Report Skipping doses could be deadly
Mon, 30 Jul 2007 18:57:15 GMT
By LAURAN NEERGAARD, AP Medical Writer
WASHINGTON - Consider it the other drug problem: Millions of people don't take their medicine correctly — or quit taking it altogether — and the consequences can be deadly.
On average, half of patients with chronic illnesses like heart disease or asthma skip doses or otherwise mess up their medication, says a report being issued later this week that calls the problem a national crisis costing billions of dollars.
The government is preparing new steps to try to persuade patients and their doctors to do better.
But with contributors that range from too-hurried doctor visits to confusing pill bottles, there's no easy solution.
"We go into this with some humility," says Dr. Carolyn Clancy, director of the Agency for Healthcare Research and Quality, which is planning what she calls an "in your face" campaign to improve medication adherence. "It's really pretty appalling how badly we do."
This goes far beyond the issue of affording prescriptions. Often people buy their drugs but misunderstand what they're supposed to take, or how. Or forget doses. Or start feeling better and toss the rest of the bottle. Or skip doses for fear of side effects.
It's not just a problem of poverty or poor education. Even the rich and highly educated skip their medicine. Perhaps the most high-profile example is former President Clinton, who stopped taking his cholesterol-lowering statin drug at some point and later needed open-heart surgery to avoid a major heart attack. Statins offer significant heart protection, but about half of patients on statins quit using them within a year.
And remember the globe-trotting tuberculosis patient who was briefly quarantined in May after ignoring doctors' orders not to travel by airplane? He's out of the hospital now but, like all patients with hard-to-treat TB, must take his remaining antibiotics while health workers watch. So many TB patients skip their pills when they feel better — but before all the bacteria are wiped out — that health departments now enforce what's called "directly observed therapy."
For most diseases, however, patients must choose to take their medicines. The new report combs a decade of research to conclude people generally do a lousy job. Among findings from the nonprofit National Council on Patient Information and Education:
_Particularly at risk are people whose diseases are initially symptom-free. Although high blood pressure more than triples the risk of heart disease, for example, just 51 percent of patients stick with their prescribed antidote.
_Also at high risk are the elderly, but adherence is a problem for all ages. As few as 30 percent of teenagers correctly take drugs to prevent asthma attacks, for example.
_Dire consequences aren't always a deterrent. Among patients already blind in one eye from glaucoma, only 58 percent were protecting the other eye. Another study found 18 percent of kidney transplant recipients weren't following instructions to prevent organ rejection.
_Even doctors mess up, acknowledging in one study adhering to their own prescriptions just 79 percent of the time.
_Poor medication adherence can cost an extra $2,000 a year for each patient in extra doctor visits alone, and it's associated with as many as 40 percent of nursing home admissions, even more costly.
_Add preventable hospitalizations and premature death, and the report estimates that poor medication adherence could be costing the country $177 billion in medical bills and lost productivity.
Why is taking medicines correctly so tough? One reason is the general confusion surrounding drugs, says Dr. Ruth Parker of Emory University, a co-author of the new report who has studied the issue for the American College of Physicians Foundation.
When the pharmacy hands over your prescription, there are bunches of papers — stapled to the bag, outside the box, glued to the bottle — that all bear drug information, but often with different wording. Bottles are covered in warning stickers — such as "Take with food" or "Swallow whole" or "Don't use with XYZ other drug" — in so many colors that Parker compares pill containers to Christmas trees.
What in that jumble should patients pay most attention to?
Then there's the wording. Parker recently helped test the seemingly simple instruction "Take two tablets twice daily." Did that mean a total of two, or a total of four? A third of patients who were deemed literate got confused. A more clear instruction would be: "Take two tablets in the morning and two tablets at night."
Beyond literacy, poor eyesight plays a role. Pill-bottle instructions are pretty tiny.
Whatever the cause, Clancy hopes to make "take your medicine" a new priority. Her Agency for Healthcare Research and Quality is starting discussions with the new report's authors, the Food and Drug Administration and health groups about steps to do that. Options range from attention-grabbing ads about the dangers of misusing medicines to better drug labels.
And in October, the National Council on Patient Information and Education will release Web-based videos designed to train seniors about adhering to their meds.
___
EDITOR'S NOTE — Lauran Neergaard covers health and medical issues for The Associated Press in Washington.
Exercise caffeine fight skin cancer
Mon, 30 Jul 2007 17:01:44 GMT
By RANDOLPH E. SCHMID, AP Science Writer
WASHINGTON - Can adding a cup or two of coffee to the exercise routine increase protection from skin cancer? New research indicates that just might be the case.
The combination of exercise and caffeine increased destruction of precancerous cells that had been damaged by the sun's ultraviolet-B radiation, according to a team of researchers at Rutgers University.
Americans suffer a million new cases of skin cancer every year, according to the National Cancer Institute.
In mice there is a protective effect from both caffeine and voluntary exercise, and when both are provided — not necessarily at the same time — protection is even more than the sum of the two, said Dr. Allan H. Conney of the laboratory for cancer research at Rutgers.
"We think it likely that this will extrapolate to humans, but that has to be tested," Conney said in a telephone interview.
Nonetheless, he added, people should continue to use sunscreen.
Exposing the mice to ultraviolet-B light causes some skin cells to become precancerous.
Cells with damaged DNA are programmed to self-destruct, a process called apoptosis, but not all do that, and damaged cells can become cancerous.
The researchers report in Tuesday's issue of Proceedings of the National Academy of Sciences that they studied hairless mice in four groups. Some were fed water containing caffeine, some had wheels on which they could run, some had both and a control group had neither.
"The most dramatic and obvious difference between the groups came from the caffeine-drinking runners, a difference that can likely be attributed to some kind of synergy," Conney said.
Compared with the control animals, those drinking caffeine had a 95 percent increase in apoptosis in damaged cells. The exercisers showed a 120 percent increase, and the mice that were both drinking and running showed a nearly 400 percent increase.
Just what is causing that to happen is not yet clear, though the researchers have several theories.
"We need to dig deeper into how the combination of caffeine and exercise is exerting its influence at the cellular and molecular levels, identifying the underlying mechanisms," Conney said.
"With an understanding of these mechanisms we can then take this to the next level, going beyond mice in the lab to human trials," he said. "With the stronger levels of UVB radiation evident today and an upward trend in the incidence of skin cancer among Americans, there is a premium on finding novel ways to protect our bodies from sun damage."
Conney said the researchers were originally interested in the effects of green tea in preventing skin cancer and were doing tests on regular and decaffeinated teas.
They found the regular tea had an effect, but not the decaffeinated brew.
And, he said, researchers also observed that mice drinking caffeine were more active than those that didn't get it, so they decided to study the effects of exercise too.
They put running wheels into some of the cages. The mice "love to go on it," he said, and will jump on the wheels and run for several minutes, then get off for a while, and then get on and run some more.
And they found that both caffeine and exercise helped eliminate damaged skin cells, but the combination worked better than either alone.
"What we would like to see next is a clinical trial in people," Conney said.
Dr. Michael H. Gold, a Nashville, Tenn., dermatologist and a spokesman for the Skin Cancer Foundation, said he believes "the concept of systemic caffeine should be addressed further."
"I think the concept potentially has a lot of merit," he said in a telephone interview. But mice and humans are different and studies need to be done to be sure this also applies to people.
In the meantime, he said: "If you go outside, you have to wear a sunscreen ... it has to be caffeine and exercise with your sunscreen."
___
On the Net:
Proceedings of the National Academy of Sciences: http://www.pnas.org
Boston hospital offers face transplants
Mon, 30 Jul 2007 09:15:52 GMT
BOSTON - Brigham and Women's Hospital has given a surgical team permission to perform partial face transplants to certain disfigured patients, a newspaper reported.
Brigham and Women's is the second U.S. hospital to make public its plans to offer the rare medical procedure, The Boston Globe reported. The first hospital was the Cleveland Clinic.
To date, only three partial face transplants have been announced worldwide. Two were performed in France, and one in China.
Critics argue that it's unethical to expose patients to the risks of a transplant for a non-lifesaving procedure. The newspaper reported that Brigham and Women's would sanction transplants only for patients already taking immunosuppressant drugs because that would reducee the risk of tissue rejection and infection.
Dr. Bohdan Pomahac, who is associate director of the hospital's burn unit, said he's motivated in part by the "helplessness I feel when I have a very difficult case." He said he has seen four patients in recent years who might qualify.
Isabelle Dinoire received the world's first partial face transplant. Dinoire was severely disfigured in May 2005 by her pet Labrador. In November 2005, surgeons grafted the lips, nose and chin of a brain-dead woman onto her face.
Dinoire's immune system nearly rejected the transplant twice, but she was given immunosuppressants that helped overcome the threat.
Dengue fever rages across Asia
Mon, 30 Jul 2007 16:08:03 GMT
By MARGIE MASON, AP Medical Writer
HANOI, Vietnam - Dengue fever is raging across Asia, prompting the World Health Organization to warn that the region could face the worst outbreak of the mosquito-borne virus in nearly a decade.
The disease, commonly called the 'bone breaker' illness because of the excruciating joint pain it causes, has flared everywhere from ultramodern Singapore to poor Vietnam. There are four different types of dengue, but none have a cure or vaccine.
Cambodia is now one of the most worrisome spots, where the disease has attacked about 25,000 people and killed nearly 300 children this year. That's about three times more than the number of cases for all of 2005, according to WHO.
Sick children have overwhelmed ill-equipped hospitals there, forcing babies burning with fever to wait for beds outside with IV drips attached to their arms.
The last major outbreak to hit Southeast Asia was in 1998, when about 350,000 cases were reported in the region, including nearly 1,500 deaths. Indonesia and Thailand were not included in that tally.
John Ehrenberg, WHO's regional adviser on vector-borne diseases, said it could potentially reach that level this year.
"It looks like it might be a bad year," he said. "I think we're in the building-up stage, but it could very well peak by August or September."
Malaysia has seen a 50 percent jump in cases this year over the same period in 2006, with more than 1,000 patients admitted every week for the past month and 56 deaths recorded through June, according to Health Ministry figures.
In Indonesia, more than 100,000 infections have been reported this year, including 1,100 deaths. That compares to 114,000 cases and the same number of fatalities for all of 2006, said Nyoman Kandun, a senior health ministry official who predicted the number will hit 200,000 by year's end.
More than a dozen children infected with dengue filled beds in Jakarta's Tarakan Hospital. Some had IV drips in their hands while others had tubes in their noses.
Muhammad Wildan, 5, was hospitalized last week and remained in critical condition due to internal bleeding. Doctors said he was lucky his family did not wait any longer to bring him in.
"It did not come to us that it was dengue," said Padmi Sari, the boy's grandmother. "We thought it was just a common fever."
Singapore, known for its spotless streets and cutting-edge health facilities, has not escaped dengue this year. The government has reported nearly 5,000 cases and at least three deaths. Early rains also caused a surge in cases in Thailand, with more than 20,000 cases reported through June, including 17 deaths.
In Vietnam, which also typically logs a high number of annual cases, health officials have seen a 40 percent increase over last year, reporting more than 33,000 infections this year and 32 deaths.
In addition to joint pain, rashes, nausea, severe headaches and high fever that typically accompany the disease, patients stricken with a more serious form, called dengue hemorrhagic fever, can experience internal bleeding, liver enlargement and circulatory shut down.
"You don't want to have people staying at home and starting to bleed," Ehrenberg said. "By the time they go to the hospital they're in shock and they will die."
The disease is not nearly as lethal as malaria, which kills more than 1 million people annually. But WHO estimates dengue infects up to 50 million people every year worldwide, mostly in Asia and Latin America. About a half million of those cases are severe, and some 19,000 deaths were recorded in 2002.
"We always think next year it will get better, but we always find next year it gets worse," said Kroeger Axel, a dengue research coordinator at the WHO in Geneva. "There's a very clear upward trend."
He said outbreaks run in cycles, occurring roughly every four years. Mosquitoes breed in stagnant pools of water ranging from flower pots to old tires, and residents across the region are urged to avoid letting water collect near houses.
____
Associated Press reporters Heng Sinith in Phnom Penh, Cambodia; Sean Yoong in Kuala Lumpur, Malaysia; Tran Van Minh in Hanoi, Vietnam, and Zakki Hakim in Jakarta, Indonesia contributed to this report.
Overweight women at risk of pregnancy complications
Mon, 30 Jul 2007 18:22:06 GMT
NEW YORK - The heavier a woman is before
pregnancy, the greater her risk of a range of pregnancy
complications, a large study suggests.
Using data from more than 24,000 UK women who gave birth
between 1976 and 2005, researchers found that the risk of
problems, such as high blood pressure, pre-eclampsia and
premature delivery climbed in tandem with a woman's
pre-pregnancy weight.
The findings, published in the online journal BMC Public
Health, add to evidence that obesity is a risk for mothers and
newborns.
They also support the belief that all pregnancies in obese
women should be considered &;high risk,&; and managed
accordingly, conclude the study authors, led by Dr. Sohinee
Bhattacharya of Aberdeen Maternity Hospital.
The researchers found that compared with normal-weight
women, obese women were 50 percent more likely to have
post-delivery bleeding and twice as likely to deliver
prematurely. They were also more likely to need an emergency
C-section or to have labor induced.
Morbidly obese women had the highest risk of suffering
pre-eclampsia, a potentially serious pregnancy complication
marked by a sudden rise in blood pressure and kidney
abnormalities.
In contrast, the study found that women who were
underweight before pregnancy tended to have the lowest risk of
all these complications. They were, however, more likely than
normal-weight women to have an underweight newborn.
The results add to growing evidence of the importance of a
mother's weight in pregnancy outcomes, according to
Bhattacharya's team.
&;The evidence for obesity as an important complication in
pregnancy is mounting,&; the researchers write, it is time for
physicians to be aware of these findings and start using them
in their practice.
Besides good prenatal care, they note, this means
counseling overweight women to lose weight before they become
pregnant.
SOURCE: BMC Public Health, online July 24, 2007.
Pregnancy reported despite drug warning
Mon, 30 Jul 2007 20:49:49 GMT
By LAURAN NEERGAARD, AP Medical Writer
WASHINGTON - More than 120 women became pregnant in the past year while taking an acne medicine that causes birth defects — despite being enrolled in a program designed to prevent those pregnancies from happening.
Long-awaited data from that national registry was released Monday, two days before the Food and Drug Administration was to bring together its scientific advisers to evaluate safety restrictions on Accutane and its generic competitors.
The new figures show the 122 pregnancies reported in the first year of the so-called iPledge program are about the same as the number reported annually before the FDA tightened restrictions on the drug, known chemically as isotretinoin.
Whether the tougher program is working becomes a question for Wednesday's advisory committee debate.
It's a difficult comparison because until the national registry began, officials weren't sure if they were learning about all the pregnancies affected by this very risky drug, said FDA deputy drug director Dr. Sandra Kweder.
"Our goal of course is zero," Kweder told The Associated Press on Monday.
But with pregnancies still occurring, "a big question is why is that," she added. "These are women who for the most part have pregnancy tests, who are counseled about birth control, who say they understand the risks."
If a woman becomes pregnant while taking the acne drug, her baby can suffer severe brain and heart defects, mental retardation and other abnormalities, even if the mother took only a small dose for a short period. That's a risk for 30 days after stopping the drug, too.
Isotretinoin is supposed to be for severe acne only, but it is widely acknowledged to be prescribed for more minor cases. The iPledge computerized registry, which became mandatory last year, marked 20 years of escalating FDA efforts to limit fetal exposures.
All patients — men and women — who want the drug must enroll, plus doctors who prescribe it and pharmacies that sell it. Women must meet additional requirements, including using birth control and passing pregnancy tests before each monthly refill.
Monday, the FDA posted on its Web site a report from isotretinoin manufacturers on iPledge's first year. Among the findings:
_More than 305,000 patients registered to use the drug, including 137,415 women of childbearing age. The registry allowed 91,894 of them to receive at least one prescription.
_Of the 122 pregnancies, 78 were taking the drug when they became pregnant. Another 10 were already pregnant when they started isotretinoin, including two who had a prescriber falsify pregnancy test results. The report didn't give a reason. Another eight became pregnant in the month after stopping the drug. The program couldn't provide details on the remaining pregnancies.
_Most of the pregnancies appear due to forgetting to stick with their birth control plan. Some 72 percent of the women had reported they were using birth control pills and a male condom, and 18 percent said they had been relying on abstinence.
_Two prescribers were kicked out of the registry for not following rules.
Dermatologists have been critical of the program, saying it unnecessarily locked out some patients. On Wednesday, manufacturers were expected to ask that FDA tweak the rules to make it easier for all but at-risk women to comply.
The March of Dimes had pushed for the tougher program and was assessing whether changes are needed.
Hospitalized elderly get barely enough calories
Fri, 27 Jul 2007 19:48:25 GMT
By Anthony J. Brown, MD
NEW YORK - The energy input from food
taken in by hospitalized elderly patients is only just
sufficient to cover their minimal energy output, French
researchers estimate. The group believes such patients could
benefit from higher caloric intake.
Malnutrition is known to be common among elderly patients
hospitalized with acute illness, because they often have little
appetite and don't eat much. Exactly how much energy these
patients expend and what their calorie requirements are,
however, have been unclear.
As reported in the Journal of the American Geriatric
Society, Dr. Patrick Ritz, from University Hospital, Angers,
and colleagues calculated the energy intake and energy
expenditure at rest in 90 acutely ill patients ranging in age
from 65 to 99 years.
The resting energy expenditure was multiplied by the
physical activity level constant to determine the actual
energy input needed to cover normal activity.
The team found that energy intake was 1.29-times higher
than the REE, so it fell short of energy requirements by 205
kcal/day, on average.
The results indicate that the energy intake in hospitalized
elderly patients is equivalent to the amount needed to sustain
vital functions in healthy individuals, the authors conclude.
&;This is notably inadequate in elderly patients in acute care
units,&; they point out, since people battling illness expend
more energy.
&;Spontaneous food intake being just sufficient to match
minimal requirements, higher calorie intakes are likely to be
beneficial for hospitalized elderly patients in acute care
units,&; Ritz's team concludes.
SOURCE: Journal of the American Geriatric Society, July
2007.
Caffeine exercise may help ward off skin cancer
Mon, 30 Jul 2007 20:38:52 GMT
By Will Dunham
WASHINGTON -
Exercise and moderate caffeine
consumption together could help ward off sun-induced skin
cancer, researchers said on Monday, but cautioned against
ditching the sun screen in favor of a jog and a cappuccino.
Experiments on mice showed that caffeine and exercise
together somehow made them better able to destroy precancerous
cells whose DNA had been damaged by ultraviolet-B radiation,
according to scientists at Rutgers University in New Jersey.
&;We think that it will be important in terms of prevention,
and possibly not only for skin cancer but possibly for other
cancers as well,&; Rutgers cancer researcher Allan Conney, one
of the scientists, said in a telephone interview.
The researchers studied groups of hairless mice that were
exposed to lamps generating ultraviolet-B radiation that
damaged DNA in their skin cells.
One group drank water containing the human equivalent of
one or two cups of coffee a day. A second group exercised on a
running wheel. A third group exercised and drank the caffeine.
A fourth group neither exercised nor drank caffeine.
Both caffeine and exercise alone increased by roughly 100
percent the mice's ability to kill off precancerous cells that
could lead to skin cancer compared to the mice that did
neither. But the mice that did both showed a nearly 400 percent
increase in this ability, the researchers found.
The researchers are eager to discover if the findings would
apply to humans, but in the meantime warned people not to give
up the sunscreen.
&;Don't go out and exercise and drink a lot of coffee and
assume you're going to be protected,&; Conney said.
&;Keep in mind that these are studies in mice. Although I
think that they may be applicable to humans, it really has to
be studied carefully before we can say that,&; Conney added.
The study was published in the Proceedings of the National
Academy of Sciences.
The researchers said some previous studies have provided
evidence that exercise and caffeine consumption through coffee
may be linked to reduced risk for some other cancers.
STUDYING COMBINATION
Conney said they want to figure out precisely how the
combination of caffeine and exercise seems to have a protective
effect against skin damage caused by the sun.
&;It's great that people are doing research looking for
different ways to help reduce the risk of skin cancer,&;
dermatologist Dr. Bruce Katz, a spokesman for the Skin Cancer
Foundation and the director of the Juva Skin & Laser Center in
New York City, said in a telephone interview.
But the study provided &;extremely preliminary data,&; and
there is no evidence of such an effect in people, Katz added.
The foundation said skin cancer is the most common form of
cancer in the United States, with more than 1 million people
diagnosed with it annually.