In addition to cholesterol-lowering effect, statins exhibit anti-thrombotic and anti-inflammatory properties, which may affect coagulation cascade. In cancer patients, the use of statins decreased the odds of developing venous thromboembolism, when compared with non-statins users.
Abstract
Background
Recent data suggest a reduction in the occurrence of venous thromboembolism in select groups of patients who use statins. The objective of this study is to evaluate the impact of statin use on the occurrence of venous thromboembolism in patients with solid organ tumor.
Methods
We conducted a retrospective, case-control study reviewing 740 consecutive patients with a diagnosis of solid organ tumor who were admitted to the Albert Einstein Medical Center, Philadelphia, Penn, between October 2004 and September 2007. Patients treated with anticoagulation therapy before their first admission were excluded. The occurrence of venous thromboembolism, risk factors for venous thromboembolism, and statin use were recorded. Patients who never used statins or had used them for less than 2 months were relegated to the control group.
Results
The mean age of the study population was 65 years, and 52% of the patients were women and 76% were African American. The occurrence of venous thromboembolism was 18% (N = 132), and 26% (N = 194) were receiving statins. Among patients receiving statins, 8% (N = 16) developed a venous thromboembolism compared with 21% (N = 116) in the control group (odds ratio 0.33; 95% confidence interval, 0.19-0.57). A logistic regression analysis including risk factors for venous thromboembolism (metastatic disease, use of chemotherapy, immobilization, smoking, and aspirin use) along with statin use yielded the same results.
Conclusion
This study suggests that the use of statins is associated with a significant reduction in the occurrence of venous thromboembolism. This pleiotropic effect warrants further investigation.
To read this article in its entirety, please visit our website.
-- Danai Khemasuwan, MD, Matthew L. DiVietro, DO, Kawin Tangdhanakanond, MD, Sherry C. Pomerantz, PhD, Glenn Eiger, MD
This article originally appeared in the January 2010 issue of The American Journal of Medicine.
Selasa, 19 Januari 2010
Care of the Cancer Survivor: Metabolic Syndrome after Hormone-Modifying Therapy
Hormone-modifying cancer therapy can lead to increased risk of metabolic syndrome. Vigilant screening and treatment for metabolic syndrome is an important component of care for cancer survivors.
Abstract
Emerging evidence implicates metabolic syndrome as a long-term cancer risk factor but also suggests that certain cancer therapies might increase patients' risk of developing metabolic syndrome secondary to cancer therapy. In particular, breast cancer and prostate cancer are driven in part by sex hormones; thus, treatment for both diseases is often based on hormone-modifying therapy. Androgen suppression therapy in men with prostate cancer is associated with dyslipidemia, increasing risk of cardiovascular disease, and insulin resistance. Anti-estrogen therapy in women with breast cancer can affect lipid profiles, cardiovascular risk, and liver function. As the number of cancer survivors continues to grow, treating physicians must be aware of the potential risks facing patients who have been treated with either androgen suppression therapy or anti-estrogen therapy so that early diagnosis and intervention can be achieved.
To read this article in its entirety, please visit our website.
-- Amanda J. Redig, PhD, Hidayatullah G. Munshi, MD
This article originally appeared in the January 2010 issue of The American Journal of Medicine.
Abstract
Emerging evidence implicates metabolic syndrome as a long-term cancer risk factor but also suggests that certain cancer therapies might increase patients' risk of developing metabolic syndrome secondary to cancer therapy. In particular, breast cancer and prostate cancer are driven in part by sex hormones; thus, treatment for both diseases is often based on hormone-modifying therapy. Androgen suppression therapy in men with prostate cancer is associated with dyslipidemia, increasing risk of cardiovascular disease, and insulin resistance. Anti-estrogen therapy in women with breast cancer can affect lipid profiles, cardiovascular risk, and liver function. As the number of cancer survivors continues to grow, treating physicians must be aware of the potential risks facing patients who have been treated with either androgen suppression therapy or anti-estrogen therapy so that early diagnosis and intervention can be achieved.
To read this article in its entirety, please visit our website.
-- Amanda J. Redig, PhD, Hidayatullah G. Munshi, MD
This article originally appeared in the January 2010 issue of The American Journal of Medicine.
'So, Doctor, What's So Bad About Being Fat?' Combating the Obesity Epidemic in the United States
Each week, many of my middle-aged patients ask me the question cited above. Obesity has become so commonplace in the United States that thin, healthy individuals are becoming the exception rather than the rule. With the rising prevalence and incidence of obesity in our society, patients have begun seeing this state of body habitus as the norm rather than the exception. “What's the matter with being a little overweight, doc; everyone in my family is fat, so why not me?”
In response, I deliver my “fat” talk. In this sermonette on obesity, I stress the many increased health risks that overweight individuals incur: atherosclerosis, hypertension, gallstones, diabetes, colonic adenomas, degenerative joint disease, sleep apnea, deep venous thrombosis, and pulmonary embolism, among others. I try to communicate to my obese patients the importance of modest and gradual weight loss as compared with the cycle of rapid weight loss and equally rapid weight gain that is so common in our society. “Bouncing your weight up and down may even put you at greater risk for heart disease,” I continue, hoping that my message will take root in the patient's mind. “Regular exercise such as daily walking is a great help in losing weight. Try to cut back on portion size, simple carbohydrates such as sugar and products made with white flour, as well as saturated fat in your diet. Would you like to speak with one of our dieticians?”
My daily preaching often goes unheeded and leads me and my internal medicine colleagues to become cynical about the possibility of ever convincing our patients to lose weight. This is, unfortunately, the price to be paid in a society that gratifies itself with every type of food taken in excess combined with widespread physical inactivity. Many of my patients ask about the surgical procedures that can lead to dramatic weight loss. I inform them that these operations carry risk and are really designed only for patients who are massively obese. Fortunately, most of my patients are only 30-50 pounds overweight and not massively obese.
Clinical science and epidemiology have convincingly shown that increasing body mass correlates well with rising blood pressure, lipid levels, and blood glucose, all important atherosclerotic risk factors. In general, the more obese the individual, the worse the combined burden of atherosclerotic risk factors. However, obesity alone is not a perfect predictor of atherosclerotic disease risk. For example, a number of epidemiological studies have shown that obesity alone is not a major predictor of coronary heart disease death once more prominent atherosclerotic risk factors that correlate with obesity have been removed. Thus, an obese person with normal values for blood pressure, serum lipids, and blood glucose is not at major risk for the development of atherosclerotic arterial disease. The most important issue to be considered in patients who are overweight is not weight per se, but rather the metabolic consequences of obesity.
As noted earlier, obese patients are at risk for many other health problems. Thus, an obese patient who is normotensive, normolipemic, and euglycemic might still develop severe, crippling degenerative arthritis or sleep apnea as a result of his/her adiposity. Consequently, physicians, including internists and other primary care providers, as well as specialists such as cardiologists, rheumatologists, endocrinologists, gastroenterologists, and other internal medicine specialists, need to look at the entire picture of a particular obese patient's health and not just his/her risk for coronary artery disease. Indeed, physicians should not reassure obese patients about their future health if their atherosclerotic risk factors are normal, because other disease entities might come to plague such patients in the future.
It is important that modest weight loss in an obese patient with atherosclerotic risk factors can result in remarkable improvement in these risk factors. Indeed, it has often been observed that modest (~10% of body weight) loss of weight produces marked amelioration in elevated blood pressure, abnormal serum cholesterol, and glucose intolerance. Moreover, demanding that a patient try to reach his/her ideal body weight is often unrealistic and discourages compliance with the prescribed program of diet and exercise. In the end, “the enemy of good is perfect,” that is, we should strive to enlist our patients in a program that produces moderate, sustained weight loss rather than advising a draconian strategy that will almost certainly fail.
The National Task Force on the Prevention and Treatment of Obesity advises that the best strategy for weight loss is one of moderate caloric restriction, increased activity (that is, regular exercise), and a supportive program of behavioral modification to assist patients in remodeling their eating habits and style (1).
As always, I welcome your comments on our blog.
1) National Task Force on the Prevention and Treatment of Obesity. Dieting and the development of eating disorders in overweight and obese adults. Arch Intern Med. 2000;160:2581–2589.
-- Joseph S. Alpert, MD, editor-in-chief
This article was originally published in the January 2010 issue of The American Journal of Medicine.
In response, I deliver my “fat” talk. In this sermonette on obesity, I stress the many increased health risks that overweight individuals incur: atherosclerosis, hypertension, gallstones, diabetes, colonic adenomas, degenerative joint disease, sleep apnea, deep venous thrombosis, and pulmonary embolism, among others. I try to communicate to my obese patients the importance of modest and gradual weight loss as compared with the cycle of rapid weight loss and equally rapid weight gain that is so common in our society. “Bouncing your weight up and down may even put you at greater risk for heart disease,” I continue, hoping that my message will take root in the patient's mind. “Regular exercise such as daily walking is a great help in losing weight. Try to cut back on portion size, simple carbohydrates such as sugar and products made with white flour, as well as saturated fat in your diet. Would you like to speak with one of our dieticians?”
My daily preaching often goes unheeded and leads me and my internal medicine colleagues to become cynical about the possibility of ever convincing our patients to lose weight. This is, unfortunately, the price to be paid in a society that gratifies itself with every type of food taken in excess combined with widespread physical inactivity. Many of my patients ask about the surgical procedures that can lead to dramatic weight loss. I inform them that these operations carry risk and are really designed only for patients who are massively obese. Fortunately, most of my patients are only 30-50 pounds overweight and not massively obese.
Clinical science and epidemiology have convincingly shown that increasing body mass correlates well with rising blood pressure, lipid levels, and blood glucose, all important atherosclerotic risk factors. In general, the more obese the individual, the worse the combined burden of atherosclerotic risk factors. However, obesity alone is not a perfect predictor of atherosclerotic disease risk. For example, a number of epidemiological studies have shown that obesity alone is not a major predictor of coronary heart disease death once more prominent atherosclerotic risk factors that correlate with obesity have been removed. Thus, an obese person with normal values for blood pressure, serum lipids, and blood glucose is not at major risk for the development of atherosclerotic arterial disease. The most important issue to be considered in patients who are overweight is not weight per se, but rather the metabolic consequences of obesity.
As noted earlier, obese patients are at risk for many other health problems. Thus, an obese patient who is normotensive, normolipemic, and euglycemic might still develop severe, crippling degenerative arthritis or sleep apnea as a result of his/her adiposity. Consequently, physicians, including internists and other primary care providers, as well as specialists such as cardiologists, rheumatologists, endocrinologists, gastroenterologists, and other internal medicine specialists, need to look at the entire picture of a particular obese patient's health and not just his/her risk for coronary artery disease. Indeed, physicians should not reassure obese patients about their future health if their atherosclerotic risk factors are normal, because other disease entities might come to plague such patients in the future.
It is important that modest weight loss in an obese patient with atherosclerotic risk factors can result in remarkable improvement in these risk factors. Indeed, it has often been observed that modest (~10% of body weight) loss of weight produces marked amelioration in elevated blood pressure, abnormal serum cholesterol, and glucose intolerance. Moreover, demanding that a patient try to reach his/her ideal body weight is often unrealistic and discourages compliance with the prescribed program of diet and exercise. In the end, “the enemy of good is perfect,” that is, we should strive to enlist our patients in a program that produces moderate, sustained weight loss rather than advising a draconian strategy that will almost certainly fail.
The National Task Force on the Prevention and Treatment of Obesity advises that the best strategy for weight loss is one of moderate caloric restriction, increased activity (that is, regular exercise), and a supportive program of behavioral modification to assist patients in remodeling their eating habits and style (1).
As always, I welcome your comments on our blog.
1) National Task Force on the Prevention and Treatment of Obesity. Dieting and the development of eating disorders in overweight and obese adults. Arch Intern Med. 2000;160:2581–2589.
-- Joseph S. Alpert, MD, editor-in-chief
This article was originally published in the January 2010 issue of The American Journal of Medicine.
Senin, 04 Januari 2010
A Fall in Ghana
Presentation
A fall marked the beginning of a perilous medical journey for a 34-year-old man. He had traveled from the United States, where he lives with his family, to Accra, Ghana for business purposes and was well until the ninth day of his trip, when he fell and twisted his lower back. Although he was able to stand immediately afterwards, the back pain worsened as the morning progressed and was then compounded by malaise, leading him to spend the remainder of the day in bed. He had no neurologic deficits or loss of bowel or bladder continence.
That evening, the patient developed a fever of 102.1° F (38.9° C) with chills and progressive malaise. His health status began to rapidly deteriorate, and he was evacuated to the United States the following day. En route he developed hypoxia, which was corrected with supplemental oxygen. Tachycardia and hypotension responded to intravenous fluid. Upon arrival, he was evaluated at a community hospital, where he received empiric ceftriaxone. He was determined to be in critical condition and was transferred urgently to the intensive care unit (ICU) of the National Naval Medical Center in Bethesda, Md for further management.
Previously healthy, the patient had an unremarkable medical history. A systems review revealed no further complaints, and he had been fully compliant with his malaria prophylaxis. Throughout his stay in Ghana, he had no contact with sick people, animal exposure, or insect bites. He did not leave the luxury hotel complex and only ate approved prepared meals, except for 1 dinner on day 3, which took place at a high-end restaurant with colleagues. His vaccinations were current.
To read this article in its entirety, please visit our website.
-- Michael Eberlein, MD, PhD, Mayy F. Chahla, MD, Sammy A. Baierlein, MD, Richard T. Mahon, MD
This article was originally published in the December 2009 issue of The American Journal of Medicine.
A fall marked the beginning of a perilous medical journey for a 34-year-old man. He had traveled from the United States, where he lives with his family, to Accra, Ghana for business purposes and was well until the ninth day of his trip, when he fell and twisted his lower back. Although he was able to stand immediately afterwards, the back pain worsened as the morning progressed and was then compounded by malaise, leading him to spend the remainder of the day in bed. He had no neurologic deficits or loss of bowel or bladder continence.
That evening, the patient developed a fever of 102.1° F (38.9° C) with chills and progressive malaise. His health status began to rapidly deteriorate, and he was evacuated to the United States the following day. En route he developed hypoxia, which was corrected with supplemental oxygen. Tachycardia and hypotension responded to intravenous fluid. Upon arrival, he was evaluated at a community hospital, where he received empiric ceftriaxone. He was determined to be in critical condition and was transferred urgently to the intensive care unit (ICU) of the National Naval Medical Center in Bethesda, Md for further management.
Previously healthy, the patient had an unremarkable medical history. A systems review revealed no further complaints, and he had been fully compliant with his malaria prophylaxis. Throughout his stay in Ghana, he had no contact with sick people, animal exposure, or insect bites. He did not leave the luxury hotel complex and only ate approved prepared meals, except for 1 dinner on day 3, which took place at a high-end restaurant with colleagues. His vaccinations were current.
To read this article in its entirety, please visit our website.
-- Michael Eberlein, MD, PhD, Mayy F. Chahla, MD, Sammy A. Baierlein, MD, Richard T. Mahon, MD
This article was originally published in the December 2009 issue of The American Journal of Medicine.
Jumat, 01 Januari 2010
Hospital Computing and the Costs and Quality of Care: A National Study
Abstract
Background
Many believe that computerization will improve health care quality, reduce costs, and increase administrative efficiency. However, no previous studies have examined computerization's cost and quality impacts at a diverse national sample of hospitals.
Methods
We linked data from an annual survey of computerization at approximately 4000 hospitals for the period from 2003 to 2007 with administrative cost data from Medicare Cost Reports and cost and quality data from the 2008 Dartmouth Health Atlas. We calculated an overall computerization score and 3 subscores based on 24 individual computer applications, including the use of computerized practitioner order entry and electronic medical records. We analyzed whether more computerized hospitals had lower costs of care or administration, or better quality. We also compared hospitals included on a list of the “100 Most Wired” with others.
Results
More computerized hospitals had higher total costs in bivariate analyses (r=0.06, P=.001) but not multivariate analyses (P=.69). Neither overall computerization scores nor subscores were consistently related to administrative costs, but hospitals that increased computerization faster had more rapid administrative cost increases (P=.0001). Higher overall computerization scores correlated weakly with better quality scores for acute myocardial infarction (r=0.07, P=.003), but not for heart failure, pneumonia, or the 3 conditions combined. In multivariate analyses, more computerized hospitals had slightly better quality. Hospitals on the “Most Wired” list performed no better than others on quality, costs, or administrative costs.
Conclusion
As currently implemented, hospital computing might modestly improve process measures of quality but does not reduce administrative or overall costs.
To read this article in its entirety, please visit our website.
-- David U. Himmelstein, MD, Adam Wright, PhD, Steffie Woolhandler, MD, MPH
This article originally appeared in the January 2010 issue of The American Journal of Medicine.
Background
Many believe that computerization will improve health care quality, reduce costs, and increase administrative efficiency. However, no previous studies have examined computerization's cost and quality impacts at a diverse national sample of hospitals.
Methods
We linked data from an annual survey of computerization at approximately 4000 hospitals for the period from 2003 to 2007 with administrative cost data from Medicare Cost Reports and cost and quality data from the 2008 Dartmouth Health Atlas. We calculated an overall computerization score and 3 subscores based on 24 individual computer applications, including the use of computerized practitioner order entry and electronic medical records. We analyzed whether more computerized hospitals had lower costs of care or administration, or better quality. We also compared hospitals included on a list of the “100 Most Wired” with others.
Results
More computerized hospitals had higher total costs in bivariate analyses (r=0.06, P=.001) but not multivariate analyses (P=.69). Neither overall computerization scores nor subscores were consistently related to administrative costs, but hospitals that increased computerization faster had more rapid administrative cost increases (P=.0001). Higher overall computerization scores correlated weakly with better quality scores for acute myocardial infarction (r=0.07, P=.003), but not for heart failure, pneumonia, or the 3 conditions combined. In multivariate analyses, more computerized hospitals had slightly better quality. Hospitals on the “Most Wired” list performed no better than others on quality, costs, or administrative costs.
Conclusion
As currently implemented, hospital computing might modestly improve process measures of quality but does not reduce administrative or overall costs.
To read this article in its entirety, please visit our website.
-- David U. Himmelstein, MD, Adam Wright, PhD, Steffie Woolhandler, MD, MPH
This article originally appeared in the January 2010 issue of The American Journal of Medicine.
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