By using MRI (magnetic resonance imaging) it may be possible to prevent the development of invasive cancer by diagnosing breast caner in its intraductal stage, according to an article in The Lancet. A Comment in The Lancet believes that these findings demonstrate that MRI should now be used as another method, in its own right, to detect early stage breast cancer.
Professor Christiane Kuhl, Department of Radiology, University of Bonn, Germany, and team examined details on 7,319 women over a period of five years. They had all been referred to an academic breast center. As well as conventional mammography for diagnostic assessment and screening they all received MRI as well. The aim here being to find out how sensitive each method was in diagnosing DCIS (ductal carcinoma in situ). Different radiologists then assessed the mammograms and MRI scans. They assessed the relative sensitivity of each detection method by comparing the biological profiles of mammography-detected DCIS with those of MRI-detected DCIS.
The scientists found that:
– Of 167 women who had a DCIS diagnosis, 92% were diagnosed with MRI– Of 167 women who had a DCIS diagnosis, 56% were diagnosed by mammography– MRI sensitivity for diagnosing DCIS increased with nuclear grade– Mammography sensitivity for diagnosing DCIS decreased with nuclear grade– Of 89 women with high grade DCIS diagnosis, 98% were diagnosed by MRI– Of 89 women with high grade DCIS diagnosis, 52% were diagnosed by mammography– 48% were missed by mammography but diagnosed by MRI aloneThe MRI’s higher sensitivity was not linked to a significantly higher number of false positive diagnoses.
“Our study suggests that the sensitivity of film screen or digital mammography for diagnosing DCIS is limited. MRI could help improve the ability to diagnose DCIS, especially DCIS with high nuclear grade,” the authors conclude.
“These findings can only lead to the conclusion that MRI outperforms mammography in tumour detection and diagnosis. MRI should thus no longer be regarded as an adjunct to mammography but as a distinct method to detect breast cancer in its earliest stage. A large-scale multicentre breast-screening trial with MRI in the general population is essential,” Dr Carla Boetes and Dr Ritse Mann, Radboud University Nijmegen Medical Centre, Netherlands, wrote in the accompanying Comment.
http://www.thelancet.com
Wednesday, October 10, 2007
Using MRI To Diagnose BreastCancerIn Its Intraductal Stage May Stem Development Of Invasive Cancer
AHA Affiliate Releases Toolkit For ED-Based HIV Testing Programs
HIV Testing Programs Toolkit, Health Research and Educational Trust: HRET, an affiliate of the American Hospital Association, has launched a no-cost, online toolkit to facilitate planning, implementation or expansion of hospital emergency department-based HIV testing programs for clinicians and administrators. The toolkit examines different approaches, considerations and resources needed in making HIV testing a routine part of ED treatment. The toolkit can be used to guide program-design and resource-allocation decisions, as well as to inform policies for ED HIV testing. The toolkit is based on HRET findings from site visits and interviews with ED personnel and was supported by CDC and the National Center for HIV/AIDS, STD and TB Prevention (HRET, July 2007).
Reprinted with kind permission from http://www.kaisernetwork.org. You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery at http://www.kaisernetwork.org/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork.org, a free service of The Henry J. Kaiser Family Foundation.
Blood Clots Outside Hospital Could Be Prevented Inside Hospital
Even though more blood clots, or venous thromboembolisms are diagnosed during the three months after patients’ hospitalizations than while they are in hospital, fewer than half of them receive medications to prevent blood clots while they are inpatients, according to a new report published in Archives of Internal Medicine (a JAMA/Archives journal), July 23 issue.
Researchers examined the results of several previous studies and found that both unfractionated and low-molecular-weight heparin are effective in preventing venous thromboembolisms in the legs and lungs of hospitalized patients.
According to background information in this study, venous thromboembolism and pulmonary embolism are major causes of complications and death among hospitalized patients. It is estimated that up to 10% of hospital deaths may be attributed to pulmonary embolism. Venous thromboembolisms, on the other hand, tend to happen out of the hospital.
Frederick A. Spencer, M.D., McMaster University Medical Center, Hamilton, Ontario, Canada, and team looked at the medical records of people from Worcester, Massachusetts, who were diagnosed with venous thromboembolism during 1999, 2001 and 2003.
The authors wrote that “A total of 1,897 subjects had a confirmed episode of venous thromboembolism. In all, 73.7 percent of patients developed venous thromboembolism in the outpatient setting; a substantial proportion of these had undergone surgery (23.1 percent) or hospitalization (36.8 percent) in the preceding three months.” 67% of all those patients experienced venous thromboembolisms within one month of their hospitalization. Two other risk factors were active cancer (29%) and a previous blood clot (19.9%).
The authors wrote “Because most of the cases of venous thromboembolism occurred within 29 days of hospital discharge (41% occurred within 14 days), it is not unreasonable to assume that some of these cases may have been prevented simply by increased use of appropriate in-hospital deep vein thrombosis prophylaxis (such as, compression stockings, pneumatic compression devices and, in high-risk patients, anticoagulants.”
The study states that about half of the outpatients who experienced venous thromboembolism after hospitalization had been in hospital for four days or less. They indicate that patients who are in hospital for a short time should receive preventative therapy. As hospital stays are getting shorter, patients are spending more recovery time at home without moving about - they would benefit from anti-clotting therapy even after discharge.
Another meta-analysis, carried out by Lironne Wein, Monash University and Alfred Hospital, Melbourne, Australia, and colleagues, looked at 36 previously published randomized controlled trials which compared drugs used to prevent venous thromboembolism - comparisons were made against a control group who did not receive prophylactic therapy. 14 of the studies compared unfractionated heparin with a control, 11 compared low-molecular weight heparin to a control, 10 compared two types of heparin to each other, and 1 compared fondaparinux sodium to a placebo.
The findings were as follows:
* Unfractionated heparin was linked to a 67% lower deep vein thrombosis risk and a 36% lower pulmonary embolism risk, compared to control groups.* Low-molecular-weight heparin was linked to a 44% % lower deep vein thrombosis risk and a 63% lower pulmonary embolism risk, compared to control groups.* Fondaparinux was shown to be effective in preventing venous thromboembolism.* When compared with each other, low-molecular-weight heparin was associated with a 32% lower risk of deep vein thrombosis and a 53% lower rate of hematoma at the injection site.* Prophylactic therapy, however, was not linked to lower mortality rates.
The authors wrote “This meta-analysis has shown that unfractionated heparin and low-molecular-weight heparin are both associated with a reduced risk of venous thromboembolism in medical patients, with low-molecular-weight heparin being more effective in preventing deep vein thrombosis than unfractionated heparin when considering trials that directly compared the two agents. The unfractionated heparin dosage of 5,000 units three times daily was more effective than the unfractionated heparin dosage of 5,000 units twice daily in reducing the risk of deep vein thrombosis. We believe that routine prophylactic anticoagulation has an important place in the medical setting.”
“Although such therapy may not necessarily decrease mortality among hospitalized medical patients, it will reduce the occurrence of deep vein thrombosis and pulmonary embolism and therefore the burden of illness currently caused by these events.”
“Venous Thromboembolism in the Outpatient Setting”Frederick A. Spencer, MD; Darleen Lessard, MS; Cathy Emery, RN; George Reed, PhD; Robert J. Goldberg, PhDArch Intern Med. 2007;167:1471-1475Click here to view abstract online
Related Articles:
Editorial:“Outpatient Venous Thromboembolism - A Common But Often Preventable Public Health Threat”Arch Intern Med. 2007;167:1451-1452.Click here to read the first 150 words of the full text
“Pharmacological Venous Thromboembolism Prophylaxis in Hospitalized Medical Patients: A Meta-analysis of Randomized Controlled Trials”Lironne Wein, Sara Wein, Steven Joseph Haas, James Shaw, and Henry KrumArch Intern Med. 2007;167:1476-1486.Click here to view abstract online
Specific Gene Supressor Described As A 'Dictator With A Conscience'
University of New South Wales (UNSW) researchers have uncovered an important naturally occurring mechanism in the body where “bad” cells that cause blockages in our blood vessels are kept under strict growth control, while “good” cells that keep our blood vessels free of clots and growths are left unaffected.
The discovery is expected to benefit those who will need heart coronary bypass surgery, an angioplasty — the mechanical widening of a narrowed or totally blocked blood vessel — or will undergo haemodialysis.
Professor Levon Khachigian, from UNSW’s Centre for Vascular Research, who previously pioneered “molecular assassin” drug technology, describes this novel mechanism he discovered as “a molecular dictatorship with a conscience”.
“The dictator is a specific gene suppressor called YY1, which has the therapeutically appealing capacity to differentiate between certain cell types when it goes about its activity,” says Professor Khachigian.
This key finding has just been published in the world’s premier cardiovascular research journal, Circulation Research.
Professor Khachigian’s research provides new hope in tackling the global problems of coronary bypass graft failure, and restenosis — the closing or narrowing of an artery that was previously opened by a procedure such as angioplasty.
“While the most effective way to head off restenosis is a drug-coated stent, the drugs that sit on these stents inhibit the growth of good cells as well as the bad.
“If you had to have catheter intervention to re-open an occluded artery, for sustained symptom-free benefit you would be hoping for suppressed smooth muscle cell growth, without affecting endothelial cell growth,” says Professor Khachigian.
“And that’s exactly what happens when we simply top up blood vessels with the body’s natural reserves of YY1.”
Better Clinical Model Required For The Treatment Of Heart Failure And Associated Depression
The National Institute of Mental Health (NIMH) has awarded researchers at the University of Pittsburgh School of Medicine a three-year, $500,000 grant to develop a novel intervention strategy for simultaneously treating congestive heart failure and major depression. The study is designed to obtain the necessary feasibility and clinical data required to plan a large-scale trial, which will compare the impact of a “blended” depression/heart failure care management programs vs. traditional heart failure care management program on cardiovascular morbidity and mortality, health-related quality of life, mood symptoms, health care costs and a variety of other outcomes of interest.
Heart failure affects 5 million Americans, with more than 550,000 newly diagnosed cases, 287,000 deaths and $30 billion in both direct and indirect costs each year. It also is the leading cause for hospitalization, and its five-year mortality rate following first hospital admission for heart failure exceeds that of most cancers.
Depression is present in approximately 20 to 50 percent of heart failure patients and compelling evidence links it to increased morbidity and mortality and reduced quality of life. Yet, although the University of Pittsburgh Medical Center (UPMC) and several other integrated health care delivery systems across the United States have implemented outpatient care management programs for heart failure, none routinely screen for and treat depression.
The study of the connections between mental health and cardiovascular disease is not new to the study’s principal investigator, Bruce L. Rollman, M.D., M.P.H., associate professor of medicine and psychiatry, University of Pittsburgh School of Medicine. Since 2004, he and his co-principal study investigator, Charles F. Reynolds III, M.D., UPMC Professor of Geriatric Psychiatry, University of Pittsburgh School of Medicine, and their research team have been recruiting patients from several Pittsburgh-area hospitals, including UPMC Presbyterian and UPMC Passavant, into the first NIH-funded clinical trial titled, “Bypassing the Blues,” designed to examine the impact of treating depressive symptoms following coronary artery bypass graft (CABG) surgery.
In this latest study, Drs. Rollman and Reynolds, with the help of their co-investigators Dennis McNamara, M.D., professor of medicine and director of UPMC Heart Failure Transplantation, and Rene Alvarez, M.D., associate professor of medicine and director of UPMC Heart Failure/Pulmonary Hypertension Network, will modify their “Bypassing the Blues” protocol for treating post-CABG depression. They will employ the UPMC outpatient guidelines for treating heart failure and then pilot their “blended” treatment strategy for treating depressed heart failure patients. They will recruit approximately 500 patients admitted for an acute episode of heart failure from UPMC Presbyterian, UPMC St. Margaret, UPMC Braddock and UPMC McKeesport hospitals, and then conduct follow-up telephone assessments at one, three and six months to estimate suitably sensitive and specific cut-off scores for treating depression by gender and severity of heart failure.
“The subject of depression and congestive heart failure has received little attention until recently. We need to look at these two conditions differently than in the past, as depression is seldom diagnosed and often untreated in patients with congestive heart failure,” commented Dr. Rollman. “We also hope to learn through the cohort study how to better determine the severity of depressive symptoms that merit further attention from heart failure specialists.”
“Cardiologists can help their patients if they are provided with the knowledge of depression’s devastating effects on heart disease. Early studies have demonstrated that if patients are treated for depression after heart surgery or any invasive heart procedure, they are more likely to stick to their scheduled treatments and have a better, more positive outlook toward recovery,” says Dr. McNamara.
“Depression is a complex disease with many symptoms similar to heart failure. If we can develop a better clinical model in recognizing and detecting depression, we hope to be able to gather enough data to support the need for a large-scale trial to test the effectiveness of a combined depression and heart failure treatment over the current standard of care for heart failure which does not address depression,” added Dr. Reynolds.
Defibrillators Can Control Dangerous Heart Condition
And a number of people benefiting from the implantable cardioverter-defibrillators (ICDs) had only one risk factor for sudden cardiac death, meaning that more people may benefit, a new study suggests.
“Hypertrophic cardiomyopathy is the most common cause of sudden death in young people, including athletes, and a defibrillator affords the opportunity, as it turns out, to change the natural course of the disease and prevent sudden death,” said Dr. Barry Maron, director of the Hypertrophic Cardiomyopathy Center at the Minneapolis Heart Institute Foundation. “In a way, this highlights the use and effectiveness of the device in this genetic disease in these young patients and expands the number of patients that could be eligible at least for consideration of a defibrillator.”
Maron was lead author of the study, which is published in the July 25 issue of the Journal of the American Medical Association.
Other experts, however, pointed out that much of the information in the study has already been known.
“Some of this data has been published in a smaller number of patients. This study confirms what has already been done,” said Dr. Jose Joglar, director of clinical electrophysiology, and associate professor of medicine at the University of Texas Southwestern Medical Center at Dallas. “This is not going to expand the use of defibrillators.”
Hypertrophic cardiomyopathy is a genetic disease that causes the heart muscles to thicken abnormally. This, in turn, can upset the heart’s electric system and cause life-threatening rhythm disturbances called arrhythmias.
Implantable defibrillators (ICDs), which terminate these dangerous rhythm disturbances, have become routine over the past few years in high-risk patients with hypertrophic cardiomyopathy. But it’s not always easy to identify the people with hypertrophic cardiomyopathy who would benefit from a defibrillator.
“It’s traditionally difficult to determine precisely which patients among all with this disease are at high risk and would deserve consideration for an ICD, because HCM [hypertrophic cardiomyopathy] is a particularly heterogeneous disease,” Maron explained.” Most of the patients at high risk have no symptoms or only mild symptoms and are younger than those who have coronary disease by, on the average, 25 years. And there is no one single risk factor that has emerged such as with coronary disease following a heart attack.”
“Because the patients are younger, the decision for these ICDs are bigger because of the time period they will have them is longer,” he continued.
Although the new study isn’t the first study to look at ICDs in patients with hypertrophic cardiomyopathy, it is the largest.
Maron and his colleagues analyzed data from an international, multi-center registry of defibrillators implanted between 1986 and 2003 in 506 patients with hypertrophic cardiomyopathy. All of the patients, whose average age was 42 years, were considered at high risk for sudden death, although 87 percent had no or only mild symptoms. Average follow-up was 3.7 years. The defibrillators were implanted both in patients who had never had a problem (primary prevention) and in patients who had already had a problem (secondary prevention).
Twenty percent of the patients experienced one or more incidents in which the ICD terminated ventricular fibrillation (severely abnormal heart rhythm that results in cardiac arrest) or ventricular tachycardia (abnormally rapid heartbeat).
The defibrillator terminated abnormal heart rhythms in 10.6 percent of patients annually who had a device for secondary prevention and in 3.6 percent of patients a year for primary prevention.
The probability of a defibrillator intervening five years after implantation was almost 25 percent, the study found.
More than 40 percent of patients in whom the device intervened appropriately were under 40 years of age.
Thirty-five percent of the patients who had a defibrillator for primary prevention had undergone implantation based on just one risk factor. The likelihood that the device would intervene was similar in patients with one, two or three or more risk factors.
The risk factors evaluated in the study included a history of hypertrophic cardiomyopathy-related sudden death in one or more relatives under the age of 50; fainting; and abnormally rapid heart rhythm.
“This is a select patient population. The risk factors are pretty significant; the patients were probably sicker,” Joglar said. “The great majority of patients with HCM will have a better prognosis than that.”
The study authors cautioned that defibrillators should not necessarily be implanted in everyone with hypertrophic cardiomyopathy. Patients will still have to rely on individual doctors’ judgment.
Analyzing Beating Heart Stem Cells Could Lead To Heart Attack Treatments
New research at the University of Nottingham, funded by the Biotechnology and Biological Sciences Research Council (BBSRC), is paving the way for techniques that use stem cells to repair the damage caused by heart attacks.
The research, highlighted in the new issue of BBSRC Business, is looking at the process that turns a stem cell into a cardiomyocyte — the beating cell that makes up the heart. The Nottingham researchers are developing a new system to monitor cardiomyocytes in real time as they differentiate from stem cells into beating heart cells. The system uses electrophysiology to record the electrical properties in a cell and will be the first time it has been used to study cardiomyocyte cells in the UK.
The researchers hope that their research could provide more detailed information on the electrical activity of stem cell derived cardiomyocytes. In the longer term, this could facilitate their use in regenerating the damaged hearts of heart attack victims.
“Human embryonic stem cells promise unrivalled opportunities. However, they are difficult, time-consuming and expensive to grow in the lab”, Dr Denning explains. “Our understanding of how to convert them into cardiomyocytes is poor. At the moment we only know how to produce a few million cardiomyocytes, but to treat just one heart attack patient, we may need one billion that all function in the correct way.”
To help overcome the many challenges that stem cells bring, Dr Denning and his team plan to engineer a novel system for real-time analysis of cardiomyocytes during early development so their properties are better understood.
The team have already demonstrated that sufficient numbers of stem cell-derived cardiomyocytes can be produced for detailed analysis and they plan to use new ‘electrophysiology’ systems to record changes in the cells when cultured. Electrophysiology is the study of cells’ electrical properties and this is the first time that the method has been used in the UK to study stem cell-cardiomyocyte biology.
“This research will enable rapid development of stem cell-derived cardiomyocytes as a tool for understanding the heart and its diseases,” says Dr Denning. However, he cautions: “Before we can consider using stem cells to treat heart-attack patients there are many problems which will take many years to solve. We don’t yet know how to deliver the cells to a patient’s heart and prevent them being washed away so that they actually stay in the heart and both survive and function. It will take many years to overcome these challenges and put stem cell-derived cardiomyocytes into medical usage.”
The researchers will also be monitoring how the cells respond to different pharmacological agents in order to improve drug-screening processes and reduce the need for animal testing.
“A key part of the project is to monitor the effects of different drugs on the cells. At present, only limited information is available on how they respond to pharmacological or gene modulating agents.
“Between 1990 and 2001, 8 different drugs were withdrawn from the market in the USA at an estimated cost of $8billion because they caused unexpected deaths in several hundred patients. Our aim is to reduce such occurrences by having better test methods to test the drugs before they reach the clinic.
“By studying the drugs’ effects on the heart cells in the lab, this could reduce the need for animals in clinical trials.”
