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For
some patients,
the enemy is anemia
A link is found between
low red blood count, high mortality among elderly cardiac patients.
Although clinicians
have long been uncertain about the benefits of blood transfusions in patients
with heart attacks, a study by Yale investigators has found that they
significantly improve chances for survival.
“Our principal finding
is that a low hematocrit on admission is associated with higher mortality
rates in elderly heart attack patients,” said principal investigator
Harlan M. Krumholz, M.D., associate professor of medicine (cardiology)
and epidemiology. “However, blood transfusions, when given to these
patients, can significantly decrease their mortality risk. This is the
first study to highlight the important link between anemia, blood transfusion
and mortality among elderly patients hospitalized for a heart attack.”
Krumholz and researchers at
Brown University Medical School, Yale’s Department of Epidemiology
and Public Health and the Yale-New Haven Hospital Center for Outcomes
Research and Evaluation conducted a retrospective study of 78,964 Medicare
beneficiaries 65 years and older who were hospitalized with acute myocardial
infarction. After categorizing patients on the basis of their hematocrit
levels, the researchers then explored links between transfusions and 30-day
mortality. “Surprisingly, we found that 43.4 percent of elderly patients
hospitalized with a heart attack are anemic, or have a blood count below
39 percent, at the time of admission,” said co-author Saif S. Rathore,
M.P.H., a lecturer in the Department of Internal Medicine.
The study also found that
the most severely anemic patients were twice as likely to die within 30
days as those who were not anemic. Despite the higher mortality risk,
fewer than a quarter of the patients with clinically significant anemia
received a blood transfusion.
“Our data indicate that
blood transfusions provided to elderly anemic patients can significantly
reduce their risk of short-term mortality,” said Krumholz. “Most
promisingly, our data indicate that this benefit is observed in elderly
patients with blood count levels as high as 33 percent, a higher level
than previously considered by clinicians. These data are particularly
compelling given the lack of clinical guidelines concerning hematocrit
levels at which to transfuse elderly patients with heart disease.”
The study was published in
the October 25 issue of The New England Journal of Medicine. In
an editorial accompanying the study, Lawrence T. Goodnough, M.D., and
Richard G. Bach, M.D., of the Washington University School of Medicine,
underscored the importance of these findings. “For the first time,
we have evidence that patients with a specific clinical presentation are
affected adversely by the underuse of transfusion,” Goodnough and
Bach wrote. Based on this research, they suggested “that hematocrit
levels should be maintained above 33 percent in patients who present with
acute myocardial infarction.”
“We certainly feel that
our findings should result in a change in clinical practice,” said
first author Wen-Chih Wu, M.D., a teaching fellow in internal medicine
(cardiology) at Brown University.
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Meat
the culprits
Eating one’s vegetables
could help ward off a form of cancer that has been on the rise for the
last quarter-century, according to a study by investigators at Yale and
around the country. Since the mid-1970s the rate of adenocarcinomas of
the esophagus and gastric cardia has increased by 300 percent. “We
found that many nutrients in foods of animal origin are significantly
associated with a risk of developing this class of cancers,” said
lead author Susan T. Mayne, Ph.D. They also found that certain plant-based
nutrients, including dietary fiber, dietary beta-carotene, folic acid
and vitamins C and B6, were associated with a lower risk. Harvey A. Risch,
M.D., Ph.D., was the principal investigator on the study, published in
the October issue of Cancer Epidemiology, Biomarkers & Prevention.
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Sedative
linked to delirium
Older, hospitalized patients
who take diphenhydramine, an often-prescribed antihistamine and sedative,
run a 70 percent greater risk of delirium, according to a study by Yale
physicians. “The findings suggest that using diphenhydramine as a
routine sleeping aid and for most other reasons should be actively discouraged
in the older hospitalized population,” said Joseph V. Agostini, M.D.,
a postdoctoral fellow in the Robert Wood Johnson Clinical Scholars Program,
whose findings were published in the September 24 issue of Archives
of Internal Medicine. Diphenhydramine is a component of many over-the-counter
cold remedies and allergy and insomnia medications such as Benadryl and
Sominex.
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Another
approach to ADHD
The drug guanfacine can treat
attention deficit hyperactivity disorder (ADHD) without worsening tics,
Yale investigators have found. Stimulants are first-round agents for ADHD,
but may worsen tics in some cases. “Guanfacine,” said first
author Lawrence Scahill, M.S.N., M.P.H. ’89, Ph.D. ’97, associate
professor in the Child Study Center and at the School of Nursing, “appears
to be a safe and effective treatment for children with tic disorders and
ADHD.” For the study, published in the July issue of The American
Journal of Psychiatry, the researchers followed 34 children diagnosed
with ADHD and a tic disorder. Guanfacine was associated with improvement
on the teacher-rated ADHD Rating Scale, fewer tics and better performance
on laboratory tests of attention and impulse control.
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Life
and death on the gridiron
This year across America,
a handful of apparently healthy athletes will die on the playing field.
Though efforts are made to detect abnormalities that might predict the
sudden deaths resulting from hypertrophic cardiomyopathy and undiagnosed
asthma, there has been no cost-effective way of screening entire teams
before the start of each season. But last August, Yale surgeon James “Butch”
Rosser, M.D., launched his “Operation Beating Heart” telemedicine
program during football practice at Savannah State University in Georgia.
Rosser’s exam uses a five-pound ultrasound device and other portable
gear to transmit data to Yale physicians. Rosser plans to expand the program
to other schools this year.
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