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The erectile dysfunction drug sildenafil, commonly known as Viagra, boosts the heart’s pumping ability in children and young adults who’ve had the Fontan operation to correct single-ventricle heart defects, researchers report.
In the Fontan operation, doctors direct venous blood directly to the pulmonary arteries, bypassing the heart. The procedure is the third surgery in staged reconstruction for children with single-ventricle defects, explained the researchers from the Children’s Hospital of Philadelphia in a news release from the American Heart Association.
The study included 27 children and young adults who’d undergone the Fontan operation an average of 11 years earlier. The patients, average age 15, were given either a placebo or 20 milligrams of sildenafil three times daily for six weeks. That was followed by six weeks of no drug or placebo, and then the participants were switched to the opposite arm of the study for another six weeks.
Before and after each phase of the study, researchers assessed the participants’ heart function and found significant improvements in the myocardial performance index during the sildenafil phase compared to the placebo phase. They also found that taking sildenafil improved diastolic performance and increased heart output, but the differences didn’t reach statistical significance.
There was no difference in the average myocardial performance index improvement between the right ventricular dominant subgroup and the non-right ventricular dominant subgroup, indicating a benefit regardless of ventricular structure.
The findings suggest that improved ventricular performance associated with taking sildenafil may improve patients’ exercise performance and quality of life, the researchers concluded.
The study was scheduled to be presented Tuesday at the American Heart Association’s annual meeting in Orlando, Fla.
A squeeze on finances is now playing a key role in many couples’ decisions about fertility treatments, including whether they will try to conceive using assisted reproductive technology or whether they will discard leftover embryos put into storage, new studies show.
Among the new findings, presented this week at the annual meeting of the American Society for Reproductive Medicine in Atlanta:
More than half (58 percent) of couples diagnosed as infertile who opted not to pursue treatment said cost was the primary reason;
About 7 percent of couples who had leftover embryos in cold storage discarded the embryos from October 2008 to March 2009, a number that was almost three times higher than six months prior;
About 57 percent of young women who donated eggs to infertile couples in 2008 now say they planned to use the money to pay for school, up from 28 percent in 2002-2004.
Given the high cost of fertility treatments, which are often not covered by insurance, experts said they weren’t surprised by the findings. A single cycle of in vitro fertilization (IVF) costs about $12,000, and several cycles may be needed, according to the ASRM.
Yet some fertility experts said they were hesitant to blame the recession on the new numbers. Dr. Peter McGovern, director of the division of reproductive endocrinology and infertility at Hackensack University Medical Center, said his practice is as busy as ever.
“We’re not seeing much of a difference, quite honestly, compared to better times,” McGovern said. “It could be that the drive to reproduce is so important people are somehow making it happen.”
In one study, researchers followed 448 infertile couples from eight fertility clinics for 18 months. Of those, about 27 percent decided not to pursue treatments including in vitro fertilization, in which the egg and sperm are joined outside the womb and then the embryo is placed back into the mother.
About 58 percent of these couples said the primary reason to discontinue treatments was money, 38 percent cited life conflicts such as moving or a death in the family, and 26 percent cited medical futility.
Depression and increasing age also made it less likely a couple would pursue treatment, while those with a college education and higher incomes were more likely to go through with it.
“It’s financially challenging for some patients to pursue fertility treatments,” said Andrew La Barbera, scientific director of the American Society for Reproductive Medicine. “In most states insurance coverage for assisted reproductive technology [ART] is not mandated. Most patients have to pay for ART procedures themselves and it’s not easy.”
Financial stress linked to a worsening economy may be prompting more couples to dispose of leftover embryos being kept in cold storage, a second study found.
Researchers found that between October 2008 and March 2009, about 7 percent of couples discarded frozen embryos, compared to rates between 4.3 percent and 2.3 percent in the two years prior.
Fees to store embryos at minus 310 degrees Fahrenheit can cost several hundred dollars a year. For many couples, deciding what to do with unused embryos is a difficult ethical and emotional decision. The researchers concluded that “extreme economic conditions have forced patients to address an issue they have historically chosen to postpone when financially viable.”
The economic downturn may even be affecting the decisions of egg donors, who are paid between $4,000 to $10,000 to donate eggs to infertile women undergoing IVF.
In another study presented at the ASRM meeting, researchers found little change over the past few years in prospective egg donors’ average age, education level and marital status. However, they did find a change in what donors planned on doing with the money.
Researchers at Reproductive Medicine Associates of New York and Mount Sinai School of Medicine in New York City compared the screening interview records of 54 women who sought to donate eggs between 2002 and 2004 against the records of 46 women who sought to donate eggs in 2008.
About 57 percent of the women said they planned to use the money for schooling in 2008, compared to 28 percent in 2002-2004. Yet fewer said they planned to pay down debt or save the money in 2008 than in the earlier period.
Despite a difficult economic climate, many women who donate eggs do it for reasons beyond the money, McGovern reasoned. Donating eggs requires substantial time, effort and discomfort, including physical and psychological screenings, daily injections of fertility drugs that can cause side-effects including headache, cramping and bloating, multiple trips to the clinic, ultrasounds and blood tests.
“Egg donors don’t tend to be very mercenary,” McGovern said. “I find them to be a very generous group. It’s a lot of work, not like being a sperm donor.”
The outcomes of a twin pregnancy — including the infants’ size and delivery date — might be affected by whether a woman is carrying boys or girls.
Sharing the womb with a female produces better results, in terms of birth weight and other factors, than sharing it with a male, whether the other twin is male or female, according to researchers from the Helen Schneider Hospital for Women and the Sackler School of Medicine at Tel Aviv University in Israel.
“A male fetus affects his co-twin negatively, probably due to the interfetal transport of substances, mainly hormones,” said Dr. Marek Glezerman, a university professor and chairman of the hospital’s obstetrics and gynecology department and a co-author of the study.
But a U.S.-based expert who reviewed the study calls it interesting but no cause to change the way pregnant women are followed during their pregnancies, regardless of whether they are carrying two girls, two boys or one of each.
“I don’t think it translates to changes in clinical practice,” said Dr. Steven Ory, a past president of the American Society for Reproductive Medicine and a fertility specialist in Margate, Fla.
The study is published in the November issue of Obstetrics & Gynecology.
The researchers evaluated 2,704 twin pregnancies, looking only at twins within separate placentas born from 1995 through 2006. Previous studies had not differentiated between twins with common or separate placentas, Glezerman said, and this could have blurred the effect of the fetus’s sex on the outcome of the pregnancies.
About 16 percent of the pregnancies involved female-female twins, 70 percent were male-female and 14 percent were male-male.
Preterm deliveries were most common among women carrying male-male twins, the study found. Of the male-male twins, 9.2 percent were delivered at less than 31 weeks, compared with 7.5 percent of the male-female twins and 5.5 percent of the female-female twins. Earlier studies have found a higher risk for premature delivery for a male fetus compared with a female.
In the new study, birth weight was higher, on average, for boys than girls: 4.95 pounds, compared with 4.75. But boys in the boy-boy pairs had lower average birth weights than boys in the boy-girl pairs: 4.85 pounds versus 4.99. Boys in the boy-boy pairs also had lower growth rates than boys in boy-girl pairs.
Girls in the girl-girl pairs had fewer respiratory and neurological problems than those in the girl-boy pairs.
The researchers attribute the findings to what they call a “male offending factor,” which means that the presence of a male fetus negatively affects the prospects of the co-twin in the womb, whether that co-twin is a sister or a brother.
However, the reasons for this aren’t clear. The researchers speculate that one possibility is that male fetuses who share the womb with females could be more successful in competing for nutrients because females tend to grow more slowly. As a result, a boy in a boy-girl pair might end up weighing more than one in a boy-boy pair. Hormonal influences might help explain the differences, too.
None of this should worry expectant mothers, says another U.S. expert.
“Look at this study with a grain of salt and move on,” said Dr. Abdulla Al-Khan, director of perinatal diagnostics and therapeutics in the maternal-fetal medicine division at Hackensack University Medical Center in New Jersey. The study’s findings have not been noticeable, he said, at his hospital. They deliver more than 6,000 babies a year, including twins, he said, and women carrying twins are already followed closely to monitor the babies’ progress.
Both Al-Khan and Ory also pointed out some of the study’s limitations. It is retrospective, looking back, which they said makes it subject to bias. And, Al-Khan said, it’s not clear whether the twins were conceived spontaneously or through fertility treatments, which might have affected the results.
Since routine vaccination of infants against rotavirus started in the United States in 2006, there’s been a substantial reduction in the number of cases of rotavirus disease in children, a new government study shows.
Rotavirus is the leading cause worldwide of severe acute diarrhea in children younger than 5. Before 2006, rotavirus caused 20 to 60 deaths each year in the United States, along with 55,000 to 70,000 hospitalizations, 205,000 to 272,000 emergency department visits, and 410,000 outpatient visits among children younger than 5.
An analysis of data from a national network of sentinel laboratories showed that the 2007-2008 and 2008-2009 rotavirus seasons were both shorter and began later than pre-vaccine seasons (2000 to 2006), wrote researchers from the U.S. Centers for Disease Control and Prevention. Specifically, onset of the rotavirus season in 2007-2008 was 11 weeks later than the median for 2000 to 2006, and the number of positive test results was 64 percent lower than in the pre-vaccine seasons.
There were 15 percent more positive rotavirus test results in the 2008-2009 season than in the 2007-2008 seasons, but the number of positive test results for both seasons were substantially lower than during the 2000 to 2006 seasons, the study found.
While cases of rotavirus disease have decreased since the introduction of rotavirus vaccination, continued surveillance is needed to better understand the impact of the rotavirus vaccine, the researchers said.
Vaginal hysterectomy is the safest and most cost-effective method to remove the uterus for noncancerous reasons, according to a new Committee Opinion released today by The American College of Obstetricians and Gynecologists (ACOG) and published in the November issue of Obstetrics & Gynecology. In general, based on the medical evidence, vaginal hysterectomy is associated with better outcomes and fewer complications than either laparoscopic or abdominal hysterectomy.
Hysterectomy (removal of the uterus) is one of the most frequently performed surgical procedures in the US. Approximately 600,000 hysterectomies are performed each year. The most common reason for hysterectomy is fibroids (40.7%), followed by endometriosis (17.7%), and uterine prolapse (14.5%). Hysterectomy can be performed by several methods: via an open incision in the abdomen; through small incisions in the abdomen with the aid of a laparoscope; or through a small incision in the vagina. The standard procedure to remove the uterus has been through an open incision in the abdomen, but it is more invasive and requires the longest recovery time when compared to newer techniques which generally have shorter hospital stays and a faster return to normal activity for women. However, current national data show that the standard abdominal hysterectomy method is performed in 66% of cases. Vaginal hysterectomy is performed in 22% of cases and laparoscopic hysterectomy in 12% of cases.
“Vaginal hysterectomy is better for women in terms of fewer complications and quicker recoveries compared with abdominal or laparoscopic surgery,” says Cheryl B. Iglesia, MD, of Washington Hospital Center in Washington, DC, and chair of ACOG’s Committee on Gynecologic Practice. “Vaginal hysterectomy also is the most cost-effective method.”
Although vaginal hysterectomy is the approach of choice, it’s not always feasible in every situation. “The paramount concern is that we provide the safest procedure for our patients. That being said, based on the national data, it’s pretty clear that more hysterectomies in the US could be performed using the less invasive vaginal approach than are currently being done,” says Dr. Iglesia.
Physicians should consider which surgical procedure is safest and the most cost-effective to meet the needs of each patient undergoing hysterectomy, according to ACOG. A number of factors may influence the route of hysterectomy, including the size and shape of the vagina and uterus; accessibility to the uterus; surgeon training and experience; extent of disease; available hospital technology, devices, and support; and the preference of the informed patient.
Cancer is a bigger killer in developing countries than tuberculosis, malaria and AIDS combined and a “tsunami” of the disease threatens to overwhelm the nations worst equipped to cope, experts said Tuesday.
While only about 5 percent of global resources for cancer are spent in developing countries, the burden of the disease is far greater there, they said, with 60 percent of last year’s 7.6 million cancer deaths occurring in poorer nations.
Women-specific cancers like breast and cervical cancer, which account for more than a quarter of all female deaths worldwide, could be dramatically cut in low and middle-income nations by improving awareness and detection, they said.
“There are tens of millions of people living with cancer or at risk of cancer in low and middle-income countries who do not benefit from all these advances,” said Anne Reeler, who launched a report on cancer in poorer countries at the ECCO-ESMO European cancer congress in Berlin.
Reeler noted that while experts gathered in Berlin to discuss ground-breaking and often highly expensive medical advances that may help cancer sufferers in the rich world, poorer nations have almost no access to even the most basic treatments.
“In Ethiopia, for instance, what we often find is that by the time women come to a clinic they literally have a tumor protruding through the breast,” she said. “They’ve spent two years going to see traditional healers and using holy water, and when they come to clinics it’s too late to do anything for them.
“So awareness — getting rid of the myth that cancer kills and you can do nothing about it — is really important.”
Oncology experts expect a doubling of cancer cases across the world in the next 20 years and estimate that more than half of the 12.4 million new cases in 2008 occurred in low and middle income countries, a pattern predicted to continue.
David Kerr, a contributor to the report by a international cancer working group called CanTreat, and a professor of cancer medicine at Britain’s Oxford University, said this was “wake-up call” for those concerned about the developing world.
“If there is a coming tsunami of cancer, and there surely is, then now is when we need to start working together to develop new models of cancer care so that we are prepared for it in the developing world,” he told Reuters.
“We are facing a huge increase in cancer burden, and that burden will fall predominantly in those countries which are least well-equipped to deal with it — no infrastructure, no training, no docs, no nurses, no gadgets, no nothing.”
The CanTreat experts said in their report that changing lifestyles, aging populations, urbanization and infections all played a part in the rise in cancer.
The CanTreat report called on governments in developed nations to work with pharmaceutical and healthcare industries on new ideas for improving access to cancer medicines and diagnostics, including deals to cut drug prices.
The experts also urged health authorities in low and middle-income countries to improve education to encourage women to recognize possible signs of the disease and act quickly and without fear of stigma if they suspect they are ill.
CanTreat authors compared the current threat to that posed by AIDS in developing countries and by cancer in richer nations several decades ago.
“Cancer in developing countries now is like cancer in rich countries 30 years ago — there was little that could be done, and people were dying stigmatized,” said Joseph Saba, another CanTreat member. “The difference is that now we know what to do. Then we didn’t.”
Very light-skinned children who tan in the sun develop significantly more moles than their peers who stay pale in the sun, new research shows.
The number of moles a person has is among the strongest risk factors for developing melanoma, the most deadly form of skin cancer, so the findings suggest that parents of these children should take extra care to protect them from the sun’s rays, Dr. Lori A. Crane of the University of Colorado in Denver and her colleagues conclude in a report in the Archives of Dermatology.
While sunburns are known to increase melanoma risk, Crane and her team note in the report, the effect of tanning on skin cancer risk isn’t clear; in fact, some studies suggest it’s protective.
To investigate, they looked at 131 very-light-skinned children and 444 darker-skinned white kids born in Colorado in 1998. All underwent full-body mole counts at age 6, 7 and 8 years.
The researchers gauged their skin color using a device called a colorimeter. To determine whether or not the children tanned, they used the device to compare the color of their skin at the inside of their upper arm to the color of the skin on the outside of their lower arm.
At age 6, the average number of moles for the minimally tanned light-skinned children was 14.8, compared to 21.2 for the more darkly tanned children. At age 7, the paler kids had 18.8 moles, on average, while the tanned kids had 27.9 moles. By age 8, the untanned children had 22.3 moles, compared to 31.9 for the tanned kids.
But among the darker-skinned children, whether or not they were tanned made no difference in the number of moles they had on their bodies.
The current study didn’t determine whether the untanned children were simply unable to tan, or had been protected from the sun, Crane told Reuters Health. No matter what, she added, the findings suggest “there should be more careful protection of those children, which is probably not very surprising.”
And parents shouldn’t rely on sunscreen alone for shielding kids from the sun, the researcher added; while it can protect against sunburn, it doesn’t do a good job of preventing tanning.
Also, she added, parents may let their children stay out in the sun longer when they wear sunscreen, which could be harmful. Crane suggests protecting kids with lightweight, loose clothing, including hats, and avoiding the strong mid-day sun.
Binge drinking can weaken the body’s ability to fight infections for at least 24 hours, say U.S. researchers.
Binge drinking is defined as consuming large amounts of alcohol over a short period of time to deliberately get drunk.
In experiments with mice, the researchers found that binge drinking affects toll-like receptor 4 (TLR4), a protein that plays an important role in immune system activation. Specifically, heavy drinking suppresses TLR4’s ability to send signals that activate production of inflammatory cytokines — signaling molecules that begin the inflammatory response to infection.
The researchers also determined that binge drinking inhibits NF-B, a protein complex that controls DNA transcription and expression of some of the cytokines inhibited by alcohol.
“The time frame [after binge drinking] during which the risk of infection is increased might be at least 24 hours,” study author Stephen Pruett, of the College of Veterinary Medicine at Mississippi State University, said in a news release. “A persistent effect of ethanol on cells is indicated, such that inhibition of the response of some cytokines occurs even after the ethanol is cleared” from the body.
Fatigue isn’t the only contributor to medical errors among medical residents. A new study finds that financial woes, family concerns and other elements of distress also play a major role in potentially fatal mistakes.
Fatigue and distress among doctors are known causes of medical errors, but Mayo Clinic researchers say that theirs is the first study to show how each contributes to mistakes. And they recommend that distress be considered independently of fatigue when new training guidelines are considered.
“Changes to the process of physician training should address both resident fatigue and distress to improve resident and patient safety as both factors independently increase the risk of self-reported major medical errors,” said lead researcher Dr. Colin P. West, a internist at the Mayo Clinic in Rochester, Minn.
Fatigue, along with lower quality of life, burnout, depressive symptoms and other signs of distress, independently led to increased rates of self-reported major medical errors among internal medicine residents, West said.
“In fact, common levels of fatigue and distress are associated with double or triple the risk of these errors,” he said.
This is an important distinction, West said, because most current efforts to reform medical training that are intended to promote resident and patient safety have focused on fatigue.
“Our results support this, but suggest that specific attention to promoting resident well-being is needed as well,” he said. “We don’t know enough about effective ways to promote physician well-being, however, and further research is needed to answer this question.”
The report is in the Sept. 23/30 issue of the Journal of the American Medical Association.
Medical mistakes are a serious issue. Nearly 100,000 people in the United States die each year from preventable medical errors, according to a report in 1999 from the Institute of Medicine.
West’s team used data from 430 internal medicine residents, who were surveyed quarterly from 2003 through 2008. The survey asked about their medical errors, if any, as well as quality of life, fatigue, burnout, depression and sleepiness.
Among the 378 doctors who answered questions about medical errors, 39 percent said they had made at least one major error.
West’s group found a connection between these errors and fatigue. For every point increase in the fatigue score, doctors were 14 percent more likely to make a medical error. In addition, for every point increase in the sleepiness score, doctors were 10 percent more likely to err.
Medical errors were also linked to burnout, depression and overall quality of life, the researchers found.
Changes in how doctors are trained are making things better for doctors and safer for patients, said Dr. David J. Birnbach, a professor and vice provost of the University of Miami and associate dean and director of the UM-Jackson Memorial Hospital Center for Patient Safety at the Miller School of Medicine.
“We’ve known for a long time that fatigue in anyone is bad, and medical personnel who are very fatigued tend to make more errors,” he said. “We in the United States have made a dramatic change in the way we train residents to limit the number of hours they work. That’s regulated at a federal level.”
But more needs to be done, Birnbach said. “If you are distressed or fatigued, either of them will impact on your ability to function optimally,” he said. “At the end of the day, you are going to make more mistakes. Medical errors kill people.”
Birnbach said he’s concerned that, although residents are working shorter hours, no system exists to monitor whether they are tired or whether the hospital is complying with current regulations.
Also, he said, no mechanism is in place to deal with distress and fatigue among older practicing doctors, who make up the bulk of physicians. “We have not regulated the group that is most sensitive to sleep deprivation,” he said. “We have no rules for the 65- or 70-year-old practitioner.”
Regulating the hours residents can work in training is “a good start,” he said, “but eventually, we are going need to regulate everybody’s hours in medicine to increase the safety.”
In another report in the same issue of JAMA, doctors who participated in a program that included meditation, self-awareness exercises and stories of “meaningful clinical experiences” improved their well-being, had more empathy toward patients and were less “emotionally exhausted” or burned out, the researchers found.
The study demonstrated that primary care physicians participating in a continuing medical education program that focused on self-awareness experienced improved personal well-being, including burnout and improved mood, the researchers wrote.
“They also experienced positive changes in empathy and psychosocial beliefs, both indicators of a patient-centered orientation to medical care,” they said. Such changes are associated with positive patient associations, such as taking a patient’s experience of illness into account and promoting patients’ participation in care, the study concluded.