Body

In the current issue of Family Medicine and Community Health (Volume 6, Number 4, 2018; DOI: https://doi.org/10.15212/FMCH.2018.0123, Nur Izzati Mohammad, Selasawati Ghazali and Mohd Nazri Shafei of the Department of Community Medicine, School of Medical Sciences, Universiti Sains Malaysia and Hospital Raja Perempuan Zainab 2, Kota Bharu, Malaysia consider how cigarette smoking is one of the risk factors leading to noncommunicable diseases such as cardiovascular and respiratory system diseases and cancer. Quitting smoking is difficult for many people and may involve multiple attempts. A quit smoking clinic is designed to assist smokers with tobacco dependence to quit smoking. There are many factors that contribute to successfully quitting smoking. The present study found that from a total of 202 respondents who attended the clinic, 42.6% of them successfully quit smoking. In addition, the number of cigarettes smoked per day and a previous quit attempt were significant predictors for successfully quitting smoking. These findings should be taken into consideration in interventions for smokers who wish to quit smoking.

In the current issue of Family Medicine and Community Health (Volume 6, Number 4, 2018; DOI: https://doi.org/10.15212/FMCH.2018.0115, Nnenna A. Osuji, Oluwaseun Solomon Ojo, Sunday O. Malomo, Peter T. Sogunle, Ademola O. Egunjobi and Olufisayo O. Odebunmi of the Family Medicine Department, Federal Medical Centre, Abeokuta, Nigeria describe how Nigeria and other sub-Saharan African countries are currently experiencing a rapid increase in the incidence of noncommunicable diseases, especially diabetes mellitus (DM), as a result of increasing urbanization and changing lifestyles. People with diseases such as DM that require lifelong management may be tired of taking medications and adhering to the lifestyle modifications over time. This underscores the importance of motivation in people with DM. The authors consider whether support from the family can motivate people with DM to improve self-management behaviors and ultimately their glycemic control? Few studies have looked at the relationship between perceived family support and glycemic control among people with type 2 DM.

ALBUQUERQUE, N.M. -- When people are in the early stages of an undiagnosed disease, immediate tests that lead to treatment are the best first steps. But a blood draw -- usually performed by a medical professional armed with an uncomfortably large needle -- might not be quickest, least painful or most effective method, according to new research.

Now a technique using microneedles able to draw relatively large amounts of interstitial fluid -- a liquid that lurks just under the skin -- opens new possibilities. Previously, microneedles -- tiny, hollow, stainless steel needles -- have drained tiny amounts of interstitial fluid needed to analyze electrolyte levels but could not draw enough fluid to make more complicated medical tests practical. The new method's larger draws could be more effective in rapidly measuring exposure to chemical and biological warfare agents as well as diagnosing cancer and other diseases, says Sandia National Laboratories researcher and team lead Ronen Polsky, who is principal investigator on the project sponsored by the Defense Threat Reduction Agency and Sandia's Laboratory Directed Research and Development program.

"We believe interstitial fluid has tremendous diagnostic potential, but there has been a problem with gathering sufficient quantities for clinical analysis," said Polsky. "Dermal interstitial fluid, because of its important regulatory functions in the body, actually carries more immune cells than blood, so it might even predict the onset of some diseases more quickly than other methods."

Polsky, along with the University of New Mexico, the U.S. Army Edgewood Chemical Biological Center and other Sandia researchers described the new technique in an Oct. 22 paper in the Nature journal, Communications Biology.

The relatively large quantities of pure interstitial fluid extracted, which have never before been achieved, make it possible to create a database of testable molecules, such as proteins, nucleotides, small molecules and other cell-to-cell signaling vesicles called exosomes. Their presence or absence in a patient's interstitial fluid would then indicate, when an individual's data is transmitted by electronic means to a future data center, whether bodily disorders like cancers, liver disease or other problems might be afoot.

The new microneedle extraction protocol achieved its latest results by modifying a technique described in a 1999 technical paper. The original technique drew fluid with a microneedle attached to a flat substrate penetrating the skin. In the recent modification, a concentric ring from a horizontally sliced insulin pen injector surrounding the needle was used serendipitously and a far greater amount of fluid became available.

"The earlier paper showed less than a microliter per insertion and our new needles were getting up to 2 microliters per needle, so we hypothesized the difference had to be the mounting around the needle modulating the pressure pressed on the skin," said Sandia researcher Phillip Miller, the lead author on the paper. "By creating arrays of needles, our extractable amount increased from 2 microliters to up to 20 microliters in human subjects." One microliter is about 0.000034 fluid ounces.

Interstitial fluid, the transparent fluid that surrounds all human cells, is most commonly experienced as the liquid that puffs up blisters. It is so important for the transport of biomolecules between cells and as an intermediary between blood and the lymphatic system that some researchers have referred to it, like skin, as another bodily organ.

Interstitial fluid's advantage for patients is that it can be probed by 1.5-millimeter (approximately .06 inches) needles that are too short to reach nerves that cause pain. It also has no red blood cells to cloud the results of tests. Until this latest research, the fluid had only one difficulty: the inability of researchers to collect enough of it unspoiled by cell fragments to perform an adequate number of tests for complete characterization. A microneedle pressed into the skin would send up just the interstitial fluid it had displaced -- a fraction of a microliter. Alternatively, inserting a tiny fluid pump brought forth large but damaged quantities of fluid.

Million-dollar research agreement

Work over the last decade has used the needles in the laboratory to collect tiny amounts -- fractions of microliters -- of interstitial fluid to detect real-time changes in body salts that indicate fatigue. Researchers envisioned a wristwatch-sized device that gave instant electrolyte readouts to athletes and their coaches, military personnel in the field or ordinary citizens feeling a bit down.

That technique has proved of more than theoretical interest: Sandia Labs, with Polsky as lead investigator, has just signed a $1 million Cooperative Research and Development Agreement with an Australia-based company, Microfluidics Biomedical Pty. Ltd., to develop just such a watch that senses lactate and glucose in real-time. The watch is projected to be market-ready within three years. Polsky spoke about this concept in a TEDxABQ talk in September 2017.

The agreement is based upon the company's interest in creating a real-time measurement device for sports enthusiasts, soldiers in the field and ordinary people interested in determining personal health issues immediately. The company's expertise in algorithm development and Sandia's expertise in microfabrication of autonomous integrated sensors and microneedle technology will join in the product's development.

Various watch designs will be tested for sensitivity and selectivity, as well as for long-term use over relevant concentration ranges in a synthetic interstitial fluid and then in live subjects. Microfluidics Biomedical will design the wireless technology for transmitting the signal generated by the sensors, which can be read by coaches, military team leads or the person who owns the watch.

This research agreement is significant because it is a step in crossing what entrepreneurs call the "valley of death" that often separates laboratory innovation from realization as a commercial product.

But the research community investigating the medical use of microneedles wanted to examine bigger game, including detecting dreaded diseases more intrusive than a mere shortage of electrolytes.

More tests will be needed to collect data on those interstitial fluid components that mirror in kind, though not in quantity, many of those available for blood. Once achieved, the stage will be set for simpler, cheaper, faster, painless tests expected in the future to be transmitted electronically from a participant's wrist watch to a central data bank, to determine in real-time the existence of a medical problem and its remedy at the earliest stage.

It will take many years to make a complete database for the world's diseases, Polsky said. So currently, he and his team are starting a new project to look at biomarkers in interstitial fluid that evolve after flu vaccinations. The effort will use volunteer Sandia employees. "Flu vaccinations are an ideal way to study the pathogenesis of infectious diseases and this study can lead to a new way to diagnose influenza and characterize its spread," said Polsky.

NEW YORK (January 3, 2019)--There are important lessons to be learned from the successes and failures of the AIDS response that could inform our response to the opioid epidemic, according to a new paper by researchers at the Columbia University Mailman School of Public Health. Decades of HIV research have demonstrated that the existence of an effective biomedical treatment is rarely, in and of itself, sufficient to combat an epidemic, suggesting that both a social as well as a biomedical response to the opioid crisis are necessary in order to be effective. The paper is published in the New England Journal of Medicine.

"Despite the effectiveness of medication-assisted treatment for opioid use disorders, the mortality rate for opioids has surpassed that of the AIDS epidemic during its peak in the early 1990s--a time when there was no effective treatment for HIV/AIDS," says Silvia Martins, MD, PhD, associate professor of Epidemiology at Columbia Mailman School.

Over 2 million Americans had an opioid use disorder in 2016. The rate of opioid overdose deaths has increased by 500 percent since 1999.

"Even as efforts are under way to scale up access to medication-assisted treatment for opioid use, it is vital not to assume a position of 'if we build it, they will come,'" says Caroline Parker, PhD candidate in the Department of Sociomedical Sciences. In the case of HIV/AIDS, "the benefits of scientific progress have been unequally distributed, with growing ethnic and sexuality-related disparities. This failure of equity should draw our attention to the importance of social factors in shaping who benefits from effective biomedical therapies."

To improve the population health impact of opioid use medication-assisted treatment (MAT), the researchers provide a five-point action plan:

1. Identify the cultural, social, economic, and structural barriers to care for the 80 percent of people with opioid use disorders who currently receive no treatment. "As the HIV/AIDS epidemic has taught us, the existence of effective medical treatment does not mean that people who need treatment can and will obtain it," says Parker.

2. Stop considering only one person at a time and address the structural drivers of the crisis, such as profit-driven health care, insufficient regulation of pharmaceutical markets, and eroding economic opportunity.

3. Address stigma and discrimination against people with opioid use disorder through legislation to decriminalize substance use disorders, and through training key community actors, such as police and churches, rather than just focusing on changing individual attitudes. "It is critical to directly engage affected families and communities in policymaking and changing legislation to stop the criminalization of substance use disorders," observes Parker.

4. Mobilize family and community support networks to help improve healthcare engagement. Leverage the resources and social networks that facilitated HIV treatment and adherence to improve access to MAT. Develop policies that recognize and compensate people for caring for people living with opioid use disorder.

5. Recognize that community activism is crucial to making MAT widely available just like engaging society and stakeholders was central for expanding access to antiretroviral therapy.

"As millions of dollars are appropriated at the state and federal levels for the opioid crisis, we face a choice. Committing those resources exclusively to biomedical solutions is likely to reproduce the sharp disparities that we have seen with HIV, but learning from the failures and successes of our response to HIV can help us leverage support to ensure that the opioid response benefits all sectors of society," says Martins.

Familial hypercholesterolemia is a hereditary genetic disorder predisposing in premature atherosclerosis and cardiovascular complications. Early diagnoses as well as effective treatment strategies in affected children are challenges among experts. Universal screening and cascade screening among families with familial hypercholesterolemia are being controversially discussed.

Treatment approaches for familial hypercholesterolemia in the pediatric population are multidisciplinary and aim to reduce total cardiovascular risk. Diagnosis of familial hypercholesterolemia in children and adolescents is usually based on clinical phenotype upon LDL-C levels and family history of premature cardiovascular and/or elevated LDL-C. The most widely recommended and effective pharmacotherapy in the pediatric age group is currently statins. Ezetimibe and bile acid sequestrants are usually used as second-line agents.

Evidence would be expected in the near future by cohort and registry studies. New therapeutic approaches, such as mipomersen and PCSK9 inhibitors seem promising. The main gap of evidence remains the lack of longitudinal follow up studies investigating cardiovascular outcomes, side effects, and effectiveness of treatment starting from childhood.

A major Cardiovascular (CV) risk factor is low-density Lipoprotein Cholesterol (LDL-C). A lot of evidence that was accumulated supports a linear association between LDL-C levels and CV risk. However, whether the lower limit of LDL-C might offer CV benefits without any safety concerns is still a topic of debate.

This review discusses data from studies of several safety events that have been associated with low LDL-C levels achieved with major lipid-lowering drug.

Commonly with the use of a combination of statins with ezetimibe or proprotein convertase subtilisin kexin 9 inhibitors, several large trials have evaluated the safety or reducing LDL-C to levels lower than 50 mg/dl or even lower than 25 mg/dl. Most of the trials showed CV benefits which were observed with LDL-C levels of 50 mg/dl or less compared with higher levels. Favorable results for LDL-C levels lower than 25 mg/dl are limited.

Of importance, cancer and hemorrhagic stroke incidences were not increased in patients attaining LDL-C lower than 40-50 mg/dl. In terms of safety, the reduction of LDL-C to such levels was not associated with any significant adverse event. Data regarding the impact of lowering LDL-C with neurocognitive disorders are contradictory; nevertheless, most studies stand in favor of neurocognitive safety with LDL-C reductions to low levels.

Familial hypercholesterolemia (FH) is an inherited autosomal dominant disorder which is characterized by substantially increased Low-Density Lipoprotein Cholesterol (LDL-C) levels. Timely reduction of LDL-C is of paramount importance to ameliorate the risk for CV disease as patients with FH have a significantly higher risk for Cardiovascular (CV) events. Pro-protein Convertase Subtilisin/Kexin type 9 (PCSK9) inhibitors have emerged as a very promising class of drugs for the management of such patients, among the available lipid-lowering novel therapies.

To discuss the potential differences between the two drugs, this review presents the available data on the efficacy and safety of the two available PCSK9 inhibitors in patients with FH. To identify available data from clinical studies evaluating the impact of evolocumab or alirocumab on lipid and CV parameters in patients with FH, a comprehensive literature search was performed.

In patients with FH, several studies have assessed the lipid-lowering profile of PCSK9 inhibitors. Furthermore, data also support a lower rate of lipid apheresis in FH patients receiving a PCSK9 inhibitor. Both evolocumab and alirocumab were found to significantly reduce LDL-C by more than 50-60% in FH patients. However, alirocumab reduced all-cause mortality, as well, a finding not observed with evolocumab. In terms of CV outcomes, both drugs were found to possess CV-ameliorating effects of the same extent in patients with CV disease. Several differences in the study population characteristics might explain this and other mild differences observed in the CV trials of these drugs.

LEXINGTON, Ky. (Jan. 3, 2019) -- In an editorial published in CNS Spectrums, Jay Avasarala, MD, PhD, takes the research community to task for its lack of minority representation in Phase III clinical trials for drugs to treat Multiple Sclerosis (MS).

Noting that the disease course of MS in African American (AA) patients is more aggressive, he urged researchers to make more effort to stave off the persistent slide in minority representation, which he believes skews efficacy and disability data and prevents physicians' ability to extrapolate whether drugs are effective in these populations.

"The MS phenotype in the African American patient is an ideal model to study drug efficacy since the disease follows a rapidly disabling course," he wrote. "AA MS patients admitted to US nursing homes are six years younger but more disabled compared to Caucasian American (CA) patients with MS. Since phenotypes between CA and AA can be clinically distinct, it is remarkable that not a single study has compared how drugs perform in such diverse groups."

According to Avasarala, a neurologist specializing in Multiple Sclerosis and neuroimmunology at UK HealthCare's Kentucky Neuroscience Institute, minority recruitment for clinical trials for MS drugs has declined from 7.7% in 2002 to about 2% in 2013.

In 2014, the FDA's Center for Drug Evaluation and Research (CDER) launched the Drug Trials Snapshots initiative that endeavored to increase minority representation in drug trials and improve public transparency by providing drug trial data online. While Avasarala acknowledges that the initiative was a good first step, he emphasizes that it does not require drug package inserts to include efficacy data from minority populations, making it difficult for prescribing physicians to determine whether the drug will help patients from minority ethnicities.

In the editorial, Avasarala proposed several changes to help spur minority recruitment, which will in turn improve the quality of data for minority populations and make it easier for physicians to treat their AA patients.

"First, I believe we should require pharmaceutical companies to collect post-marketing data in all minority groups who receive FDA-approved drugs for management of MS and classify responsiveness based on ethnicity," he said, noting that the FDA has required manufacturers to provide post-marketing data on drug safety for many years.

Avasarala also advocates for a requirement that package labelling include efficacy data from minority populations and that no publication should accept study data without a clarifying statement that acknowledges the lack of sufficient data to make reasonable conclusions in non-Caucasian minorities.

Since the 1970's, science has documented that MS among African Americans is clinically distinct in its progression and presentation, according to Avasarala, but research into treatments that address their particular phenotype has not kept pace.

"The scientific community has published reams of data , but all that matters to a patient is, 'OK, doc, how can you treat me?' "What drugs would you recommend?" And we fall short for African Americans, because we simply don't have the data."

"I feel powerless to help them. There needs to be a change. And change ought to begin in the form of a policy shift."

Avasarala states that his research at UK HealthCare will focus on the translational aspects of MS, datamining, the application of retinal imaging techniques to advance disease diagnosis, and studying in vitro blood-brain barrier models to facilitate drug transportation.

A new study suggests that people over age 65 who are newly diagnosed with heart failure can continue to drink moderate amounts of alcohol without worsening their condition.

The study, from Washington University School of Medicine in St. Louis, showed a survival benefit for moderate drinkers compared with those who abstained from alcohol. On average, survival for moderate drinkers was just over a year longer than abstainers, a difference that was statistically significant. However, the findings do not suggest that nondrinkers should start imbibing after a heart failure diagnosis, the researchers emphasized.

The study is published Dec. 28 in JAMA Network Open.

"My patients who are newly diagnosed with heart failure often ask me if they should stop having that glass of wine every night," said senior author and cardiologist David L. Brown, MD, a professor of medicine. "And until now, I didn't have a good answer for them. We have long known that the toxic effects of excessive drinking can contribute to heart failure. In contrast, we have data showing that healthy people who drink moderately seem to have some protection from heart failure over the long term, compared with people who don't drink at all. But there was very little, if any, data to help us advise people who drink moderately and have just been diagnosed with heart failure."

The new study suggests that such patients can safely continue to drink in moderate amounts -- one serving of alcohol per day for women and two for men. The researchers found a slight association between moderate drinking and longer survival times. But since the study doesn't establish cause and effect, the researchers can't conclude that moderate drinking is actively protective. It is possible there is some other factor, or combination of factors, common among moderate drinkers that leads to this benefit. As such, the evidence does not support the idea that nondrinkers with heart failure will improve if they begin moderate alcohol consumption.

The researchers analyzed data from a past study called the Cardiovascular Health Study, conducted from 1989 to 1993. It included 5,888 adults on Medicare. Of these, 393 patients developed heart failure during the nine-year follow-up period. Heart failure occurs when the heart gradually loses the ability to pump sufficient blood to the body. It can be triggered by a heart attack or other chronic conditions such as diabetes or kidney disease.

With an average age of 79, slightly more than half of the heart failure patients were women, and 86 percent were white. The patients were divided into four categories for the analysis: people who never drank, people who drank in the past and stopped, people who had seven or fewer drinks per week, and people who had eight or more drinks per week. The researchers defined one serving of alcohol as a 12-ounce beer, a 6-ounce glass of wine or a 1.5-ounce shot of liquor.

The researchers accounted for important variables in their analysis, including age, sex, race, education level, income, smoking status, blood pressure and other factors. After controlling for these variables, the investigators found an association between consuming seven or fewer drinks per week and an extended survival of just over one year, compared with the long-term abstainers. The extended survival came to an average of 383 days and ranged from 17 to 748 days. The greatest benefit seems to be derived from drinking 10 drinks per week, but so few patients fell into that category that the data were insufficient to draw definite conclusions.

"People who develop heart failure at an older age and never drank shouldn't start drinking," Brown said. "But our study suggests people who have had a daily drink or two before their diagnosis of heart failure can continue to do so without concern that it's causing harm. Even so, that decision should always be made in consultation with their doctors."

Bottom Line: Pain relief for pregnant women in labor is commonly given in the form of epidural, spinal or combined spinal-epidural blockade, which is collectively referred to as neuraxial analgesia. This study used birth certificate data and found wide variation in neuraxial analgesia use across the United States. Among 2.6 million pregnant women who underwent labor in 2015, neuraxial analgesia was used by 73 percent, with the lowest frequency in Maine and the highest in Nevada. Variation between states was only partly explained by state-level factors, which suggests other unmeasured patient-level and hospital-level factors likely were at play. It's important to understand the main reasons behind the variation and to know whether it influences health outcomes for women and newborns.

Authors: Alexander J. Butwick, M.B.B.S., F.R.C.A., M.S., Stanford University School of Medicine, Stanford, California, and coauthors

To Learn More: The full study is available on the For The Media website.

(doi:10.1001/jamanetworkopen.2018.6567)

Editor's Note: The article contains conflict of interest and funding/support disclosures. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Bottom Line: Having seven or fewer alcoholic drinks a week was associated with increased survival in older adults with newly diagnosed heart failure compared with patients who abstained from alcohol after accounting for other potential mitigating factors. Conflicting data exist about an association between alcohol consumption and heart failure but not much is known about the safety of alcohol consumption in patients after a new diagnosis of heart failure. This observational study of 393 patients suggests limited alcohol consumption of seven drinks a week or fewer was associated with an additional average survival of just over one year at 383 days compared with abstinence from alcohol. Survival after a new diagnosis of heart failure was about 7.5 years among patients in the study. Researchers didn't have information about the cause of heart failure in these patients. Optimal levels of alcohol consumption by adults with heart failure remain to be determined. These results should not be interpreted as suggesting that individuals with newly diagnosed heart failure show begin drinking alcohol after their diagnosis if they did not drink previously.

Authors: David L. Brown, M.D., Washington University School of Medicine, St. Louis, Missouri, and coauthors

To Learn More: The full study is available on the For The Media website.

(doi:10.1001/jamanetworkopen.2018.6383)

Editor's Note: The article contains conflict of interest and funding/support disclosures. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

CORVALLIS, Ore. - If quitting smoking is one of your New Year's resolutions, you might want to consider cutting back on your drinking, too.

New research has found that heavy drinkers who are trying to stop smoking may find that reducing their alcohol use can also help them quit their daily smoking habit. Heavy drinkers' nicotine metabolite ratio - a biomarker that indicates how quickly a person's body metabolizes nicotine - reduced as they cut back on their drinking.

Past research has suggested that people with higher nicotine metabolism ratios are likely to smoke more and that people with higher rates have a harder time quitting. Slowing a person's nicotine metabolism rate through reduced drinking could provide an edge when trying to stop smoking, which is known to be a difficult task, said Sarah Dermody, an assistant professor at Oregon State University and the study's lead author.

"It takes a lot of determination to quit smoking, often several attempts," Dermody said. "This research suggests that drinking is changing the nicotine metabolism as indexed by the nicotine metabolite ratio, and that daily smoking and heavy drinking may best be treated together."

The study was just published in the journal Nicotine & Tobacco Research.

Dermody, who is based in in the School of Psychological Science in OSU's College of Liberal Arts, studies risky behaviors such as alcohol and nicotine use with the goal of better understanding factors that contribute to alcohol and nicotine use and how best to intervene with problematic use of these substances.

Use of both alcohol and cigarettes is widespread, with nearly 1 in 5 adults using both. Cigarette use is especially prevalent in heavy drinkers. Drinking is a well-established risk factor for smoking, and smoking is well-established risk factor for drinking.

Dermody and colleagues at the Centre for Addiction and Mental Health in Toronto, Canada, wanted to better understand the links between the two. They studied the nicotine metabolite ratio, an index of nicotine metabolism, in a group of 22 daily smokers who were seeking treatment for alcohol use disorder - the medical term for severe problem drinking - over several weeks.

"What's really interesting is that the nicotine metabolite ratio is clinically useful," Dermody said. "People with a higher ratio have a harder time quitting smoking cold turkey. They have are also less likely to successfully quit using nicotine replacement therapy products."

They found that as the men in the study group reduced their drinking - from an average of 29 drinks per week to 7 - their nicotine metabolite rate also dropped.

The researchers' findings for men replicated those of an earlier study that found similar effects and provide further evidence of the value of the nicotine metabolite ratio biomarker to inform treatment for smokers trying to quit, Dermody said.

"The nicotine metabolite ratio was thought to be a stable index, but it may not be as stable as we thought," Dermody said. "From a clinical standpoint, that's a positive thing, because if someone wants to stop smoking, we may want to encourage them to reduce their drinking to encourage their smoking cessation plan."

The women in the study did not see reductions in their nicotine metabolite ratio, but the researchers also did not find that the women in the study reduced their drinking significantly during the study period.

"The rate of drinking for women in the study started low and stayed low," Dermody said. "I anticipate that in a larger generalized study we would not see the difference between men and women like that."

Dermody is preparing a new study of the links between smoking and drinking. She hopes to recruit heavy drinkers who also smoke to participate in an intervention to reduce their drinking. The study will also examine the effects on smoking to try and replicate the findings in a larger group.

"This research is demonstrating the value in addressing both smoking and drinking together," she said. "The question now is how best to do that."

Cancer patients are often prescribed pain medications, for example during recovery from surgical procedures. However, for many cancer patients, the use of opioid pain medications during treatment can be a gateway to misuse or addiction once treatment ends. Now with cancer patients living longer than ever before, protecting quality of life in the months, years, or decades after treatment is becoming increasingly important, including guarding against the risk of opioid addiction.

"We felt like it was long term problem for some of our head and neck cancer patients, but didn't know how much of problem," says first author Jessica McDermott, MD, investigator at CU Cancer Center and assistant professor at the CU School of Medicine.

To discover the extent of opioid use and abuse in head and neck cancer patients, McDermott and colleagues searched the SEER/Medicare database to identify 976 patients treated between 2008 and 2011 for oral or oropharynx cancer. In all, 811 of these patients received prescriptions for opioid pain medications during treatment. Three months after treatment ended, 150 of these patients continued to have active opioid prescriptions. Six months after treatment, 68 patients or 7 percent of the total population continued to use opioid pain medication. Results are published online ahead of print in the journal Otolaryngology-Head and Neck Surgery.

"You shouldn't need opioids at the six-month point," McDermott says. "We hope that we can use this data to help patients manage pain better."

In fact, McDermott suggests that because younger patients in this (and other) studies were at greater risk for opioid misuse, and the SEER/Medicare database is heavily skewed to include data from older patients, the true percent of opioid misuse in the overall head and neck cancer patient population is likely higher than the current study suggests. Additional risk factors for continued opioid use included opioid prescription prior to cancer treatment, and a history of smoking and/or alcohol use.

Interestingly, patients prescribed oxycodone as their first opiate were less likely to continue use at 3 and 6 months after treatment, than patients initially prescribed hydrocodone or other opiates including fentanyl, hydromorphone, meperidine hydrochloride, morphine, nalbuphine, or tramadol.

"We don't know why this is the case, but we think that maybe patients know the word 'oxycodone' and are more aware of the potential for addiction than they might be if prescribed a less well-known drug or one they consider less dangerous like hydrocodone," McDermott says.

The group sees the current study as a way to understand the ecosystem of pain control and opioid dependence in head and neck cancer patients, with the goal of working to change doctors' strategies for pain control.

"If a patient needed opioids for pain, I wouldn't keep them away, but especially if they have risk factors, I might counsel them more about the risks of addiction and misuse, and keep an eye on it," McDermott says.

1. Catheter ablation superior to standard drug therapy for heart failure

Abstract: http://annals.org/aim/article/doi/10.7326/M18-0992

URLs go live when the embargo lifts

A meta-analysis of randomized controlled trials found that catheter ablation was superior to conventional drug therapy alone for patients with atrial fibrillation and heart failure. Findings are published in Annals of Internal Medicine.

Atrial fibrillation is associated with thromboembolic stroke, systemic embolism, and decompensated heart failure. Catheter ablation is an established therapeutic strategy for atrial fibrillation, but guidelines recommend caution in certain patients. The benefits and harms of catheter ablation versus drug therapy for patients with atrial fibrillation have not been firmly established.

Researchers from Icahn School of Medicine at Mount Sinai reviewed six published randomized controlled trials to compare the benefits and harms between catheter ablation and standard drug therapy (rate or rhythm control medications) in adult patients with atrial fibrillation and heart failure. Their analysis showed that compared to medication, catheter ablation was associated with reductions in all-cause mortality and heart failure hospitalizations and improvements in left ventricular ejection fraction; quality of life; cardiopulmonary exercise capacity; and 6-minute walk test distance, with no statistically significant increase in serious adverse events.

The major adverse events rates observed in the pooled analysis were 7.2 percent in the ablation group and 3.8 percent in the standard therapy group. Despite the complications associated with catheter ablation, the authors explain that the long-term benefits in all-cause mortality, heart failure hospitalizations, and overall clinical outcomes must be weighed in clinical decision making.

Media contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To interview the lead author, Vivek Reddy, MD, please contact Wendi Chason at wendi.chason@mountsinai.org.

2. Proposed technique prevents confused patients from dislodging central line

Abstract: http://annals.org/aim/article/doi/10.7326/L18-0439

URLs go live when the embargo lifts

A proposed technique for placing a central venous catheter that may prevent confused patients from pulling it out or dislodging it easily. Findings from a case report are published in Annals of Internal Medicine.

Sometimes patients, particularly confused patients, dislodge or pull out central venous catheters inadvertently or intentionally. Although this occurrence is uncommon, it is not rare, and it may have negative consequences.

Physicians from Beth Israel Deaconess Medical Center and Harvard Medical School saw a 77-year-old patient with waxing and waning mental status who required dialysis for chronic kidney failure. The patient became confused and repeatedly pulled out his hemodialysis catheters. Since he was unsuitable for an arteriovenous access and the medical literature offered no solution, the physicians developed a novel technique. They placed a right external jugular vein catheter, tunneling subcutaneously to exit from the patient's upper back, near the midline, just below his neck. It was out of reach to the patient, but not in an area where it would cause pressure on his skin when he was lying on his back. It worked well enough that the authors suggest clinicians consider this placement when caring for patients at risk for central line dislodgement.

Media contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To interview the lead author, Robert S. Brown, MD, please contact Jacqueline Mitchell at jsmitche@bidmc.harvard.edu.