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Patients
underestimate risks, overestimate benefits of elective angioplasty
When it comes
to electing to undergo angioplasty, many patients believe that
the procedure to open up clogged blood vessels can prevent heart
attacks and prolong their lives without any significant danger.
According to Yale investigators, this is a misperception and
patients need a better understanding of the potential risks and
benefits from their health care providers well before they undergo
the procedure.
Angioplasty
is an invasive procedure in which a balloon is inflated inside
a blood vessel, most often a coronary artery, to flatten any
plaque that blocks flow through the vessel. A metal device called
a stent is often inserted to help keep the artery open. It can
relieve chest pain, but there is no definite evidence to date
that it will lower the risk of a future heart attack. Moreover,
angioplasty itself poses risks of inducing a heart attack or
stroke, as well as hemorrhage and infection. Eric Holmboe, M.D.,
assistant professor of medicine, and his colleagues interviewed
52 patients, ages 39 to 87, on the eve of the procedure about
their views of the potential benefits and risks. Three-quarters
believed the procedure would prevent a future heart attack, and
almost as many thought it would prolong their lives. When asked
about risks, less than half could recall a single risk associated
with angioplasty. Results of the study appeared in the Journal
of Internal Medicine in October.
“Our findings
show that patients do not have the information they need in a
format they can use to make the best decision about angioplasty
for themselves,” says Holmboe. “In my opinion, patients
need to have a discussion about the benefits and risks a good
week before any elective procedure in order to think about the
risks and benefits.” To achieve this goal, Holmboe plans
to create a multifaceted approach to help inform patients and
answer their questions and to set up a program to train young
physicians to provide risk explanations patients can understand. |
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Study
knocks popular cough and cold medication ingredient off the market
A study by Yale
investigators of phenylpropanolamine, or PPA, one of the most
frequently used ingredients in many cough and cold medications,
found that it leads to increased risk of hemorrhagic stroke in
women. Men may also be at a lesser risk. The findings provoked
the Food and Drug Administration (FDA) in October to advise ending
the marketing and distribution of PPA, prompting manufacturers
to withdraw many of the most popular over-the-counter (OTC) products
using PPA, such as Alka-Seltzer Plus, Dimetapp Elixir and Robitussin.
The study took
place at four research centers and was coordinated by the Yale
investigators under a grant from two manufacturers of PPA. The
results made front-page headlines worldwide because of the popularity
of the products affected. Walter N. Kernan, M.D., associate professor
of medicine, one of four co-investigators at Yale, says of the
OTC products, “They’re essentially gone.”
The paper detailing
the five-year, $5 million study did not appear in the New
England Journal of Medicine until Dec. 14, but the results
were released earlier on the journal’s Web site because
of their importance to public health. “I think the FDA decision
was cautious but very appropriate,” says Kernan. “There
are alternative OTC medications for relief of cough and cold
symptoms.”
The study was
undertaken because of case reports associating PPA with hemorrhagic
stroke—bleeding between the cerebral lobes or around the
edges of the brain—an uncommon form of stroke, especially
in the 18- to 49-year-old age group that was the focus of the
study. The study did not look at ischemic stroke, by far the
most common form of stroke.
The investigators
examined 702 people who had suffered a hemorrhagic stroke and
compared them to twice that number of control subjects who had
not had a stroke. That database is the largest of its kind. The
investigators are now using it to study other risk factors for
stroke. “We expect to find new and more precise information
about other risk factors for hemorrhagic stroke, including other
drug products,” says Kernan. “These additional analyses
may have important public health implications as well.” |
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Third
of doctors don’t practice what they preach
Public health
experts decry health care conditions that result in 20 percent
of the American population not getting routine examinations,
preventive inoculations and screenings. They often cite barriers
to entry into the health care system, such as lower economic
status, language difficulties and lack of education. A study
of physicians directed by a Yale investigator came up with the
surprising result that doctors seem even less likely than the
rest of the population to have a regular source of care (RSOC)
such as a primary physician.
The study was
done while Assistant Professor of Medicine Cary P. Gross, M.D.,
was a fellow at The Johns Hopkins School of Medicine. Of 915
physicians who graduated from Hopkins between 1948 and 1964,
some 35 percent had no RSOC during a seven-year survey period.
While doctors may have other sources of care, those without an
RSOC were much less likely to get cancer screening or an influenza
vaccine.
Gross speculates
that doctors don’t go to doctors because of what he terms
a “fallacious” belief in their capacity for self-care
combined with the time demands of their medical careers. As is
true of those who do not seek preventive care, he found that
these physicians often also exhibit a “fatalistic”
attitude, attributing health outcomes to chance. Gross says of
the findings, which appeared in November in the Archives of
Internal Medicine, “You have to wonder why we’re
not heeding our own advice.” He does not know whether Yale
graduates are more or less likely than other physicians to go
to the doctor. |
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Shedding
new light on depression
A Yale investigator
and his Israeli colleagues have shown for the first time that
the body has light receptors other than those in the eye’s
visual system. That finding may help explain why using artificial
light as therapy helps people with seasonal affective disorder
(SAD), a form of depression believed to result from light deprivation,
occurring most commonly during winter. It could also help lead
to the development of light therapies for other forms of depression,
according to the paper’s senior author, Associate Professor
of Psychiatry Dan A. Oren, M.D.
For the study,
which appeared in the March 1 issue of the journal Biological
Psychiatry, light from a type of light box commonly used
to treat SAD was directed on skin cells grown in culture. Within
10 minutes, the light stimulated production of molecules containing
so-called free radicals, which are gases that can deliver energy
through the bloodstream. This may help explain why light can
help treat SAD, which affects as many as 20 million Americans,
and provides, said Oren, “a new pathway toward understanding
how the brain works.”
Oren is also
principal investigator for a study using light to treat pregnant
women suffering from depression. Oren and C. Neill Epperson,
M.D., assistant professor of psychiatry and of obstetrics and
gynecology, are testing women to see whether light therapy will
allow them to avoid antidepressant medications, because of concerns
about the drugs’ potential side effects and/or toxic effects
on the fetus. According to Oren, an open-treatment trial had
“very encouraging” results. Yale and two other research
centers are now pursuing a pilot study in hopes of undertaking
a larger-scale investigation. |
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A
molecular clue for detecting bladder cancer
Discovered three
years ago, a gene called survivin holds promise as a diagnostic
marker for bladder cancer, according to a study published by
Professor of Pathology Dario C. Altieri, M.D., of the Yale Cancer
Center, and several colleagues in the Jan. 16 issue of JAMA:
The Journal of the American Medical Association. The sixth
most common cancer in the United States, bladder cancer has a
5-year survival rate of 93 percent if it is discovered and treated
early.
The current
means of diagnosis, cystoscopy and biopsy, are accurate but also
expensive and painful. What the Yale study found may lead to
a noninvasive approach, examining cells that the body abundantly
sloughs off every day into the urine. In an analysis of urine
samples from 16 healthy volunteers and 60 volunteers with various
types of cancer, the protein product of the survivin gene appeared
in the samples from patients with new or recurring bladder cancer—but
not in those from the healthy volunteers or volunteers with prostate,
renal, cervical or vaginal cancer.
“The potential
outlook for a test like this would be to improve the follow-up
measures” for patients after treatment, says Altieri. Since
bladder cancer all too often does recur, he adds, “We hope
to see this urine-cell analysis develop into an alternative,
safe, noninvasive and reliable approach at the first line of
diagnosis.”
The lead author
of the study was Shannon Smith, M.D., a urology fellow who died
in March after a five-year struggle with brain cancer. “Her
spirit was strong and inspiring and her commitment to this experimental
work, even in the midst of the progressing disease, was admirable,”
Altieri said. |
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Radiation
multiplies Salmonella’s anti-tumor properties
Traditional
radiation therapy, when combined with a genetically modified
form of the deadly bacterium Salmonella, could help some
cancer patients, Yale scientists have found.
Writing in the
European Journal of Cancer, the scientists say they have
developed a nontoxic strain of the dangerous “wild type”
of Salmonella and used it in conjunction with X-rays to
fight tumors in mice. The study, done in collaboration with Vion
Pharmaceuticals, showed a remarkable gain in the ability to halt,
although not completely eliminate, tumor growth.
Initial results
from a Phase I clinical trial indicated that the bacterium can
safely be used in humans. Yale scientists John M. Pawelek, Ph.D.,
K. Brooks Low, Ph.D., and David G. Bermudes, Ph.D., who is also
director of biology at Vion, have received a patent for the cancer
vector.
Pawelek, a senior
research scientist in the Department of Dermatology, said the
team was surprised at the effectiveness of the two therapies
together. While either radiation or Salmonella alone prevented
cancer growth for as much as three weeks, the combination stopped
the tumors for more than twice as long.
While treating
cancer patients with forms of bacteria has been done for at least
100 years, the reasons for its occasional success have eluded
scientists. New ways of altering Salmonella and combining
it with radiation are the novel aspects of the current work.
“You can go into great detail about why X-rays and Salmonella
are so effective together, but that is really speculation at
this point,” Pawelek said. “We have discovered a novel
therapy, and one of the things we are doing now is trying to
understand how it works.” |
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With
chest pain, need for treatment can be a matter of perspective
Chest pain is
not the same for everyone. It keeps some patients from enjoying
daily activities. For others, despite identical diagnoses, the
pain does little to reduce their quality of life. According to
a Yale study, physicians will provide patients with better care
by considering that difference before recommending invasive procedures,
such as angioplasty, to improve blood flow to the heart to reduce
the pain.
“There
can be an important discordance between a patient’s objective
capacity and the patient’s quality of life,” says Harlan
M. Krumholz, M.D., associate professor of medicine and of epidemiology
and public health. “For an Olympic swimmer, a minor injury
could be devastating, but for someone who is mostly sedentary
it might be barely noticed.”
He directed
the study, which was undertaken by Jennifer A. Mattera, M.P.H.
’95, director of the Center for Outcomes Research at Yale-New
Haven Hospital, for her master’s thesis, along with other
researchers at Yale. The investigators compared the results from
patients’ diagnostic tests—exercise electrocardiogram
treadmill testing and myocardial perfusion imaging—with
the patients’ views of their physical functioning and general
health gathered from a questionnaire. The researchers found that
the test results correlated with the patients’ perceptions
of their quality of life most of the time, but that in many cases
patients’ perceptions of their health and physical functioning
differed markedly from what the test results showed.
“It highlights
the importance of talking to the patient,” says Krumholz.
“We can have all these sophisticated tests, but the ultimate
measure of quality of life and functioning should be understood
from the patient’s own perspective. There needs to be a
connection between their goals of therapy and our goals of therapy.
If our therapy is intended to help them live better, then we
should be sure that we are treating the patient and not just
their test results.” |
