Archive for the ‘Archives of Internal Medicine’ Category

Environmental Causes of Breast Cancer and Radiation From Medical Imaging Findings — From the Institute of Medicine Report

August 1, 2012 Comments off

Environmental Causes of Breast Cancer and Radiation From Medical Imaging Findings — From the Institute of Medicine Report

Source: Archives of Internal Medicine

Susan G. Komen for the Cure asked the Institute of Medicine (IOM) to perform a comprehensive review of environmental causes and risk factors for breast cancer. Interestingly, none of the consumer products (ie, bisphenol A, phthalates), industrial chemicals (ie, benzene, ethylene oxide), or pesticides (ie, DDT/DDE) considered could be conclusively linked to an increased risk of breast cancer, although the IOM acknowledged that the available evidence was insufficient to draw firm conclusions for many of these exposures, calling for more research in these areas. The IOM found sufficient evidence to conclude that the 2 environmental factors most strongly associated with breast cancer were exposure to ionizing radiation and to combined postmenopausal hormone therapy. The IOM’s conclusion of a causal relation between radiation exposure and cancer is consistent with a large and varied literature showing that exposure to radiation in the same range as used for computed tomography will increase the risk of cancer. It is the responsibility of individual health care providers who order medical imaging to understand and weigh the risk of any medical procedures against the expected benefit.

Susan G. Komen for the Cure, the largest grassroots network of breast cancer survivors and activists in the United States, asked the Institute of Medicine (IOM) to perform a comprehensive and evidence-based review of environmental causes and risk factors for breast cancer, with a focus on identifying evidence-based actions that women can take to reduce their risk.1 Environmental exposures were defined broadly to include all factors not genetically inherited, and the IOM committee appointed to write this report included academicians and chairs from departments of environmental health, toxicology, cancer epidemiology, preventive medicine, and biostatistics in addition to advocates for patients with breast cancer. Committee members conducted their own reviews of the peer-reviewed epidemiological and basic science literature, commissioned several papers specifically for their report, and drew on evidence-based reviews already completed by organizations such as the Agency for Research on Cancer and the World Cancer Research Fund International. The publication Breast Cancer and the Environment: A Life Course Approach was released online in December 2011.

Application of “Less Is More” to Low Back Pain

June 16, 2012 Comments off

Application of “Less Is More” to Low Back Pain
Source: Archives of Internal Medicine

An initiative of the National Physicians Alliance, the project titled “Promoting Good Stewardship in Clinical Practice,” developed a list of the top 5 activities in primary care for which changes in practice could lead to higher-quality care and better use of finite clinical resources. One of the top 5 recommendations was “Don’t do imaging for low back pain within the first 6 weeks unless red flags are present.” This article presents data that support this recommendation. We selectively reviewed the literature, including recent reviews, guidelines, and commentaries, on the benefits and risks of routine imaging in low back pain. In particular, we searched PubMed for systematic reviews or meta-analyses published in the past 5 years. We also assessed the cost of spine imaging using data from the National Ambulatory Medical Care Survey. One high-quality systematic review and meta-analysis focused on clinical outcomes in patients with low back pain and found no clinically significant difference in pain or function between those who received immediate lumbar spine imaging vs usual care. Published data also document harms associated with early imaging for low back pain, including patient “labeling,” unneeded follow-up tests for incidental findings, irradiation exposure, unnecessary surgery, and significant cost. Routine imaging should not be pursued in acute low back pain. Not imaging patients with acute low back pain will reduce harms and costs, without affecting clinical outcomes.

Nature and Impact of Grief Over Patient Loss on Oncologists’ Personal and Professional Lives

May 28, 2012 Comments off

Nature and Impact of Grief Over Patient Loss on Oncologists’ Personal and Professional Lives (PDF)
Source: Archives of Internal Medicine

Caring for critically ill and terminal patients can generate grief reactions in health care professionals (HCPs). While all HCPs can potentially experience grief over patient loss, oncologists face unique pressures because they are legally responsible for the patients’ care and may be blamed when patients die.5 Despite the evidence that grief over patient loss is an intrinsic part of clinical oncology, there are no qualitative studies examining the nature and extent of oncologists’ grief over patient loss nor the impact of this grief on oncologists’ lives. The objectives of our study were to explore and identify oncologists’ grief over patient loss and the ways in which this grief may affect their personal and professional lives.

Red Meat Consumption and Mortality

March 13, 2012 Comments off

Red Meat Consumption and Mortality
Source: Archives of Internal Medicine

Red meat consumption has been associated with an increased risk of chronic diseases. However, its relationship with mortality remains uncertain.

We prospectively observed 37 698 men from the Health Professionals Follow-up Study (1986-2008) and 83 644 women from the Nurses’ Health Study (1980-2008) who were free of cardiovascular disease (CVD) and cancer at baseline. Diet was assessed by validated food frequency questionnaires and updated every 4 years.

We documented 23 926 deaths (including 5910 CVD and 9464 cancer deaths) during 2.96 million person-years of follow-up. After multivariate adjustment for major lifestyle and dietary risk factors, the pooled hazard ratio (HR) (95% CI) of total mortality for a 1-serving-per-day increase was 1.13 (1.07-1.20) for unprocessed red meat and 1.20 (1.15-1.24) for processed red meat. The corresponding HRs (95% CIs) were 1.18 (1.13-1.23) and 1.21 (1.13-1.31) for CVD mortality and 1.10 (1.06-1.14) and 1.16 (1.09-1.23) for cancer mortality. We estimated that substitutions of 1 serving per day of other foods (including fish, poultry, nuts, legumes, low-fat dairy, and whole grains) for 1 serving per day of red meat were associated with a 7% to 19% lower mortality risk. We also estimated that 9.3% of deaths in men and 7.6% in women in these cohorts could be prevented at the end of follow-up if all the individuals consumed fewer than 0.5 servings per day (approximately 42 g/d) of red meat.

Red meat consumption is associated with an increased risk of total, CVD, and cancer mortality. Substitution of other healthy protein sources for red meat is associated with a lower mortality risk.

The Cost of Satisfaction: A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality

February 16, 2012 Comments off

The Cost of Satisfaction: A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality
Source: Archives of Internal Medicine

Patient satisfaction is a widely used health care quality metric. However, the relationship between patient satisfaction and health care utilization, expenditures, and outcomes remains ill defined.

We conducted a prospective cohort study of adult respondents (N = 51 946) to the 2000 through 2007 national Medical Expenditure Panel Survey, including 2 years of panel data for each patient and mortality follow-up data through December 31, 2006, for the 2000 through 2005 subsample (n = 36 428). Year 1 patient satisfaction was assessed using 5 items from the Consumer Assessment of Health Plans Survey. We estimated the adjusted associations between year 1 patient satisfaction and year 2 health care utilization (any emergency department visits and any inpatient admissions), year 2 health care expenditures (total and for prescription drugs), and mortality during a mean follow-up duration of 3.9 years.

Adjusting for sociodemographics, insurance status, availability of a usual source of care, chronic disease burden, health status, and year 1 utilization and expenditures, respondents in the highest patient satisfaction quartile (relative to the lowest patient satisfaction quartile) had lower odds of any emergency department visit (adjusted odds ratio [aOR], 0.92; 95% CI, 0.84-1.00), higher odds of any inpatient admission (aOR, 1.12; 95% CI, 1.02-1.23), 8.8% (95% CI, 1.6%-16.6%) greater total expenditures, 9.1% (95% CI, 2.3%-16.4%) greater prescription drug expenditures, and higher mortality (adjusted hazard ratio, 1.26; 95% CI, 1.05-1.53).

In a nationally representative sample, higher patient satisfaction was associated with less emergency department use but with greater inpatient use, higher overall health care and prescription drug expenditures, and increased mortality.

Likelihood That a Woman With Screen-Detected Breast Cancer Has Had Her “Life Saved” by That Screening

October 28, 2011 Comments off

Likelihood That a Woman With Screen-Detected Breast Cancer Has Had Her “Life Saved” by That Screening
Source: Archives of Internal Medicine

Background Perhaps the most persuasive messages promoting screening mammography come from women who argue that the test “saved my life.” Because other possibilities exist, we sought to determine how often lives were actually saved by mammography screening.

Methods We created a simple method to estimate the probability that a woman with screen-detected breast cancer has had her life saved because of screening. We used DevCan, the National Cancer Institute’s software for analyzing Surveillance Epidemiology and End Results (SEER) data, to estimate the 10-year risk of diagnosis and the 20-year risk of death—a time horizon long enough to capture the downstream benefits of screening. Using a range of estimates on the ability of screening mammography to reduce breast cancer mortality (relative risk reduction [RRR], 5%-25%), we estimated the risk of dying from breast cancer in the presence and absence of mammography in women of various ages (ages 40, 50, 60, and 70 years).

Results We found that for a 50-year-old woman, the estimated risk of having a screen-detected breast cancer in the next 10 years is 1910 per 100 000. Her observed 20-year risk of breast cancer death is 990 per 100 000. Assuming that mammography has already reduced this risk by 20%, the risk of death in the absence of screening would be 1240 per 100 000, which suggests that the mortality benefit accrued to 250 per 100 000. Thus, the probability that a woman with screen-detected breast cancer avoids a breast cancer death because of mammography is 13% (250/1910). This number falls to 3% if screening mammography reduces breast cancer mortality by 5%. Similar analyses of women of different ages all yield probability estimates below 25%.

Conclusions Most women with screen-detected breast cancer have not had their life saved by screening. They are instead either diagnosed early (with no effect on their mortality) or overdiagnosed.

Diagnostic Blood Loss From Phlebotomy and Hospital-Acquired Anemia During Acute Myocardial Infarction

August 10, 2011 Comments off

Diagnostic Blood Loss From Phlebotomy and Hospital-Acquired Anemia During Acute Myocardial Infarction
Source: Archives of Internal Medicine

To our knowledge, our study is the first to directly assess the association between DBL and HAA in a large, unselected cohort of patients with AMI from hospitals across the United States. Diagnostic blood loss was substantial, particularly among individuals with HAA, and varied widely across hospitals, suggesting that process-of-care differences may influence DBL. It is important to note that DBL was independently associated with a higher risk of HAA and that this association remained robust after multivariable adjustment and in several sensitivity analyses.

Prior studies have shown that HAA is common and associated with higher mortality and worse health status after AMI.4, 6, 24 In our study, 1 in 5 patients who did not have baseline anemia (and did not undergo coronary bypass surgery) developed moderate to severe HAA. Several factors contribute to development of HAA. Some of these are not modifiable (age, sex, chronic kidney disease, acute inflammation from AMI),4, 25 but 2 are clearly under the control of health care providers: prevention of periprocedural bleeding and minimization of phlebotomy. Alternative anticoagulants such as bivalirudin, closure devices, and radial access for coronary angiography all reduce the incidence of periprocedural bleeding.26-29 However, no clear bleeding event is identified in many patients with HAA.4, 6 Although phlebotomy has been suggested as a cause of in-hospital hemoglobin level declines in patients with AMI,30 to our knowledge, our study is the first to identify DBL as an independent predictor of HAA in a contemporary cohort reflecting real-world patient care and highlights phlebotomy as a potentially modifiable risk factor.

Our findings have important clinical implications. Among patients who developed HAA, the mean estimated phlebotomy volume was 173.8 mL, which is equivalent to nearly half a unit of whole blood, and over 12% had more than 300 mL of blood drawn over the course of hospitalization. Diagnostic blood loss remained relatively constant throughout the course of hospital stay after the first 2 days of hospitalization and was particularly high among patients with long lengths of stay. Since most diagnostic evaluation and therapeutic interventions often occur early during AMI hospitalization, it is likely that much of the blood taken later during hospitalization represents routine, scheduled laboratory draws that could lead to ongoing blood loss. Our findings are likely generalizable to other populations of seriously ill medical patients. In this regard, further studies that establish whether minimizing DBL can prevent HAA and improve patient outcomes could have broad implications for hospitalized patients.

Airport Full-Body Screening: What Is the Risk?

April 12, 2011 Comments off

Airport Full-Body Screening: What Is the Risk?
Source: Archives of Internal Medicine

In the past year, the Transportation Security Administration has deployed full-body scanners in airports across the United States in response to heightened security needs. Several groups have opposed the scans, citing privacy concerns and fear of the radiation emitted by the backscatter x-ray scanners, 1 of the 2 types of machines in use. The radiation doses emitted by the scans are extremely small; the scans deliver an amount of radiation equivalent to 3 to 9 minutes of the radiation received through normal daily living. Furthermore, since flying itself increases exposure to ionizing radiation, the scan will contribute less than 1% of the dose a flyer will receive from exposure to cosmic rays at elevated altitudes. The estimation of cancer risks associated with these scans is difficult, but using the only available models, the risk would be extremely small, even among frequent flyers. We conclude that there is no significant threat of radiation from the scans.


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