The Doctor's Channel - Medical Informatics

Magnetic stimulation shows promise for migraine with aura

2010-03-08T19:29:41+00:00

NEW YORK (Reuters Health) – A portable magnetic stimulation device is a promising noninvasive, drug-free treatment for acute migraine with aura, according to a March 4th online report in The Lancet Neurology.

However, although the single-pulse transcranial magnetic stimulation (TMS) was more effective than sham treatment, most patients still had some pain, the report indicates.

Transcranial magnetic stimulation has been “tested in individuals with migraine based on the hypothesis that a fluctuating magnetic field…applied to the back of the head, would induce electrical current and disrupt cortical spreading depression,” lead author Dr. Richard B. Lipton, from Albert Einstein College of Medicine, Bronx, New York, and co-researchers explain.

In the current study, Dr. Lipton’s team assessed response rates in 201 patients with migraine with aura who took home the hand-held Cerena Transcranial Magnetic Stimulator for TMS, or an identical sham device.

Over the 3-month study period, patients treated up to three migraine attacks while experiencing aura. Thirty-seven participants did not treat a migraine attack and were excluded from further analysis.

The main outcome -- no pain 2 hours after the first attack – occurred in 39% of TMS patients and 22% of sham treatment patients (p = 0.0179). Rates of sustained pain-free response at 24 hours were 29% vs. 16% and at 48 hours, 27% vs. 13% (p < 0.05 for both).

Non-inferiority analysis indicated that TMS was at least as effective as sham treatment in combating nausea, photophobia, and phonophobia.

No serious device-related events occurred, and the rate and severity of events was comparable in each patient group.

“For patients who commonly have aura as a signal of an impending migraine, treatment with single-pulse TMS may abort progression of the attack and abate disabling pain and other symptoms,” the authors conclude.

Because there is evidence of cortical spreading depression in migraine without aura, it is possible that TMS may be an effective treatment for these headaches as well, they add.

In an editorial, Dr. Hans-Christoph Diener of University Hospital Essen in Germany writes that with more research, “the use of TMS could be a major step forward in the treatment of migraine with aura, particularly in patients in whom presently available drug treatment is ineffective, poorly tolerated, or contraindicated.”

Reference:
Lancet Neurol 2010.

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Cardiac vegetations don't rule out percutaneous ICD lead extraction

2010-03-08T19:26:08+00:00

NEW YORK (Reuters Health) - Percutaneous extraction of pacemaker or implantable cardioverter-defibrillator (ICD) leads is safe in patients with cardiac vegetations, investigators report. And as long as blood cultures remain sterile, permanent devices can be reimplanted within a week or two.

Eradication of device-related infection requires complete system removal, the authors note in the March 2nd Journal of the American College of Cardiology. Traditionally, patients with vegetations larger than 1 cm in diameter have had their leads removed via thoracotomy, in order to avoid septic emboli -- but the surgery itself increases patients' risks for serious complications and for prolonged recovery.

Senior author Dr. Steven P. Kutalek and associates at Drexel University College of Medicine, Philadelphia, studied 100 patients (mean age, 67 years) who had 1838 leads extracted percutaneously despite echocardiographic evidence of vegetations. This group accounted for roughly 10% of all the percutaneous lead extraction cases at the authors' center between 1991 and 2007.

The vegetations ranged from 0.2 to 4.0 cm in largest diameter (mean 1.6 cm). Implants had been in place for an average of 51 months. The median extraction time (4 min per lead) was not significantly different from the median in a reference group consisting of all 66 patients without vegetations who underwent extraction in 2004.

Five patients had complications during lead extraction, including embolized vegetation in two. However, all 5 were discharged in stable condition and recovered uneventfully.

In 54 patients, surgeons reimplanted new devices during the same hospitalization, at a median of 7 days after extraction. None of these second devices had to be extracted due to relapsing infection.

Twenty-nine patients were lost to follow-up. In the remaining 71, the average follow-up was 438 days.

Nineteen patients died - 11 of persistent septicemia, 1 of sudden cardiac death, and the other 7 of unknown causes with no evidence of ongoing infection (including 4 who had received a new device).

Ten patients died within 30 days of lead extraction. "These unfortunate outcomes occurred in a critically ill subset of patients who often have extensive comorbidities," the researchers note. They attribute the operative mortality to disease severity rather than the mode of lead extraction.

Also, "given the frequent ambiguity of initial culture data," the authors recommend transesophageal ultrasonography before device extraction in order to identify patients at high risk for endocarditis.

This study demonstrates that "percutaneous lead extraction with vegetations of all sizes is possible and seemingly appropriate," Dr. James D. Maloney at Heartland Spine and Specialty Hospital, Overland Park, Kansas, and Dr. James D. Maloney III at the University of Wisconsin, Madison, write in a related editorial.

Still, they're concerned that residual infected inflammatory tissue needs to be debrided after the leads are removed.

"The question remains... if a nidus of chronic infection sometimes remains, does that cause refractory sepsis and congestive heart failure?" they ask. "Can and should it be removed surgically?"

Reference:
J Am Coll Cardiol 2010;55:886-897.

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ACE inhibitors, ARBs beat calcium blockers in cutting atrial fibrillation risk

2010-01-27T23:24:44+00:00

NEW YORK (Reuters Health) – When it comes to preventing atrial fibrillation, not all antihypertensive agents are created equal. New research suggests that angiotensin-converting enzyme (ACE) inhibitors, angiotensin II-receptor blockers (ARBs), and beta-blockers are all superior to calcium channel blockers in the reducing the risk.

Compared with calcium channel blockers, each of these agents reduces the risk of this common arrhythmia by around 25%, the findings indicate.

Hypertension is one of the primary predisposing factors for atrial fibrillation. However, little information is available regarding prevention of atrial fibrillation, and current opinions differ on the effect of various blood-pressure-lowering drugs on risk for the arrhythmia, authors point out in the January 19th Annals of Internal Medicine.

Senior author Dr. Christoph R. Meier, from University Hospital Basel, Switzerland, looked into this issue using the UK’s General Practice Research Database. Their nested case-control analysis included patients ages 20 to 79 undergoing treatment for hypertension and excluded patients with risk factors for atrial fibrillation (history of any arrhythmia, congestive heart failure, ischemic and valvular heart disease, thyrotoxicosis, alcoholism, or chronic obstructive pulmonary disease).

From a study population of around 680,000 patients, 4661 cases were first diagnosed with atrial fibrillation between 1998 and 2008. The authors matched 18642 control patients for age, gender, general practice, and calendar time. Diagnosis and treatment of hypertension had to precede the index date, at which time nearly two-thirds of patients were at least 70 years old. Forty-seven percent of patients were male.

The investigators note that they focused their analysis “on patients who received only one type of antihypertensive drug (with or without a diuretic), because these patients were likely to have mild to moderate hypertension that required only monotherapy.”

Models were adjusted for body mass index and smoking status, as well as comorbidities or drugs that could affect the risk of arrhythmia. The reference group of patients were treated with calcium-channel blockers.

In comparison, current use of other antihypertensives for at least a year was associated with a lower risk of atrial fibrillation. Adjusted odds ratios were 0.75 for ACE inhibitors, 0.71 for ARBs, and 0.78 for beta-blockers (p < 0.004 for each).

Patients who received other drugs along with ACE inhibitors or ARBs did not have lower risk of atrial fibrillation.

Dr. Meier’s team acknowledges that a limitation of the study is lack of data regarding blood pressure control. Moreover, “general health status and severity of hypertension may have differed across patients who used different antihypertensive study drugs.”

Ann Intern Med 2010;152:78-84.

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MedeFile - Features & Benefits

2010-01-27T23:10:35+00:00

Kevin Hauser, Director New Business Development at MedeFile International discusses the advanced features and benefits of their technology. These include MedeMinder and the Interactive Healthcare Calendar, which function as an electronic 'reminder service' that utilizes email (and concierge phone service if desired) to assist its subscribers in remembering scheduled doctor appointments, expiration dates on prescriptions and/or time-sensitive treatment protocols.

For more information about MedeFile and its annual subscription-based programs, please visit:
www.MedeFile.com

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MedeFile - What is it?

2010-01-27T23:08:34+00:00

Kevin Hauser, Director of New Business Development at MedeFile International discusses their technology. MedeFile has developed a proprietary system for gathering and digitizing medical records so that individuals can have a comprehensive record of all of their medical visits. MedeFile's primary product is the MedeFile system, a highly secure system for gathering and maintaining medical records. The MedeFile system is designed to gather all of its members' actual medical records and create a single, comprehensive medical record that is accessible 24 hours a day, seven days a week.

For more information about MedeFile and its annual subscription-based programs, please visit:
www.MedeFile.com

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Keas: helping physicians help their patients

2010-01-07T09:41:21+00:00

An interview with Adam Bosworth, founder of Keas. Keas is a web-based patient resource whose mission is to help patients understand what their health data means and how they can use it to be as healthy as possible.
Bosworth explains Keas Care Plans and how patients and physicians can use these resources effectively.
For more information, please visit:
Keas

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New doctor software

1970-01-01T01:00:00+01:00

Kathleen Berchelmann, MD, CPHIMS, Pediatric Hospitalist, Washington University in St Louis School of Medicine, MO, discusses a new web-based program she developed which electronically manages the pediatric sign-out sheet, doing away with potential errors caused by date entry and handwriting, as well as allowing physicians and care providers to access patient information remotely.

Reading:
Quantin C, Coatrieux G, Allaert FA, Fassa M, Bourquard K, Boire JY, de Vlieger P, Maigne L, Breton V. New advanced technologies to provide decentralised and secure access to medical records: case studies in oncology. Cancer Inform. 2009 Aug 7;7:217-29.

Wilson JF. Making electronic health records meaningful. Ann Intern Med. 2009 Aug 18;151(4):293-6.

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Health 2.0 2009 highlights

2009-11-30T17:45:27+00:00

Health 2.0 Conference in San Francisco 2009 highlights.

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Google health and MD Live Care

1970-01-01T01:00:00+01:00

Roni Zeiger, lead product manager at Google Health, speaks to The Doctors Channel at the Health 2.0 Conference in San Francisco 2009 about personal health records and how to tell your patients how best to use them. They also discuss MD Live Care, a new google product that gives patients a live online consult with a doctor.

Irani JS, Middleton JL, Marfatia R, Omana ET, D'Amico F. The use of electronic health records in the exam room and patient satisfaction: a systematic review. J Am Board Fam Med. 2009 Sep-Oct;22

Wollersheim D, Sari A, Rahayu W. Archetype-based electronic health records: a literature review and evaluation of their applicability to health data interoperability and access. HIM J. 2009;38(2):7-17.

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Pre-operative BNP level predicts cardiovascular events after noncardiac surgery

2009-10-15T15:39:42+01:00

NEW YORK (Reuters Health) – Elevated pre-operative blood levels of brain natriuretic peptide (BNP) or N-terminal-proBNP identify patients who are at increased risk for cardiovascular events within 30 days of noncardiac surgery, the results of a meta-analysis suggest.

Pre-operative assessment of clinical cardiac risk factors is of only limited value in predicting cardiovascular events postoperatively, Dr. P. J. Devereaux, from McMaster University Health Sciences Centre, Hamilton, Ontario, Canada, and colleagues note. BNP testing has been shown to have prognostic value in a number of nonsurgical settings, but its usefulness in surgical patients is unclear.

To investigate, the research team conducted a systematic review and meta-analysis of data from 9 observational studies, identified through a search of MEDLINE, EMBASE, and other sources. A total of 3281 patients were included in the analysis.

Overall, 314 patients experienced at least one cardiovascular complication within 30 days of surgery, according to the report in the Journal of the American College of Cardiology for October 20.

On average, 24.8% of patients had an elevated BNP or NT-proBNP value. A direct link between the pre-operative BNP or NT-proBNP level and the risk of cardiovascular complications was seen in all of the studies.

On pooled analysis of data from 7 studies, an elevated BNP or NT-proBNP value was associated with a 19.3-fold increased risk of a cardiovascular complication. In studies that only looked at death, cardiovascular death, or MI, an elevated value increased the odds of this composite outcome by 44.2-fold. In studies that examined these and other cardiovascular outcomes, a 14.7-fold increased risk was seen.

The present study “gives important and clear evidence for a high prognostic potential of natriuretic peptides in patients scheduled for noncardiac surgery. However, studies to evaluate whether specific NP-based treatment modifications will result in improved outcome of surgical patients still need to be performed,” note Dr. Daniel Bolliger, Dr. Manfred D. Seeberger, and Dr. Miodrag Filipovic, from the University of Basel Hospital, Switzerland, in a related editorial.

Reference:
J Am Coll Cardiol 2009;54:1599-1606,1607-1608.

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