetime, women attempt suicide two to three times as often as men," Lawrence said.

For every successful suicide attempt, there are 25 failed attempts that often leave people seriously injured and in need of medical care. More than 90 percent of all suicides are linked with a mood disorder or other psychiatric illnesses, which can be treated through behavioral therapy and medication, Lawrence said.

"So we want to build greater public awareness and understanding of suicide in order to prevent these needless deaths and injuries from occurring," she said.

As part of that effort, the ACEP wants to educate people about the warning signs of suicidal behavior, which include:

• Feeling depressed, down or excessively sad.


• Feelings of hopelessness, worthlessness or having no purpose in life, along with a loss of interest or pleasure in doing things.


• Preoccupation with death, dying or violence, or talking about wanting to die.


• Seeking access to medications, weapons or other means of committing suicide.


• Wide mood swings -- feeling extremely up one day and terribly down the next.


• Feelings of great agitation, rage or uncontrolled anger, or wanting to get revenge.


• Changes in eating and sleeping habits, appearance, behavior, or personality.


• Risky or self-destructive behavior, such as driving recklessly or taking illegal drugs.


• Sudden calmness (a sign that a person has made the decision to attempt suicide).


• Life crises, trauma or setbacks, including school, work or relationship problems, job loss, divorce, death of a loved one, financial difficulties, diagnosis of a terminal illness.


• Putting one's affairs in order, including giving away belongings, visiting family members and friends, drawing up a will or writing a suicide note.

If a person is threatening to commit suicide, take it seriously, remain calm and take the following steps, ACEP advises:

• Don't leave the person alone. Prevent access to firearms, knives, medications or any other item the person may use to commit suicide.


• Don't try to handle the situation alone. Call 911 or the local emergency response number. Phone the person's doctor, the police, a local crisis intervention team, or others who are trained to help.


• While waiting for help, listen closely to the person. Let the person know you're listening by maintaining eye contact, moving closer, or holding his or her hand, if appropriate.
  Ask questions to determine what method of suicide the person is considering and whether he or she has an organized plan.


• Remind the person that help is available.


• If the person does attempt suicide, immediately call for emergency medical assistance and administer first aid, if necessary.

More information

For more on preventing suicide, visit the U.S. Centers for Disease Control and Prevention.

Hormone Therapy Only Helps Some Older Men With Prostate Cancer

(HealthDay News) -- Adding hormone therapy to radiation treatment for fast-moving prostate cancer can save lives, but the benefit often doesn't apply to men who have other serious medical problems, a new study shows.

"The new message from this study is that there definitely is a difference in outcome, depending on the gentleman's health," said Dr. Anthony V. D'Amico, chief of genitourinary oncology at Brigham and Women's Hospital in Boston. His report is published in the Jan. 23 issue of the Journal of the American Medical Association.

The old message, reported in 2004 on the five-year point of the study, was that treatment to suppress the activity of male hormones known as androgens improved survival of older men with aggressive prostate cancer, D'Amico said.

But the new report showed the benefit was limited to men without other serious medical problems. Adding hormone therapy to radiation treatment in the 206-man study decreased the rate of death significantly, but the benefit was confined to men without other health issues.

"This report is important, because it is part of a story that is emerging about hormone therapy in men with prostate cancer who are elderly," D'Amico said. "If a man is 75 and otherwise healthy, adding hormone therapy is likely to help. If the same man has had a heart attack or stroke, or if he is a smoker or diabetic, adding hormone therapy makes it worse."

In terms of clinical practice, the finding means that "before I treat him, I get him to a specialist and try to get his health cleared up as much as possible before giving the hormone therapy," D'Amico said. "If he has heart disease, I would consult a cardiologist; if a stroke, I would consult a neurologist; if diabetes, a diabetologist."

The idea is not anything new in medicine, he added. "It is the same as with a surgical procedure," D'Amico said. "You do not give the therapy until it is cleared by the appropriate specialist."

The study is relatively small and requires further confirmation, said Dr. Durado Brooks, director of prostate and colorectal cancer at the American Cancer Society.

"But for men trying to make a decision about prostate cancer treatment, it provides useful information for the men and their physicians," Brooks said. "A man who has had radiation treatment, if he and his doctor talk about the results of this study, it can help them make a decision about hormone treatment in a more informed way."

The results apply to "a significant percentage of older prostate cancer patients," Brooks said, noting that the average age of men in the study was over 70.

Until now, only general advice about hormone treatment could be given to such men, he said. "Now we can be a little more specific and say, 'If you don't have underlying cardiac disease or other major co-morbid conditions, the chance of having a good response to the treatment is better.' But many men with heart disease or other problems may decide they do not want to deal with the side effects of hormone treatment."

More information
Learn more about prostate cancer and its treatment from the American Cancer Society.

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Dementia Diagnosis Typically Means Death Within Five Years

(HealthDay News) -- People with dementia survive an average of four and a half years following their diagnosis, new British research shows.

However, age, sex and any existing disability can alter life expectancy, according to the report in the Jan. 11 online issue of the British Medical Journal.

Common socioeconomic influences, such as marital status, social class and living in a community or residential home, did not appear to have an influence on longevity, the study found.

Researchers analyzed data on more than 13,000 people aged 65 and older who took part in a population-based study in England and Wales and were regularly assessed for dementia between 1991 and 2005.

During the 14-year study period, 438 of the participants developed dementia and 356 (81 percent) of those people died.

Dementia is known to be associated with increased risk of death, but considerable uncertainty exists about what influences survival. Worldwide, the number of people with dementia is estimated to reach 81 million by 2040.

The study found a nearly seven-year difference in survival between the youngest and oldest dementia patients -- 10.7 years for those aged 65 to 69 and 3.8 years for those aged 90 and older.

The average survival time after dementia diagnosis was 4.6 years for women and 4.1 years for men.

People who were the most disabled at the time of diagnosis lived about three years less than those who were the least disabled.

People with more education had a slightly shorter length of survival than those with less education, but researchers said the difference was not statistically significant.

Understanding factors that affect survival time after a dementia diagnosis may help health-care providers, patients, caregivers and policymakers, the study authors said.

More information
The U.S. National Institute of Neurological Disorders and Stroke has more about dementia.

'Hospitalist' Physicians Help Shorten Patient Stays

(HealthDay News) -- A new breed of medical specialists, called hospitalists, can make a small but significant difference in shortening how long a patient needs to stay in the hospital, a new study shows.

The 2002-2005 study of almost 77,000 hospital stays at 45 centers showed that treatment by a hospitalist, rather than a general internist, resulted in about a half-day reduction in overall hospital stays on average, along with an average $268 drop in costs.

At the same time, researchers found no difference in the rate of either patient death or readmission when hospitalists were involved, according to the report in the Dec. 20 issue of the New England Journal of Medicine.

A hopsitalist refers to a physician who cares solely for hospitalized patients.

The term may be new to the general public, but, in the medical profession, "hospitalist has been a recognized and accepted term that has been around for about a decade," said study author Dr. Peter K. Lindenauer, an associate professor of medicine at Baystate Medical Center and Tufts University, in Boston.

In fact, "There is a Society of Hospital Medicine with 5,000 to 10,000 members, and it is estimated that there may be 20,000 hospitalists across the United States now," Lindenauer said.

"What you can't debate is the number of hospitalists around the country -- there is no going back," added Dr. Laurence McMahon, chief of the division of general medicine at the University of Michigan, in Ann Arbor.

"We need to think about how these new doctors get into the health-care system and how they care for patients who are hospitalized," said Mcmahon, who also authored an accompanying editorial on the issue.

Traditionally, a person's private physician has been responsible for care after hospitalization, he said. That began to change about 30 years ago, with the emerging role of emergency room physicians and critical care physicians, Lindenauer said. "They have been assuming the role of attending physician in those situations," he said. "In some respect, the growth of the hospitalist model of care represents the completion of a series of steps toward specialization that began 30 years ago."

According to Lindenauer, the advent of the hospitalist means another question should be asked when individuals choose a private physician: Will that doctor turn over care to a hospitalist, if and when someone needs hospital care?

"It is a discussion that a patient should have with a primary-care physician when he is thinking about enrolling with that physician," Lindenauer said.

The differences shown in the study -- a shortening of length-of-stay by 0.4 days, on average -- are not great, he acknowledged, but they do add up over time.

"Shortening the length of stay by 0.4 days is small, but when you multiply it out over time by thousands of physicians, the effects can be very large. With 5,000 cases a year, [that's] a savings of 2,000 bed-days," he said.

The study was not able to assess patient satisfaction with treatment by a hospitalist rather than a primary-care physician, Lindenauer said, "But we know that efficiency is important, as important to patients as to physicians." he said.

And while full official recognition of the hospitalist speciality is yet to come, the Society of Hospital Medicine is working closely with the of American Board of Medical Specialties toward such an end, Lindenauer said.

"The differences between hospitalists and other doctors who take care of patients in hospitals are pretty minor," McMahon said. "What really is quite revolutionary is the change in how we take care of patients in the hospital."

More information
There's more on hospitalists at the Society of Hospital Medicine.


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Quality of Life Predicts Lung Cancer Survival

(HealthDay News) -- Quality of life is the most important predictor of survival for patients with locally advanced non-small cell lung cancer, U.S. researchers report.

"In the past, we've considered the stage of disease or tumor size along with other empirical data to predict how long a patient will survive, but now we know quality of life is a critical factor in determining survival," lead author Dr. Nicos Nicolaou, an attending physician in the radiation oncology department at Fox Chase Cancer Center in Philadelphia, said in a prepared statement.

The study of 239 patients found that those with a quality of life score less than the median (66.7) had a 69 percent higher death rate than patients with a score greater than the median.

"We conducted two different statistical analyses including all the usual prognostic factors and, either way, quality of life remained the strongest predictor of overall survival. What's more, if a patient's quality of life increased over time, we saw a corresponding increase in survival," senior author Dr. Benjamin Movsas, chairman of the radiation oncology department at Henry Ford Hospital in Detroit, said in a prepared statement.

The researchers also found that married patients or those with a partner had the highest quality of life scores.

"We found a significantly lower quality of life score for single, divorced and widowed patients, which deserves further study," Nicolaou said.

Overall, the study findings "underscore the importance of helping out patients improve the quality of life where we can in order to help them live longer better."

The study was expected to be presented Tuesday at the American Society for Therapeutic Radiology and Oncology annual meeting, in Los Angeles.

More information
The U.S. National Cancer Institute has more about non-small cell lung cancer.

Advantages and Disadvantages of Alcohol Intake on Cardiovascular Health Reviewed

News Author: Laurie Barclay, MD
CME Author: Charles Vega, MD

The latest American Heart Association guidelines caution people not to start drinking alcohol if they do not already drink alcohol, according to a review of the advantages and disadvantages of alcohol intake on cardiovascular health published in the August 23 Online First issue of the Journal of the American College of Cardiology.

"Accumulating scientific evidence indicates that light to moderate drinking done on a daily basis may significantly reduce the risks of coronary heart disease (CHD) and all-cause mortality," write James H. O'Keefe, MD, FACC, and colleagues from the Mid America Heart Institute in Kansas City, Missouri. "In contrast, excessive alcohol intake and binge drinking are toxic to both the heart and overall health and are the third leading cause of premature death among Americans.

The purpose of the present review is to:
1) outline the specific benefits and risks of alcohol, and the threshold of intake at which drinking becomes a health danger rather than an advantage;
2) detail the mechanisms whereby alcohol confers cardioprotection; and
3) discuss the ideal quantities, drinking patterns, and beverages, and which individuals are most likely to benefit."

Research to date has shown J-shaped relationships between alcohol consumption and several adverse health outcomes, including all-cause mortality, CHD, diabetes, hypertension, congestive heart failure, stroke, dementia, and Raynaud's phenomenon.

Some cardioprotective benefits have been demonstrated for light to moderate alcohol consumption (up to 1 drink daily for women and 1 or 2 drinks daily for men). Most studies have shown that light to moderate drinking is associated with risk reductions for CHD of approximately 30% to 35%.

Alcohol consumed in moderation seems to have an antiatherosclerotic effect, with decreased incidence of peripheral arterial disease and decreased atherosclerotic burden shown by coronary angiography, computerized tomography-detected coronary calcium, and carotid ultrasound.
Like exercise, alcohol consumption seems to be most cardioprotective when done daily and in moderation. However, increasingly excessive consumption is associated with proportional worsening of outcomes.

Because of the beneficial effects on high-density lipoprotein (HDL) cholesterol, insulin action, and inflammation, light to moderate alcohol intake may be particularly helpful for patients with abnormal glucose metabolism and/or insulin resistance. Light to moderate alcohol intake may be associated with reductions in the prevalence and incidence of diabetes, and a large meta-analysis with 12-year follow-up showed a 30% reduction in new diabetes in those who consumed 1 to 2 drinks daily.

The cardiovascular benefits associated with alcohol consumption protection are thought to be mediated by improvements in insulin sensitivity and HDL cholesterol. The major protective component seems to be the ethanol itself, and not the other ingredients found in different types of alcoholic beverages.

In a meta-analysis incorporating data from more than 1 million participants, consumption of 1 drink daily by women and 1 or 2 drinks daily by men was associated with an 18% reduction in total mortality, but daily intakes of more than 2 drinks in women and 3 drinks in men were associated with dose-dependent increased mortality.

Although low-dose, daily alcohol consumption has been linked to better health than less frequent use, binge drinking increases cardiovascular events and mortality, even in otherwise light drinkers.

"Alcohol should not be universally prescribed for health enhancement to nondrinking individuals owing to the lack of randomized outcome data and the potential for problem drinking," the study authors note. "Alcohol (ethanol) consumption is analogous to the proverbial double-edged sword, and perhaps no other factor in cardiovascular (CV) health is capable of cutting so deeply in either direction depending on how it is used."

Guidelines from the United Kingdom suggest that middle-aged or elderly men and postmenopausal women who drink seldom or never might consider the possibility that light drinking would benefit their health. On occasion, the reviewers have made a similar recommendation to patients who do not smoke and who have no personal or family history of substance abuse and no history of depression or bipolar disorder. However, they argue that light to moderate drinking should not be universally recommended to the general public or even to patients with cardiovascular disease.

As an analogy, they point out that observational data and findings from randomized trials using surrogate endpoints suggested that hormone replacement therapy for women and antioxidant vitamins improved cardiovascular outcomes, whereas later randomized trials with larger samples led to the opposite conclusions. They note that no randomized trials of alcohol for improving clinical outcomes have yet been performed. In observational studies, residual unmeasured confounding factors could be contributing to apparent benefits that seem to be associated with light to moderate drinking.

The investigators further note that heavy drinking has caused significant individual and societal problems and morbidity. In the past 15 years, the rates of alcohol abuse and binge drinking have been increasing, according to the findings of some studies. Alcohol abuse causes 100,000 deaths each year in the United States, and it has been deemed the third largest preventable cause of death.

Excessive alcohol consumption has been associated with increased risks for all-cause mortality, motor vehicle crashes, stroke, cardiomyopathy, cardiac dysrhythmia, sudden cardiac arrest, suicide, cancer (particularly of the breast and gastrointestinal tract), cirrhosis, fetal alcohol syndrome and sleep apnea.

"Sobering statistics warn that moderate daily drinking is a slippery slope that many individuals cannot safely navigate," the study authors conclude. "The latest American Heart Association guidelines caution people not to start drinking if they do not already drink alcohol, because it is not possible to predict in which people alcohol abuse will become a problem. Until we have more randomized outcome data, and tools for predicting susceptibility to problem drinking, it would seem prudent to encourage physicians and patients to focus on more innocuous interventions to prevent CHD."

J Am Coll Cardiol. Published online August 23, 2007.
2007;50:1009-1014.

No Link Between Anti-Nausea Drug, Heart Trouble

(HealthDay News) -- The current "black box" label warning for the anti-vomiting drug droperidol -- cautioning users against an increased risk of irregular heartbeat with use of the medication -- may be unnecessary, Mayo Clinic researchers conclude.

In late 2001, the U.S. Food and Drug Administration issued a black box warning regarding the risk of heart trouble called prolonged QT in surgical patients receiving droperidol. Prolonged QT can lead to a potentially fatal arrhythmia called torsades de pointes (TdP).

The authors of this study analyzed data on almost 140,000 patients who had surgery before the 2001 black box warning, plus 150,000 patients who had surgery after 2001. Before the black box warning, 12 percent of patients (about 16,791) received the drug. No patients received the drug after the warning.

The rate of prolonged QT, TdP, or sudden death (within 48 hours after surgery) among the first group of patients was 1.66 percent and 1.46 percent in the second group of patients. Overall, there were no documented cases of TdP among patients who took droperidol.

"We found no change in bad heart rhythms with the commonly used low-dose droperidol versus no droperidol use in a very large number of surgical patients," lead author Dr. Gregory A. Nuttall, of the Mayo Clinic in Rochester, Minn., said in a prepared statement.

He and his colleagues concluded that the black box warning for droperidol is "excessive and unnecessary."

The study is published in the October issue of the journal Anesthesiology.

More information
The Arizona Center for Education and Research on Therapeutics has more about TdP.

Experts Publish New Lung Disease Guidelines

(HealthDay News) -- Experts have devised new standards for the diagnosis, management and prevention of a widespread, deadly lung ailment -- chronic obstructive pulmonary disease (COPD).

COPD affects 15 percent to 25 percent of adults over the age of 40 and is the fourth leading cause of death in the United States. It's expected to become the fifth leading cause of death worldwide by 2020.

Cigarette smoking and exposure to secondhand smoke are among the most common risk factors for COPD in the developed world. In developing countries, major risk factors include long-term exposure to smoke from indoor cooking and heating fires.

Now, a report released Sept. 14 by the Global Initiative for Chronic Obstructive Lung Disease is setting the standard for caring for COPD patients.

The new guidelines -- published in the American Journal of Respiratory and Critical Care Medicine -- emphasize the importance of proper diagnosis, assessment of disease severity, and the need for a better understanding of co-existing conditions in order to improve treatment of COPD.

"This is an absolutely up-to-date summary of all the available evidence on the diagnosis, management and prevention of COPD," report lead author Dr. Klaus Rabe, of the department of pulmonology at Leiden University Medical Center in the Netherlands, said in a prepared statement.

"One of the most important points is that we now say COPD is preventable and treatable," Rabe said. "There are steps we can take to prevent it, and it is no longer viewed with therapeutic nihilism."

More information
The American Academy of Family Physicians has more about COPD.

Saline Reduces Mortality for Brain Injury Patients

(HealthDay News) -- A simple change in the way people with traumatic brain injuries are treated initially might make a big difference in their survival odds, a new Australian study suggests.

The study found that using saline rather than albumin fluid to maintain normal fluid volume levels in people with severe brain injuries resulted in nearly double the survival rate at 24 months after the injury.

"We determined that the 2-year mortality rate was significantly high in those patients who received albumin-based fluids compared to those who received saline, particularly those patients with severe brain injuries who presented with traumatic coma," said the study's lead author, Dr. John Myburgh, director of the division of critical care and trauma at the George Institute for International Health, in Sydney.

"Given the significant difference in mortality that we observed, we recommend that albumin-based fluids be avoided for the acute fluid resuscitation of patients with traumatic brain injury," added Myburgh, who's also a professor of critical care at the University of New South Wales.

Results of the study are published in the Aug. 30 issue of the New England Journal of Medicine.

Traumatic brain injury is caused by a sharp blow to the head that often occurs in falls, motor vehicle crashes or from physical assault, according to the U.S. Centers for Disease Control and Prevention. The CDC estimates that about 1.4 million traumatic brain injuries occur annually in the United States, and about 50,000 of those people die as a result of the injury each year.

Those who survive may have lifelong disabilities.

Some of the most serious damage to the brain occurs at the time of the injury, and soon after, when the brain swells in response to the injury. Because the brain is an enclosed system, if swelling occurs, brain tissue becomes damaged.

Fluid resuscitation is a common part of traumatic brain injury treatment to ensure normal blood circulation in the brain, according to the study. However, there's been some debate as to what type of fluid would most benefit people with traumatic brain injuries -- saline or albumin fluid.

Albumin is the main protein component of human blood.

"Albumin is a very expensive product that has to be purified," explained Dr. Keith Siller, medical director of the Comprehensive Stroke Care Center at New York University Medical Center in New York City. "If they're equally effective, you'd pick the cheaper fluid."

And, in fact, a previous study had compared the two fluids and found no statistically significant difference in the rates of death after 28 days.

But, Myburgh and his colleagues re-analyzed the original data to assess results at 24 months after injury. In the original study, 460 people with traumatic brain injuries were randomly selected to receive either saline or albumin fluid. Slightly more than two-thirds of the participants in each group were classified as having a severe traumatic brain injury.

After two years, the researchers behind the new study found that people with traumatic brain injuries who received albumin had a 63 percent higher risk of dying than those given saline. For those with severe brain injuries, the albumin group had an 88 percent increased risk of death compared to the saline group.

"These are people in very bad shape," said Siller. "If there's anything that can help them have better outcomes, we have to pay attention."

Dr. James Goodrich, director of pediatric neurosurgery at the Children's Hospital at Montefiore in New York City, said, "This is a great study that definitely found a significant difference in the sense of outcomes." But, he added, it just confirms what's already going on in the treatment of people with serious brain injury. "Albumin has pretty much been given up on," he said.

As to why saline might offer some benefit over albumin, Myburgh said the researchers can't explain the difference. "The exact mechanism by which the difference in mortality between saline and albumin remains unclear," he said.

"It's probably one of two things," said Siller. "Either albumin is making the brain swelling worse, or somehow the saline is doing something beneficial that albumin can't."

More information
To learn more about traumatic brain injury, visit the National Institute of Neurological Disorders and Stroke.

Diet Still Important to Patients on Cholesterol-Lowering Drugs

(HealthDay News) -- Patients taking cholesterol-busting statins usually eat healthy, too, a new study finds.

The finding contrasts with what many doctors believe: that patients view drugs such as Lipitor, Pravachol and Zocor as a license to eat whatever they like because they think the medication is enough to protect them from heart disease.

"We went into this study thinking that these medications are so good, and changing your diet is so hard, that we expected people to relax their dietary efforts, increasing their fat intake," said lead researcher Dr. Devin Mann, of the Mount Sinai School of Medicine in New York City.

But that wasn't as big a problem as many people assumed, Mann said. "In reality, we often have expectations of what behavior will be. But you actually have to look and check, because behavior is tricky -- it's hard to predict," he said.

In the study, which is published in the August issue of Mayo Clinic Proceedings, Mann's team collected data on 71 patients taking statins to prevent heart disease. The researchers interviewed them when they started on the drug, and again three and six months later.

The researchers found there was no significant change in how much saturated fat the patients included in their diets.

"As doctors, we have assumptions of what behaviors will be like, but we often don't get what the opinions of the patients really are," Mann said. "It was surprising how many people, even if they thought diet wasn't going to be effective, still wanted to do it," he said.

Given these findings, Mann believes doctors should continue to pursue lifestyle changes with their patients. "We shouldn't give up on lifestyle just because we are starting drug therapy -- these things should really work together," he said.

Patients already understand this, Mann said. Doctors should encourage patients to make lifestyle changes and not think it's a waste of time, he noted.

Mann also believes that patients need to tell their doctors what they think about the medications and lifestyle changes that are being recommended.

"Patients and doctors should work from common ground to make decisions, because if you make decisions without information, you make poorly informed decisions," Mann said.

One expert was encouraged by the findings.

"Achieving and maintaining healthy lipid levels is essential for prevention of cardiovascular events and premature death," said Dr. Gregg C. Fonarow, a professor of cardiology at the University of California, Los Angeles. "Many patients require both dietary modification and lipid-lowering medications to get to recommended lipid levels."

Unfortunately, study after study shows that many adults in the United States are not being adequately treated for their cholesterol levels and thus having cardiovascular events that could have been prevented, Fonarow noted.

"While many patients do not adhere to their medical regimen, missing doses or stopping altogether, little was known about whether starting lipid-lowering medications would adversely influence adherence to dietary recommendations," Fonarow said. "The results of this study -- showing no significant change in reported dietary habits after initiation of statin treatment -- should be reassuring to physicians and other health-care providers."

More information
For more information on healthy living, visit the American Heart Association.

Most Asian Men Have Better Prostate Cancer Survival Rates

(HealthDay News) -- Your prognosis for surviving prostate cancer may depend on your racial and ethnic background, a new study suggests.

Asian men have better survival rates than white males, while South Asians have the worst survival rates, according to results of a study of men living in California.

"Nearly all Asians do far better when they get prostate cancer," said study lead author Dr. Anthony Robbins, of the California Cancer Registry in Sacramento. "But Indian men didn't do as well as other Asian men, and they did worse than all other men, including blacks and whites," he added.

The reasons for these racial and ethnic differences in prostate cancer survival aren't known, Robbins said, adding, "We just couldn't explain it."

Not only couldn't the researchers explain the finding, they were left with an apparent paradox. The Asian men were usually older and had more advanced disease at the time of diagnosis, Robbins said. "Based on their risk factors, you would think they were going to do worse," he said.

In the study, Robbins and his colleagues collected data on 116,916 men (108,076 whites and 8,840 Asians from the six largest represented Asian ethnicities -- Chinese, Filipino, Japanese, Korean, South Asian, and Vietnamese) diagnosed with prostate cancer. The researchers compared prognostic factors and survival rates among the men.

The researchers found that for Asians, risk profiles were worse compared with whites. For example, Asians were more likely to have more advanced disease and use non-curative therapies. But, for Asians -- except for South Asians -- survival rates were equal to or better than rates for whites.

Japanese-American men were 34 percent less likely to die from prostate cancer compared with whites. But South Asian men -- those from India, Pakistan, Bangladesh, Sri Lanka, Nepal, and Bhutan -- were 40 percent more likely to die from the disease, Robbins said.

The study was published online Monday in the journal Cancer.

Some of the factors that may influence the findings include diet, exercise and genetics, Robbins speculated.

"Doctors that are seeing patients for prostate cancer need to be aware that these differences can be used as factors in planning the patient's treatment and telling the patient what their survival might be," Robbins said.

Dr. Durado Brooks, director of prostate and colorectal cancer at the American Cancer Society, thinks this study demonstrates the need to better understand how different racial and ethnic groups respond to diseases.

"This study points out the potential misleading conclusions we can come to when we use these large groups to lump different subpopulations into," he said.

"If you lump in the South Asian subgroup with other Asians, as is traditionally done, you totally miss the fact that these folks have a strikingly higher chance of dying from prostate cancer," Brooks said.

Brooks said the study finding can provide a basis for research to try to understand why these differences exist between populations.

Prostate cancer is the most common type of cancer to strike American men, other than skin cancer, according to the American Cancer Society, which estimates there will be about 218,890 new cases of prostate cancer in the United States in 2007, and about 27,050 men will die of the disease. Prostate cancer is the second leading cause of cancer death in males. While one in six men will get prostate cancer during his lifetime, only one man in 34 will die of the disease. The death rate for prostate cancer is declining, due in large part to earlier diagnoses, the society said.

Another paper in the same issue of the journal also found racial differences among women who survive breast cancer; with black women having poorer survival regardless of the stage of the disease.

It is known that black women had larger tumors and are more likely to have invasive breast cancer. But the study, lead by Dr. Alfred Neugut from Columbia University Medical Center and Russell McBride from Mailman School of Public Health, found that mortality among black women was up to 56 percent higher than whites.

Neugut's team says that the disparities in survival were surprising and suggest that non-clinical factors, such as access to and quality of care, may play a part.

More information
For more on prostate cancer, visit the American Cancer Society.

Cirrhosis Can Impact Heart Surgery Success

(HealthDay News) -- For patients with cirrhosis, the severity of the disease will predict how well they do after heart surgery, a new study finds.

While milder cases of the liver ailment will have less of an impact on heart surgery outcomes, patients with severe cirrhosis may require alternative approaches to managing their heart disease, according to research published in the July issue of Liver Transplantation.

Cirrhosis is a degenerative disease of the liver that causes a scarring of the tissues, prevents blood flow through the organ and ultimately impairs liver function. It is often brought on by heavy alcohol use, or infection with hepatitis B or C.

While the relationship between the degree of cirrhosis and the success of abdominal surgeries is well known, few studies have examined outcomes for heart surgery, the researchers noted.

In their study, a team led by Dr. Farzan Filsoufi of Mount Sinai Hospital in New York City examined data from patients who had heart surgeries at the center between January 1998 and December 2004. They identified 27 patients with cirrhosis.

Cirrhosis prognosis and possibility for success in surgery for cirrhosis patients is characterized according to the "Child-Pugh classification" as A, B or C, with A being the most optimistic outcome and C being the least.

According to the study, there was a 10 percent postsurgical mortality rate for those in class A, an 18 percent mortality for those in class B, and a 67 percent death rate for those in class C.

The rates of complications after the surgery were 55 percent for patients in class B and 100 percent in class C, the researchers added.

Based on the findings, the authors concluded heart surgery can be performed safely and with a good likelihood for survival for cirrhosis patients in class A. They therefore recommended careful selection of heart surgery patients with cirrhosis to help improve the chance of successful outcomes.

Patients with advanced cirrhosis may require alternative approaches to heart surgery, such as medically managing their heart disease until it is possible to perform surgery at the same time as a liver transplant, the researchers wrote.

More information
To learn about liver diseases, visit the American Liver Foundation.

CDC Panel Recommends Meningitis Vaccine for All Teens

(HealthDay News) -- Advisers to the U.S. Centers for Disease Control and Prevention recommended Wednesday that all teens between the ages of 11 and 18 be routinely vaccinated against potentially deadly bacterial meningitis.

The recommendation, issued by the CDC's Advisory Committee on Immunization Practices, broadens the current guidelines for vaccinating adolescents and will be adopted by the agency, experts said.

"The prior recommendation had focused on different age groups," said Dr. Carol Baker, chairwoman of the committee's Meningococcal Working Group. "The new recommendation will be routine vaccination of all adolescents 11 through 18 years of age."

The earlier recommendation, which targeted only 15- to 18-year-olds, was made because vaccine supplies were limited, added Baker, who is president of the National Foundation for Infectious Diseases.

"The vaccine supply to be able to immunize this many adolescents is now sufficient," she said. "Now we will prevent many more infections."

Meningococcal meningitis is a rare but sometimes fatal bacterial infection that often strikes pre-adolescents, adolescents and young adults. The disease strikes quickly and has devastating complications, including hearing loss, brain damage, limb amputations and, in some cases, death.

"Vaccination is going to do a whole lot to reduce the incidence of this disease," said Lynn Bozof, executive director of the National Meningitis Association.

"The CDC's action will raise awareness ... among parents and adolescents that this disease is out there and it is potentially vaccine-preventable," she added.

The committee recommended that teens be routinely vaccinated with Menactra, the meningococcal conjugate vaccine (MCV4) made by Sanofi Pasteur.

The vaccine has been proven to protect against up to 83 percent of meningococcal cases among adolescents, according to the National Meningitis Association.

"The CDC recognizes that all adolescents are at risk for this disease, and they are doing what is in the best interest of the public," Bozof, who lost a son to meningitis, said. "If this recommendation had been in place nine years ago, my son would be alive."

Meningitis is spread through the exchange of respiratory droplets, which can come from sharing a drink or utensils, kissing, or coughing and sneezing. Adolescents and young adults are at increased risk for the disease, which can be contracted in crowded living situations, such as dormitories, boarding schools and sleep-away camps.

Bozof believes all adolescents should be vaccinated. "You have a vaccine that can prevent the killer disease," she said. "To me it's a no-brainer -- you just go and protect your children."

More information
For more information on meningitis, visit the National Meningitis Association.

Helmets Might Help Skiers

(HealthDay News) -- Many snowboarders and skiers who pursue their pastime off the main slopes are going slow enough so that a helmet would give significant protection from head injuries, a new study finds.

Currently, ski/snowboard helmets offer only limited protection in a direct collision at speeds greater than 15 mph. On open slopes, skiers and snowboarders can reach speeds of 25 mph to 30 mph.

But in this study, U.S. researchers clocked the speeds of expert skiers and snowboarders as they went through non-traditional ski areas such as terrain parks and gladed areas.

They found that the participants' speeds were below 15 mph 87.6 percent of the time.

At these slower speeds -- which result from the variation and change of direction needed to navigate non-traditional ski areas -- helmets would offer significant protection, the researchers concluded.

Each year, about 139,000 skiers and snowboarders suffer injuries that are serious enough to require treatment in an emergency department. While traumatic brain injury is the leading cause of death and serious injury among skiers and snowboarders, rates of helmet use are low, particularly among adults, according to background information in the study.

The findings are published in the latest issue of Wilderness Medicine magazine.

More information
The American Orthopaedic Society for Sports Medicine has more about helmet use in snow sports.

Smokers' Infants Have High Nicotine Levels

(HealthDay News) -- In homes where at least one parent smokes, infants have 5.5 times higher levels of a nicotine toxin called cotinine in their urine than infants of nonsmokers, a British study finds.

Cotinine is created as the body tries to get rid of the nicotine in inhaled smoke.

The study of 104 12-week-old infants (71 with at least one parent who smoked and 33 with nonsmoking parents) also found that having a mother who smoked quadrupled urine cotinine levels. Having a father who smoked doubled cotinine levels in an infant's urine, the researchers found.

Sleeping with parents and lower-temperature rooms were also associated with increased cotinine levels in infants, said the study by researchers at the University of Leicester Medical School and Warwick University.

"Babies affected by smoke tend to come from poorer homes, which may have smaller rooms and inadequate heating," the study authors wrote. "Higher cotinine levels in colder times of year may be a reflection of the other key factors which influence exposure to passive smoking, such as poorer ventilation or a greater tendency for parents to smoke indoors in winter."

The researchers also noted that sleeping with a parent is a known risk factor for sudden infant death syndrome (SIDS). They suggest that one reason for this could be an infant's proximity to parents' clothing or other objects contaminated with smoke particles.

The findings were published online Tuesday ahead of print in the journal Archives of Disease in Childhood.

More information
The American Academy of Otolaryngology -- Head and Neck Surgery has more about children and secondhand smoke.

Higher Screening Rates Credited With Drop in Colorectal Cancer

(HealthDay News) -- Colorectal cancer is on the decline in the United States, but doctors aren't declaring victory just yet against the deadly disease.

It's one of the few completely preventable forms of cancer -- but only if people get regular screenings, doctors say.

"Unfortunately, only about half of individuals who should be screened are not up to date in their screenings," said Dr. Durado Brooks, director of colorectal cancer for the American Cancer Society.

The American Cancer Society estimates there will be about 112,340 new cases of colon cancer and 41,420 new cases of rectal cancer in 2007 in the United States. Combined, they will cause about 52,180 deaths.

A recent study by researchers at the University of California, Irvine, found that increased screening for colorectal cancer may have contributed to the disease's decline in the United States between 1988 and 2002. According to the researchers, colorectal cancer decreased from 42.8 cases per 100,000 people in 1988-90 to 38.6 cases per 100,000 in 2000-02.

Meanwhile, there was an 80 percent increased use of colonoscopy to test for the disease by Americans between 1997 and 2002.

Many health experts also credit the "Katie Couric Effect," citing the TV newswoman's nationally televised 2000 colonoscopy, prompting more Americans to get screened for the malignancy.

The falling colorectal cancer rates and the climbing colonoscopy rates are linked, because the disease can be averted by removing polyps in the colon that are known to lead to cancer. Those polyps are found through colonoscopy and other screening methods.

"By finding non-cancerous polyps and removing them, we can actually prevent cancer," Brooks said. "Avoiding the disease is probably the most important reason screening needs to be done."
Beginning at age 50, both men and women should follow one of five screening options, according to the American Cancer Society:

A yearly stool blood test or fecal immunochemical test.
A flexible sigmoidoscopy every five years.
A yearly stool blood test plus flexible sigmoidoscopy every five years.
A double contrast barium enema every five years.
A colonoscopy every 10 years.

Colonoscopy has been presented as the best option, because polyps can be detected and removed during the same procedure. During a colonoscopy, a slender, lighted tube is inserted through the anus up into the colon, allowing a thorough scan of the organ.

But Dr. Bernard Levin, vice president of cancer prevention at the University of Texas M.D. Anderson Cancer Center in Houston, said the emphasis on a colonoscopy shouldn't keep people from pursuing other forms of screening if colonoscopy isn't available where they live.

Any screening test that gets done is the best, Levin said. "We have to accept that colonoscopy is not available to everybody. Other screening methods should not be considered second-rate," he said.

Other screening methods might also seem more palatable to patients who don't want to be anaesthetized, undergo the cleansing process necessary to prepare themselves for a colonoscopy, or have some other objection to the procedure.

"Some patients absolutely refuse having anything inserted into their body as a screening tool," Brooks said.

Flexible sigmoidoscopy is similar to colonoscopy, but the tube is inserted only into the lower part of the colon, making the procedure less invasive.

In a barium enema screening, a chalky substance is used to partly fill and open up the colon. Air is then pumped in to cause the colon to expand, allowing X-rays to be taken.

An additional screening tool, virtual colonoscopy, could make it easier than ever to be checked. Virtual colonoscopy uses CT scans and computers to produce two- and three-dimensional images of the colon and display them on a screen.

However, Brooks said, it's too soon to tell whether virtual colonoscopy is a dependable means of detecting or preventing colon cancer.

"Right now, virtual colonoscopy is not recommended as a screening tool," he said. "There is a significant body of evidence that supports its usefulness as a test, but it is being evaluated."

Levin decries another misconception about colon cancer, that men are more likely than women to get the disease.

"Over a woman's lifetime, they have the same chance as men," Levin said. "It's not a man's disease."
Those who are screened regularly for colorectal cancer are being met halfway by the medical profession, which is working to improve the quality of its screenings.

For example, a recent study found that doctors are more likely to get better results during a colonoscopy if they spend at least six minutes looking for abnormal growths.

The key is withdrawing the instrument slowly after it has been fully inserted, Levin and Brooks said.
"You have to do a high-quality examination for that examination to be effective," Brooks said. "Doctors who took their time and removed the scope slowly were able to find abnormalities at a rate of three times more compared with doctors who removed the scope at a more rapid rate."

Levin agreed. "If you're not withdrawing slowly enough to see every aspect of the colon, you're short-changing that patient," he said.

More information
To learn more about colorectal cancer, visit the American Cancer Society.

New Drug Fails to Improve Odds for Heart Failure Patients

(HealthDay News) -- A new drug is no more effective at improving the survival rates of people with decompensated heart failure than a widely used medication is, a new international study has found.

Decompensated heart failure is one form of the general condition in which the heart progressively loses the ability to pump blood. It is characterized by a set of symptoms including shortness of breath and intolerance to exercise.

There were hopes that the new drug, levosimendan, would improve survival, because it uses a unique mechanism that makes heart muscle cells more sensitive to the calcium that causes them to contract. However, the study of 1,347 persons with acute decompensated heart failure, done at 75 centers in nine countries between March 2003 and December 2004, found essentially the same death rate for participants who got levosimendan as those who received an established medication, dobutamine, said a report in the May 2 issue of the Journal of the American Medical Association.

The trial leaves cardiologists without a totally satisfactory treatment for decompensated heart failure, said Dr. Robert Hobbs, a Cleveland cardiologist specializing in treatment of the condition. Some 5 million Americans have one form or another of heart failure, and about 1 million of them are hospitalized for it each year.

"The original therapy, which is still basic, is diuretics," Hobbs explained. "They make the body lose water, so people feel better. In the 1980s, ACE inhibitors came along to make people feel better and live longer, and they were added for long-term benefit. The third group of drugs to be used were beta blockers."

Dobutamine is a positive inotropic agent that has been found to improve symptoms, but it has also been associated with an increased risk of death and cardiovascular problems. In the latest trial, participants with decompensated heart failure received levosimendan or dobutamine intravenously.

"The common practice has been to give dobutamine in the belief that the heart is like a battery that has lost its charge," Hobbs said. "By giving dobutamine, you would recharge it. That didn't actually happen [in previous studies]. It appeared to be associated with complications, longer hospital stays and more mortality."

In another previous study, careful analysis indicated that levosimendan was associated with a lower risk of death than dobutamine. "It did have the different mechanism of action, and it was felt that might translate into improved safety," Hobbs said. But it proved to be no better in the new trial.

In the 180 days after drug infusion, the death rate was 26 percent among patients who got levosimendan and 28 percent in those getting dobutamine. There was no statistical difference between other endpoints, such as incidence of breathing difficulties and days spent out of the hospital.

Participants who got levosimendan were less likely to experience cardiac failure but more likely to experience the abnormal heartbeat called atrial fibrillation, low blood levels of potassium, and headache.

"The bottom line on all of this is that it is hard to show benefit for what we do for acute decompensated heart failure," Hobbs said.

More information
All aspects of heart failure are explored by the American Heart Association .