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27-05-2012 | Article

Global medical news in review: May 20-26, 2012

Genetic testing does not inflate medical care

Genetic testing does not result in increased or inappropriate use of healthcare services, show study findings.

Robert Reid (Group Health Research Institute in Seattle, Washington) and colleagues offered 1599 adults with health insurance, aged 25-40 years, access to a multiplex genetic susceptibility test that produces information on the risk for eight different medical conditions. These included Type 2 diabetes, osteoporosis, coronary heart disease, hyperlipidemia, hypertension, lung cancer, colorectal cancer, and melanoma.

The researchers compared healthcare utilization over a 12-month period between those who completed a baseline survey but did not take up genetic testing (68.7%), those who visited the study website but chose not to be tested (17.8%), and those who took up the testing option (13.6%).

In those who were tested, risks for the eight conditions were increased 1.19- to 2.0-fold, relative to the usual risk seen in the general population.

However, uptake of physician visits, common medical tests, or procedures did not differ significantly among the three groups before or after testing.

"This study supports the supposition that multiplex genetic testing offers can be provided directly to the patients in such a way that use of health services is not inappropriately increased," write Reid et al in Genetics in Medicine.

Gluten levels can be reduced in celiac challenge

Significantly less gluten is required to induce a clinically measurable response in patients undergoing testing for celiac disease than previously thought, say US researchers.

Just 3 g per day for 2 weeks elicited gastrointestinal symptoms, duodenal changes, and increased antibody titers in most celiac patients who had previously been gluten-free, reports the team from Beth Israel Deaconess Medical Center in Boston, Massachusetts.

This compares with the standard gluten challenge of two servings a day for 8 weeks, which is unpopular with patients due to intolerable symptoms over the extended period of time, explain Daniel Leffler and co-workers.

The team randomly assigned 20 adults with biopsy-proven celiac disease, who had been gluten-free for at least 1 year, to receive 3.0 or 7.5 g of gluten daily for 2 weeks. The patients were examined at baseline and at 3, 7, 14, and 28 days after beginning the gluten challenge.

One patient was excluded from the trial due to a genetic profile not supportive of a celiac disease diagnosis. Of the 19 remaining patients in the study, 17 (89.5%) met the criteria for celiac disease diagnosis by the end of the 2-week gluten challenge.

Duodenal biopsy at baseline and day 14 demonstrated a significant decrease in the ratio of villous height to crypt depth (2.2 to 1.1), and a significant increase in the intraepithelial lymphocyte count (32.6 to 51.8 per 100 enterocytes).

Patients also experienced a marked increase in levels of antibodies against tissue transglutaminase and deamidated gliadin peptides between baseline and day 14, although this did not reach statistical significance. Levels continued to rise after the challenge was completed.

By day 3 of the study, patients reported a significant increase in gastrointestinal symptoms, such as diarrhea or fatigue, measured using the Celiac Symptom Index, and the Gastrointestinal Symptom Rating Scale. Symptoms returned to baseline values by day 28 of the study.

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Electronic or paper records, diabetes care quality is the same

Primary care practices that use electronic health records (EHRs) as opposed to paper-based methods do not necessarily provide improved quality of care for patients with diabetes, report researchers in the Annals of Family Medicine.

Jesse Crosson (Robert Wood Johnson Medical School, New Brunswick, New Jersey) and colleagues analyzed diabetes quality-of-care data from practices that participated in the Using Learner Teams for Reflective Adaptation (ULTRA) trial. Sixteen of the practices used EHRs and 26 used paper-based record-keeping systems. All practices had exclusively used either one or other of the systems for at least 1 year before the study began. The team assessed data collected at baseline, and at 1 and 2 years of follow-up.

Quality of diabetes care was evaluated by assessing adherence to chronic disease guidelines (issued by the US Preventive Services Task Force and the American Diabetes Association) in three areas of diabetes care: processes of care, treatment, and achievement of intermediate outcomes.

The researchers report that EHR use was not associated with improved adherence to guidelines compared with the use of paper records.

In fact, regression analysis showed that at 2 years of follow up, patients from practices with a paper-based versus EHR record system were a significant1.7 times as likely to have met outcome targets for glycated hemoglobin, low-density lipoprotein cholesterol, and blood pressure.

Each data collection showed that over half of patients were receiving recommended processes of care, but the improvements from baseline were not significant, and did not differ significantly between the electronic and paper record groups.

Similarly, adherence to treatment guidelines overall was significantly improved at 2 years of follow up compared with baseline, at 52% versus 44%, but rates of improvement did not differ between the two groups.

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Bed shortage? You're fit to go!

Surgeons adjust their discharge practices to accommodate the availability of beds and surgical schedules, potentially compromising the quality of care, US researchers believe.

"Discharge decisions are made with bed-capacity constraints in mind," commented Bruce Golden (University of Maryland, College Park), the study's lead author, in a press statement.

Golden and colleagues analyzed discharge data for the 2007 fiscal year at a large academic medical center. During this period 6470 surgical patients were admitted for a total of 35,478 days.

Using statistical modeling, Golden's team looked for factors that correlated with discharge practices.

The major factor was downstream bed utilization, which was positively albeit weakly correlated with discharge rates. In particular, when utilization increased above a threshold of 93%, the discharge rate also rose, report Golden et al in Health Care Management.

The proportion of patients who remained in hospital for at least 6 days was 48% when the recovery ward was not full (utilization <93%), but 43% when the ward was full (utilization >93%).

Other factors that influenced discharge rates were the patients' age, the type of surgery (elective or not), and bed utilization as a continuous rather than dichotomous variable.

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Another reason to lose sleep: cancer risk

Sleep-disordered breathing (SDB), or sleep apnea, is associated with an increased risk for cancer mortality, study findings show.

"Remarkably, the association was stronger in relative terms than that of SDB with mortality from all causes as well as that previously observed for cardiovascular mortality," say F Javier Niet (University of Wisconsin School of Medicine and Public Health, Madison) and colleagues.

Data on 1522 participants of the Wisconsin Sleep Cohort were studied. Of these, 222 had mild SDB (apnea-hypopnea index [AHI]=5 to 14.9 apnea and hypopnea events per hour of sleep), 84 had moderate SDB (AHI=15 to 29.9), and 59 had severe SDB (AHI=30 or a continuous positive airway pressure [CPAP] device present during sleep assessment).

Over a 22-year period, there were a total of 112 deaths, of which 50 were attributed to cancer, the most frequent being lung cancer (n=8).

After adjusting for age, gender, body mass index, and smoking, SDB showed a doseresponse relationship with cancer mortality.

Patients with mild SDB were 1.1 times more likely to die from cancer than individuals without SDB, while those with moderate and severe SDB were a respective 2.0 and 4.8 times more likely. This relationship persisted when patients treated with CPAP were excluded from analyses, Niet et al write in the American Journal of Respiratory and Critical Care Medicine.

The researchers note that the risk for cancer mortality also increased in line with hypoxemia index severity. Participants in the top hypoxemia index category (11.2% of the night at less than 90% oxygen saturation) had more than eight times the risk for cancer mortality of those in the lowest category (0.8% of the night at less than 90% oxygen saturation).

The researchers conclude that if their findings are validated in further clinical and population-based studies, "diagnosis and treatment of SDB in cancer patients may be indicated to prolong survival in cancer patients."

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By Neil Osterweil