Laser Treatment for Vision Loss from Branch Retinal Vein Occlusion is Safer than Corticosteroid Injections and Equally Effective

Scientists have found that laser therapy is equivalent to two different dosages of corticosteroid medications for treating vision loss from the blockage of small veins in the back of the eye, a condition known as branch retinal vein occlusion (BRVO). Furthermore, laser treatment was shown to have fewer complications for patients. This research was part of the Standard Care vs. Corticosteroid for Retinal Vein Occlusion (SCORE) Study, a phase III clinical trial conducted at 84 sites and supported by the National Eye Institute (NEI) at the National Institutes of Health. "The SCORE study is the first to demonstrate that laser treatment and injections of corticosteroid into the eye have a similar impact on vision loss for patients who have retinal swelling due to branch retinal vein occlusion," said Ingrid U. Scott, M.D., M.P.H., professor at Penn State College of Medicine and co-chair of the SCORE study. "However, the lower rate of complications with laser treatment may indicate that it is the best proven treatment option for patients at this time, and that laser represents the benchmark against which other treatments should be compared in future clinical trials." In the United States, vein occlusion is estimated to be the second most common condition affecting blood vessels in the retina. In BRVO, a blood clot slows or stops circulation in a small vein within the eye's light-sensitive retinal tissue. This may lead to new blood vessel growth and blood vessel leakage, which results in retinal tissue swelling — a common cause of vision loss from BRVO. Eye doctors typically treat BRVO with laser therapy applied to the affected retina in a grid pattern. However, some ophthalmologists have treated people who have BRVO using eye injections of an anti-inflammatory corticosteroid called triamcinolone. Because clinical observations suggested a visual benefit, the SCORE study was initiated to compare the safety and effectiveness of standard care laser treatment with two different doses of triamcinolone — 1 milligram and 4 milligrams. The results appear in the September 2009 issue of Archives of Ophthalmology, published alongside findings from a separate trial within the SCORE study, which looked at blockages in larger retinal veins (http://www.nei.nih.gov/news/pressreleases/091409a.asp). Participants in the study included 411 people with BRVO who were an average of 67 years old. Patients could receive treatment every four months for up to three years. One year after patients began the trial, equal numbers of patients experienced visual improvement in each treatment group. Twenty to 30 percent of patients in each group experienced substantial visual gains of three or more lines on a vision chart — equivalent to identifying letters that were half as small as they could read before treatment. However, patients who received either dosage of corticosteroid medication were more likely to develop a cataract or have an increase in eye pressure requiring medication than patients who received laser treatment. Between one and two years after treatment was begun, patients who received the 4 milligram dosage were also more likely to undergo cataract surgery. "These results may have a significant public health impact by providing guidance for clinicians and patients in their selection of a branch retinal vein occlusion treatment," said Frederick L. Ferris III, M.D., clinical director of the NEI. "Still, better treatments for this condition are needed. This information could guide future clinical trials of new and more effective treatments for BRVO patients."

Some Parents Aren't Giving Kids Pain Meds Post-Surgery

Twenty-five percent of children aren't getting sufficient pain medication from their parents after common surgical procedures, such as having their tonsils out, a new study finds. It's not clear at this point what the ramifications of the finding are, or the reasons for it. In a worst-case scenario, kids who don't get enough medication may not be able to swallow enough water, leading to dehydration and even hospitalization, said Dr. Kenneth Goldschneider, director of the division of pain management at Cincinnati Children's Hospital. He was not involved in the new study. Another expert, Dr. Patricia Cantwell, professor and chief of pediatric critical care medicine at the University of Miami Miller School of Medicine, agreed that many young patients at her facility end up back in the emergency room as a result of unresolved pain issues. Under-medication could affect large numbers of children. According to background information in the article, published in the October issue of Pediatrics, upwards of 5 million children in the United States undergo surgery each year, with three-quarters having significant pain afterward. Tonsillectomy and adenoidectomy (to remove the adenoids) are among the most widely performed procedures in younger people. As hospital stays get shorter and more procedures are done on an outpatient basis, medication is given more often in the home. "The typical way in which pain medicine is given, I would say, is the surgical team giving the family a prescription, then you go out the door and fill it," said Cantwell. The study authors, from the University of California, Irvine and the Children's Hospital of Orange County, Calif., looked at 261 children aged 2 to 12 who had undergone one of these two procedures. On the first day home, parents reported that 86 percent of their children were experiencing "significant overall pain." Despite that, one in four children received minimal pain medication: zero or one medication dose that day. Three days after surgery, two-thirds of the children still had significant pain, with 41 percent getting minimal medication, according to the study. The study authors speculated that under-medication could be due to parents' fears that their child will become addicted to medications such as Tylenol with codeine. Parents might also not realize how much pain their children are in, especially if the child is too young to communicate verbally. "There's a lot of nervousness on using pain medications," Goldschneider said. The study also found that parents with less education and with children who were "more reactive" were less likely to give pain medications, while parents with impulsive children were more likely to follow dosing instructions. Children may also just have trouble swallowing the pills, raising the issue of whether other "delivery systems," such as a patch, might be more useful, Cantwell said. "We need to educate parents on how to use these medications," Goldschneider said. A second study in the same issue of the journal found a 70 percent jump in venous thromboembolisms (VTEs) -- blood clots that usually occur in the veins of the legs -- diagnosed at children's hospitals between 2001 and 2007. In 2007, 58 cases of VTE per 10,000 hospital admissions were recorded, versus 34 per 10,000 in 2001. Almost two-thirds of the children had underlying medical conditions, most commonly cancer, the study found. The authors, from the University of Pennsylvania and the Children's Hospital of Philadelphia, could not say if the increase was the result of more actual cases or better detection.

Combo Therapies to Lower Cholesterol Don't Work

Despite their popularity, so-called "combination therapies" may not be the most effective treatment for high cholesterol, Canadian researchers report. In their review, the scientists analyzed data from 102 studies that tested combination therapies involving ezetimibe, niacin, bile acid sequestrants and omega-3 fatty acids. They concluded that there is little evidence to support the widespread use of combination therapies to lower cholesterol. The results of this comprehensive review of clinical studies are important, as lowering cholesterol has been shown to decrease the risk of heart attack and stroke, and more than 35 million Canadians and Americans are prescribed cholesterol-lowering drugs each year, according to a news release from the Ottawa Hospital Research Institute. In the new study, stroke specialist Dr. Mukul Sharma and colleagues from the Ottawa Hospital Research Institute and the University of Ottawa looked for evidence that supported the use of combination therapies vs. high-dose statin therapy. Although statins are the most commonly used class of cholesterol-lowering drugs, some people don't respond to the standard dose. For these people, statins are increasingly being prescribed at higher doses or in combination with other types of drugs, according to the report published online Sept. 1 in the Annals of Internal Medicine. "Our review shows that so far, there is not enough evidence to support the widespread use of combination therapies over high-dose statin therapy," Sharma said in the news release. "For most patients who don't respond to a low dose of statin, it would make sense to try a higher dose of statin before trying a combination therapy. If the high-dose statin does not work or is not well-tolerated, or if there are other special circumstances, a combination therapy may be a good option, but until more research is done, this is not recommended for most patients."

Pfizer to Pay Record Fine in Fraud Probe

In what it calls the largest health-care fraud settlement in U.S. history, the Justice Department said Wednesday that pharmaceutical giant Pfizer Inc. and a subsidiary have agreed to pay a $2.3 billion penalty for illegally promoting certain drugs. Those drugs included Bextra, part of a group of painkillers called Cox-2 inhibitors, which Pfizer pulled from the market in 2005 after reports of potential heart risks to patients. The other drugs were Geodon, an antipsychotic; Zyvox, an antibiotic; and Lyrica, an anti-epileptic drug, the Justice Department said in a news release. In each case, the Justice Department accused Pfizer of marketing the drugs for uses other than those approved by the U.S. Food and Drug Administration, a practice called "off-label" use. According to the news release, the Food, Drug and Cosmetic Act stipulates that a company must "specify the intended uses of a product in its new drug application to FDA. Once approved, the drug may not be marketed or promoted for so-called 'off-label' uses." Pfizer promoted Bextra for several uses and dosages not sanctioned by the FDA due to safety concerns, the Justice Department said. As part of the settlement, Pfizer also agreed to enter into a so-called "expansive corporate integrity agreement" with the Department of Health and Human Services' Office of Inspector General. That agreement calls for the establishment of "procedures and reviews" designed to prevent a similar occurrence, the agency said. "Today's landmark settlement is an example of the Department of Justice's ongoing and intensive efforts to protect the American public and recover funds for the federal treasury and the public from those who seek to earn a profit through fraud," Associate Attorney General Tom Perrelli said in the news release. Kathleen Sebelius, secretary of the Department of Health and Human Services, said: "The Department of Health and Human Services will continue to seek opportunities to work with its government partners to prosecute fraud wherever we can find it. But we will also look for new ways to prevent fraud before it happens. Health care is too important to let a single dollar go to waste." In a statement, Pfizer general counsel Amy W. Schulman said the agreement ends all "material pending matters" with the Justice Department. "This gives us a very important opportunity to put final closure on the universe of material open items involving our U.S.-based operations," she said, Bloomberg News reported.

Retail Medical Clinics Offer Quality Care: Study

Walk-in retail clinics staffed by nurse practitioners provide high-quality care for routine illnesses, a new study has found. Writing in the Sept. 1 issue of the Annals of Internal Medicine, study author Dr. Ateev Mehrotra said that retail clinics -- which are typically staffed by nurse practitioners and found in drug stores and other retail chain stores such as Target and Wal-Mart -- provide a good standard of care for sore throat, ear infections and urinary tract infections. Mehrotra is an assistant professor at the University of Pittsburgh School of Medicine and a policy analyst at Rand Health. "I'm interested in how we deliver new forms of health care," said Mehrotra, who compared data from retail clinics, doctors' offices, urgent care centers and hospital emergency departments. "There's been a lot of discussion about the quality and effectiveness of these clinics; I wanted to find out more. From the patients' perspective, their appeal is twofold. They're convenient and they provide significant cost savings." Retail clinics have become increasingly widespread in recent years. One such operation is CVS's MinuteClinic, the focus of Mehrotra's research. MinuteClinic staffers treat minor illnesses and injuries, and provide vaccinations and various health and wellness services. Customers can walk in without an appointment, and the clinics are open seven days a week. Most visits take no more than 15 minutes, and costs vary from $30 to $110, according to the MinuteClinic Web site. According to Mehrotra, one-third of Americans live within a 10-minute drive of a retail clinic, and more than 6,000 of these clinics are expected to open across the United States within five years. Surveys of patients who received care at retails clinics have been positive, he added. Mehrotra's research team analyzed information contained in insurance claims of 2,100 Minnesotans between 2005 and 2006. The study authors chose the three diagnoses because they made up a combined 40 percent of the clinics' caseload. Using various statistical tools, the researchers found that the standards of care in retail clinics in Minnesota were consistent with accepted medical guidelines for those ailments, including the frequency and type of lab tests performed and drugs prescribed. Treatment costs at the retail clinics were 30 percent to 40 percent lower than in physicians' offices and urgent care centers, and 80 percent lower than in emergency rooms. The researchers did not detect any significant misdiagnoses, Mehrotra said. "The increasing number of patients who receive care at retail clinics has fueled concerns about increased health care costs, greater rates of misdiagnosis, overuse of antibiotics, and decreased delivery of preventive care," Mehrotra and colleagues wrote in the study. "When we compared these aspects of care in retail clinics, physician offices, urgent care centers, and emergency departments, we found little evidence to support these concerns." Dr. Scott D. Hayworth, chief executive officer of Mount Kisco Medical Group in New York, one of the largest medical practices in the Northeast, remains unconvinced and is no fan of the retail clinic model. For one, physicians provide more comprehensive and expert care, and they know their patients' medical history, he said. "These [clinics] are clearly picking a few minor ailments, which tend to be less expensive to treat," said Hayworth, who has about 200 physicians on staff as well as nurse practitioners and physician assistants. "When you have more serious illnesses, you need more back-up," which drives up costs, he added. Nurse practitioners and physician assistants (PAs) are effective in traditional medical settings, where there are always supervising doctors, Hayworth said. But in a retail clinic, there is no supervising doctor present, he said, adding, "Say a sore throat turns out to be something more serious. A PA may miss that diagnosis." Mehrotra acknowledged that his study had several limitations. It was based entirely on data from one state. It looked at predominantly young, female, insured patients who were relatively healthy and affluent. And it focused on only three diagnoses. Still, Mehrotra said, his study provides evidence that retail clinics can offer a safe level of care and have a place in the health-care system.

Be wary of 'herbal Viagra'

After the medication Viagra was introduced in the late '90s, it quickly gained a reputation as an effective treatment for the condition. A number of nonprescription products claiming to be "herbal Viagra" soon followed. Many of these products contain unknown quantities of potent ingredients similar to those in prescription medications, which can cause dangerous side effects. Some actually contain the real drug that should be given by prescription only. Although the Food and Drug Administration has banned several of these products, including Viril-Ity-Power (VIP) Tabs, V.Max and Rhino Max, a number of other potentially dangerous erectile dysfunction remedies remain on the market.

Erectile dysfunction: A sign of heart disease?

Erectile dysfunction can be a wake-up call that you're at risk of heart disease. The same factors that contribute to heart disease can cause erectile dysfunction. Though erectile dysfunction is distressing, it isn't life threatening. But heart disease can be. Erectile dysfunction — trouble keeping an erection sufficient for sex — can be an early warning sign of heart disease. Understanding the connections between erectile dysfunction and heart health can help you recognize signs and symptoms of heart disease early on. Likewise, if you have heart disease, getting the right treatment can help you maintain or improve erectile function. Factors linked to heart disease that can cause erectile dysfunction include: Atherosclerosis. This damaging process reduces blood flow to your heart and contributes to coronary artery disease. It can also affect the blood vessels to the penis, causing erectile dysfunction. Conversely, if you're having trouble with erections, it could be a sign that your heart is also at risk. Medications. Some prescriptions that men take to protect their hearts can cause erectile dysfunction. Additionally, medications that are often prescribed for erectile dysfunction may not be safe when combined with certain heart medications. Depression and anxiety. Researchers have found a connection between depression, heart disease and erectile dysfunction. Feeling anxious can also lead to erectile dysfunction. If you have heart disease, you may worry that having sex could trigger a heart attack.

Small birth size linked to sleep problems later

Children who were born at a relatively small size may be more likely than their peers to have sleep difficulties, a new study suggests. The study, which included 289 8-year-olds born healthy and full-term, found that the lower the children's weight and length at birth, the greater their odds of having poor sleep or sleep disturbances such as sleep-related breathing problems or nightmares. What's more, mothers' prenatal drinking -- a habit that can impair fetal growth and development -- was linked to a greater risk of childhood sleep problems. It's possible that in some children, smaller birth size is a marker of alterations in nervous system development, which might affect the body's sleep regulation later in life, the researchers report in the journal Sleep. "We showed that even within children born healthy and at-term gestation, smaller body size at birth increases the risk for poor sleep," lead researcher Dr. Anu-Katriina Pesonen, of the University of Helsinki in Finland, told Reuters Health in an email. That does not mean, however, that every child born at a relatively small size is destined for sleep difficulties. For one, birth size is partially determined by genetics, and Pesonen said it's possible that the current findings do not pertain to newborns who are simply naturally on the smaller size. On the other hand, she said, factors that can impair normal fetal growth -- which, besides prenatal drinking, include prenatal smoking and high chronic stress levels -- may help set the stage for sleep problems later on. For their study, Pesonen and her colleagues had each child wear an actigraph -- a watch-like device that measures sleep and activity patterns -- for one week. Their parents also completed a standard questionnaire on childhood sleep disturbances. In general, the researchers found, the smaller a child was at birth, the greater the likelihood of sleep disturbances or low sleep efficiency. Sleep efficiency refers to a person's ability to fall asleep and stay asleep once the head hits the pillow. In this study, 26 children had low sleep efficiency -- spending roughly three-quarters or less of their time in bed actually asleep. The researchers also found an association between sleep problems and mothers' prenatal drinking, even at relatively moderate levels. Among children whose mothers had consumed more than one drink per week during pregnancy, the risks of short sleep duration -- less than 7.5 hours per night -- and low sleep efficiency were about three times higher compared with other children. Prenatal smoking was not linked to sleep problems. However, Pesonen's team notes, this could be because few mothers in the study said they had smoked during pregnancy, limiting the study's ability to find an association. For now, the researchers conclude, the findings suggest that even moderate levels of drinking during pregnancy, and birth size variations within the normal range, may affect children's sleep later on.

Pain Level May Predict Survival in Certain Cancer Patients

Higher levels of post-treatment pain in head and neck cancer patients appear to be associated with lower survival rates, U.S. researchers have found. Their study included 339 patients who provided information about their health and quality of life at diagnosis and three, six, nine and 12 months later. They also rated their post-treatment pain. "Pain was associated with age, general physical and mental health conditions, depressive symptoms, survival rate and recurrence within the first year," wrote Dr. Joseph Scharpf and colleagues at the University of Iowa. "The five-year survival rate was 81.8 percent for patients with low post-treatment pain and 65.1 percent for those with high pain. Post-treatment pain and tumor site were independent predictors of recurrence. Pain level, age and treatment modality were independent predictors of five-year survival," the researchers found. "The prevalence of post-treatment pain within the first year after diagnosis of head and neck cancer suggests that physicians are not adequately addressing this issue, even though pain is associated with health-related quality of life and recurrent disease," the study authors noted. "Appropriate monitoring can be accomplished through the routine collection of pain as the fifth vital sign," they said. "Proper treatment, including an initial workup for recurrent disease, should be provided using a comprehensive, multidisciplinary approach."

Worries May Worsen Peripheral Arterial Disease

Having a negative, inhibited personality may increase the risk of death among people with peripheral arterial disease (PAD), a Dutch study suggests. PAD occurs when plaque accumulates in arteries that supply blood to areas of the body other than the heart and brain. The study included 184 PAD patients, average age 64.8, in the Netherlands. They filled out a personality questionnaire designed to assess their distress, negativity and social inhibition. During four years of follow-up, 16 patients (8.7 percent) died. After adjusting for other factors, the researchers concluded that PAD patients with a distressed personality had a higher risk of death. "Preliminary evidence suggests that personality traits such as hostility may also be associated with the severity and progression of atherosclerosis [plaque buildup] in patients with PAD," wrote Annelies E. Aquarius, of Tilburg University, and colleagues. "Another potential individual risk factor in this context is the distressed personality type [type D]. Type D refers to the joint tendency to experience negative emotions and to inhibit self-expression in social interaction." The researchers said type D personality is associated with increased activation of the immune system and changes in the body's stress response system. "Inadequate self-management of chronic disease is a potential behavioral mechanism that may explain the relation between type D personality and poor prognosis in cardiovascular disease," they noted. Although patients with peripheral arterial disease often have multiple risk factors for cardiovascular events, the authors said these patients receive "suboptimal" secondary prevention. "In addition to improving awareness of the traditional medical risk factors in peripheral arterial disease, attention should be given to psychological factors that may have an adverse effect on the clinical course of peripheral arterial disease. The present findings show that screening for type D personality may be especially important in this context," they concluded.

Gays, Bisexuals Seek More Psych Services

Gays, lesbians and bisexuals are about twice as likely as heterosexuals to seek treatment for mental health issues or substance abuse, a U.S. study finds.

Researchers analyzed data from 2,074 people who took part in the large-scale California Health Interview Survey and found that 48.5 percent of gays, lesbians, bisexuals reported receiving mental health or substance abuse treatment in the past year, compared to 22.5 percent of heterosexuals.

The study also found that lesbian and bisexual women were most likely to receive treatment while heterosexual men were least likely.

"It is well known that health services utilization is greater among women generally. Here we have shown that minority sexual orientation is also an important consideration. Lesbians and bisexual women appear to be approximately twice as likely as heterosexual women to report having received recent treatment for mental health or substance use disorders," study author Susan Cochran said in a news release.

Greater exposure to discrimination, violence and other stressful life events may explain why gays, lesbians and bisexuals are more likely to seek treatment for these disorders, she said.

"The pervasive and historically rooted societal pathologizing of homosexuality may contribute to this propensity for treatment by construing homosexuality and issues associated with it as mental health problems," Cochran said.

Health Tip: Avoiding Shin Splints

Shin splints are fairly common among athletes and people engaging in other forms of strenuous exercise. The injury is characterized by pain and soreness running down the large bone in the lower leg.

The American Academy of Orthopaedic Surgeons offers this list of common risk factors for shin splints:

• Having foot abnormalities, such as flat feet or rigid arches.
• Jogging or running for exercise.
• Dancing strenuously.
• Training for the military.
• Suddenly increasing exercise, including intensity and duration.

VIAGRA is pills to treat erectile dysfunction

Generic Name: sildenafil (oral) (sil DEN uh fil)

Viagra relaxes muscles and increases blood flow to particular areas of the body.
Sildenafil under the name Viagra is used to treat erectile dysfunction (impotence) in men. Another brand of sildenafil is Revatio, which is used to treat pulmonary arterial hypertension and improve exercise capacity in men and women.
Viagra may also be used for other purposes not listed in this medication guide.