Endoscopy better than open surgery for Abdominal Aortic Aneurysms

the January 31 issue of the New England J of Medicine reported a large observational study on endovascular vs. open repair of Abdominal Aortic Aneurysms (AAA).

Endovascular repair is a minimally invasive technique involving placing a stent via a catheter while open repair involves placing a graft through a large incision. However there have been concerns about the long term benefits of endovascular repair.

The study, including more than 45,000 patients on the US Medicare, found those who had endoscopic repairs had a higher survival rate 30 days after the procedure, the benefit is greater the older the patient. By 4 years, rupture and minor reintervention were more likely in the endovascular repair group than the open repair group. The author said these were balanced by an increase in laparotomy-related reinterventions and hospital admission after open surgery, however, not everyone is suitable for endoscopic stenting.

Source: "Endovascular vs. Open Repair of Abdominal Aortic Aneurysms in the Medicare Population" , NEJM Volume 358(5):464-474 ( subscription required)

Deep-brain stimulation could improve memory

While a team of Canadian doctors was using the technique of deep-brain stimulation to suppress an obese man's appetite, the man suddenly recalled in details a scene decades earlier instead of losing his appetite. Further tests showed his ability to learn was dramatically improved.

The lead author said the discovery was totally unexpected and the team is now applying the technique to treat patients with Alzheimer's disease in a trial. The findings, reported in the Annals of Neurology, might provide benefit to patients with memory disorders.

Exercise can make you younger

A new study based on the analysis of questionnaires of more than 2400 twins found that physically active adults are biologically younger than inactive ones - they have longer telomeres that are the caps at the end of the chromosomes. Telomeres tend to get shorter as people age and are used as an indicator of a peson's biological age.


The research team said the "differences in telomere length between active and inactive individuals cannot be explained by variations in genes, smoking, BMI and socioeconomic status", and the findings "could be used by clinicians to promote the potentially anti-aging effect of regular exercise". The study is published in the Archives of Internal Medicine, 28th issue.

In an editorial in the same issue, an expert said there could be other factors responsible for the biological differences between active and sedentary people, but the findings provide the evidence that telomere length might be targeted in studying ageing outcomes.

Source: "The Association Between Physical Activity in Leisure Time and Leukocyte Telomere Length."Arch Intern Med. 2008;168(2):154-158. ( full text via Athens)

Coffee is bad for diabetics

A small study of 10 patients with type 2 diabetes and who drank at least two cups of coffee daily found that daily consumption of caffeine increases their sugar levels by 8% and can exaggerate the rise in glucose after each meal. Higher sugar levels are bad for diabetics, complications may develop if the sugar levels are not controlled.

Source:"Caffeine Increases Ambulatory Glucose and Postprandial Responses in Coffee Drinkers With Type 2 Diabetes" Diabetes Care 31:221-222, 2008

Contraceptive pill has prevented 100,000 deaths

A large review based on 45 studies including 23,257 women with ovarian cancer and 87,303 controls found that the contraceptive pill substantially reduces women's risk of ovarian cancer for 30 years after they stop taking it, indicating a real protective effect against the cancer. Writing in the Lancet, the author said at least 100,000 deaths from ovarian cancer have been prevented worldwide by the contraceptive pill over 50 years.

It has been known that the pill increases women's risk of breast and cervical cancer, but the author said that these effects disappear after a woman stops taking it while the ovarian protection lasts for decades.

In the editorial, the author said "this study is impressive and compelling" and called for the pill to be available over-the-counter. A scientist writing in The Lancet opposed the over-the-counter access of the pill sayingthat women and their doctors must perform a balancing act between the risk and benefits.

Source: "Ovarian cancer and oral contraceptives: collaborative reanalysis of data from 45 epidemiological studies including 23,257 women with ovarian cancer and 87,303 controls"
The Lancet 2008; 371:303-314

Work stress raises heart risk

A new study involving 10,000 civil servants aged between 35 and 55 over 12 years found that chronic work stress raised the risk of coronary heart disease (CHD) and this association was stronger among the under 50.

Stress appeared to undermine the autonomic nervous system that controls the heart and the variability of the heart rate. Researchers also found higher levels of the stress hormone in workers who reported stressful job.

Source: "Work stress and coronary heart disease: what are the mechanisms?" European Heart Journal, published online on January 23, 2008 (free f/t)

Aspirin resistant may increase heart attack risk

Aspirin is widely used to prevent heart attacks, strokes and blood clot, but the Telegraph reported that a review of 20 studies involving 3000 patients has found 28% do not respond to aspirin and there is no standard test to establish who are resistant to the drug.



The author concluded that "patients who are resistant to aspirin are at a greater risk of clinically important cardiovascular morbidity long term than patients who are sensitive to aspirin" and called for further research. The report was published in the BMJ.



Source: Aspirin "resistance" and risk of cardiovascular morbidity: systematic review and meta-analysis BMJ, doi:10.1136/bmj.39430.529549.BE (published 17 January 2008)

Arthritis drug could reduce psoriasis in children

The Telegraph reported that an arthritis drug, Etanercept (Enbrel), could significantly improve the signs and symptoms of psoriasis in children.

The report is based on a double-blind randomised controlled trial published in New England Journal of Medicine, involving 211 children with psoriasis. The patients received weekly injections of etanercept or placebo for 12 weeks, followed by a 24-week period when all patients received etanercept and a 12-week period when patients were randomised to etanercept or placebo. The author concluded that Etanercept significantly reduced disease severity in children and adolescents with moderate to severe plaque psoriasis

Source: "Etanercept Treatment for Children and Adolescents with Plaque Psoriasis" NEJM 2008 358(3):241-251

Calcium supplements may increase heart attack risk

The Telegraph reported researchers in New Zealand found that calcium supplements may increase the risk of heart attack in healthy postmenopausal women.

1,471 postmenopausal women of average age 74 were randomly assigned to receive calcium supplement or placebo, followed for 5 years, researchers found heart attacks were more common in the women taking the calcium supplements. The report was published in the BMJ Online, the authors said the results are not conclusive but suggest that high calcium intakes might have an adverse effect on vascular health. Some experts in the field found the conclusion surprising and urged patients not to stop taking the supplements.

Source: "Vascular events in healthy older women receiving calcium supplementation: randomised controlled trial." BMJ 2008:394405257 published online, 15 January 2008 ( full text via Athens)

New medical training body needed in England

After the chaos of MTAS last year, Professor John Tooke, Dean of the Peninsula School of Medicine, was asked by the DH to lead an independent inquiry into Modernising Medical Careers. His interim report was published last October and was backed by doctors.

The Tooke final report was out yesterday with recommendations that a new body - NHS Medical Education England to be set up to manage postgraduate medical training and the training budget should be ring-fenced to prevent the NHS from using it to plug deficits.
The report also warns that junior doctors training could suffer when the European Working Time Directive comes into force next year, so measures need to be taken to ensure doctors have enough training time.

Junior doctors across the UK are being warned that they will face tough competition this year for specialist training jobs in the NHS after the government failed in a legal bid to give UK medical graduates priority. The report says that the Government failed to resolve its two policies that have caused the severe competition for training posts in the UK - British medical schools increasing the intake of students and the "open door" policy toward overseas doctors who want specialist training in the UK. Read more at TimesOnline .

Lack of sunlight may increase lung cancer risk

US researchers examined data from 111 countries to study the association between latitude, exposure to UVB light ( principal source of vitamin D) and rates of lung cancer.

Analysis of data showed that lung cancer rates were highest in those countries furthest from the equator where exposure to sunlight is lowest and lowest in those nearest. The researchers believed that vitamin D can halt tumor growth by promoting the factors responsible for cell death in the body. They found smoking accounted for up to 85% of all cases of lung cancer but exposure to UVB light in particular had an impact.

Experts warn that exposure to sunlight is the major cause of skin cancer and the link between vitamin D and lung cancer is still unclear. Source : "Could ultraviolet B irradiance and vitamin D be associated with lower incidence rates of lung cancer?" Journal of Epidemiology and Community Health 2008;62:69-74

Women with shorter legs may have higher risk of liver diseases

Almost 4,300 women of 60 - 79 were randomly selected from 23 British towns for an interesting study that investigated the separate associations of leg length and trunk length with levels of four liver enzymes: ALT, GGT, AST and ALP, each of these "reflects a different aspect of potential liver damage". The researchers found that women with shorter legs had higher levels of ALT, GGT and ALP ( an indicator of bone disease) while trunk length was positively associated with ALT and inversely associated with ALP.


They concluded that adult liver function is affected by childhood exposures, such as good nutrition, as reflected in leg length. This may suggest "common childhood influences on liver development and adult risk of diabetes and heart disease."


Source: "The associations between height components (leg and trunk length) and adult levels of liver enzymes" Journal of Epidemiology and Community Health 2008;62:48-53 (abstract only)

How would you manage this patient?

Every month JAMA presents a Clinical Crossroads case with patient's own view, it poses review questions and ask readers to submit their response to how they would care for the patient using evidence from the literature and his/her experience.

"Responses will be selected for posting online based on their quality, including use of the available evidence, weighing the issues, and addressing the patient's concerns." This could be another useful tool for doctors' education.

How would you manage this patient ? "A 39-Year-Old Man With a Skin Infection" JAMA. 2007;298(22)

Image Challenge

The New England Journal of Medicine features medical images every week to provide readers an opportunity to test their diagnostic skills - Image Challenge.

A question with several possible answers is given. You can "check your answer" after you have selected an answer. You can also check "how others chose", it is interesting to see that many people did not get the answers right. It could be a useful educational tool for doctors.

Take this week's Image Challenge.

Pedometer - a perfect gift for motivating physical activity.

A review of 8 randomized controlled trials and 18 observational studies with a total of 2767 participants was carried out to evaluate the association of pedometer use with physical activity and health outcomes, according to an article in JAMA.

The study found that pedometer users in RCTs significantly increased their physical activity by 2491 steps per day more than control participants while those in observational studies 2183 steps per day over baseline. The pedometer users significantly decreased their body mass index by 0.38, the intervention participants significantly decreased their systolic blood pressure by 3.8 mm Hg. However, whether these changes are durable over the long term is undetermined.

A pedometer counts steps a person takes and the distance he/she has walked and has become popular as an everyday exercise motivator - a perfect Christmas gift for someone who wants to increase physical activitity and improve health.

Source : "Using Pedometers to Increase Physical Activity and Improve Health - Systematic Review" JAMA. 2007;298(19):2296-2304. (abstract only)

Smoking associated with increased risk of diabetes

According to an article published in the current issue of JAMA , a review of 25 studies involving a total of 1.2 m patients showed that smoking is linked to an increased risk of diabetes.


Analysis of the data indicated that active smokers have a 44% increased risk of developing type 2 diabetes compared with non-smokers. The risk increased with the number of cigarettes smoked, heavy smokers had 61% of increased risk compared with lighter smokers (29%), but the authors said there is a need for further studies to establish whether this association is causal.


Source: "Active Smoking and the Risk of Type 2 Diabetes - A Systematic Review and Meta-analysis" JAMA. 2007;298(22):2654-2664 (abstract only)

Elective caesareans linked to respiratory morbidity

More and more women request a Caesarean section without good medical reasons, a lot of them are completely unaware of the negative impact on their baby.

A large-scale study carried out by Dannish experts involving 34,458 deliveries between 37 and 41 weeks found babies born through elective Caesarean are up to four times more likely to suffer breathing problems compared with those born naturally or by emergency Caesarean. The earlier the Caesarean is carried out, the higher the risk. The researchers advised women not to carry out elective Caesareans before 39 weeks. The report is published by the BMJ.

Source : "Risk of respiratory morbidity in term infants delivered by elective caesarean section: cohort study" BMJ Online (published 11 December 2007)

Mediterranean diet can lower mortality rate

According to a large scale cohort study of 380,296 people aged 50 - 71 with no history of chronic disease, eating a Mediterranean diet can cut the risk of dying early.

Participants were divided into three groups according to their dietary habits and were then followed-up over a five-year period. The study found that those who followed a Mediterranean diet closely were less likely to die of cancer or heart disease. The authors concluded that their study provided strong evidence that higher conformity with the Mediterranean diet is associated with lower mortality rate.

Source: "Mediterranean Dietary Pattern and Prediction of All-Cause Mortality in a US Population: Results From the NIH-AARP Diet and Health Study" Archives of Internal Medicine. 2007;167(22):2461-2468

Pediatricians' journal reading habits

An interesting article about American pediatricians' reading habits showed that pediatricians read journal articles primarily for current awareness. They chose the formats that were most convenient to them, read quickly and often relied on print journals and personal subscriptions. However they tended to rely on e-resources for research, writing and presentations, most likely provided by the library. The authors said this finding is similar to the results of many studies of physicians.

Summaries of findings :

Amount of reading - Read on average between 145 and 184 articles per year

Age of articles read - 81% of the reading were from the current year

Time spent - On average spent 20 minutes per reading, ie about 49 -61 hrs per year reading articles (other healthcare professionals spent an average of 118 hrs per year reading an average of 322 journal articles )

Purpose of reading - Principal purpose : 50 % for current awareness
Secondary purposes : 30.3 % for treatment, 20% for diagnosis, 18.2% for teaching

Outcomes of reading - Improved a result 43.5%, inspired new thinking 42.2%, helped narrowed the focus 17%

Source & formats of reading - Mostly from personal and print subscriptions for current awareness, but rely on electronic resources provided by the library for research, writing and presentations

Location of reading - Scholarly reading most often at home 50.5%, In office 36.8%, Hospital/clinic only 6.2%

Subscription payment - Personal subscriptions over 5.3 each ( average subscription for scientists and social scientists is under 2 per person).

PubMed use - 71% had used PubMed at some point, about 34 times on average in the past 12 months. As a result of using PubMed, they read between 0 and 1000 articles.

Use of PDA - About half of respondents used a PDA but few used PDAs to download articles .

Source: "Journal reading patterns and preferences of pediatricians" J Medical Library Association 95(1) January 2007 ( free full text)

Tomato ketchup reduces cholesterol levels

21 healthy people with normal cholesterol levels were selected by Finnish scientists for a study and were given a 3- week no tomato products diet followed by a 3-week high tomato diet including 400 ml tomato juice and 30 mg tomato ketchup daily.

The study found that a high dietary intake of tomato products significantly reduced LDL cholesterol levels and increased LDL resistance to oxidation in three weeks. However larger controlled studies are required to establish the clinical benefits in people with elevated cholesterol levels.

Source : "Tomato juice decreases LDL cholesterol levels and increases LDL resistance to oxidation" British Journal of Nutrition (6 December 2007), 98:1251-1258