MedicalResearch.com: Medical Research Interviews

MedicalResearch.com
Hemodialysis research, author interviews, dialysis updates and information on chronic
kidney disease and end stage renal failure.
Editor: Marie Benz, MD
info@medicalresearch.com
September 8 2013
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Read more interviews on Hemodialysis.com

ICD Implantation and Cardiac Perforation Risk
MedicalResearch.com Interview with: Jonathan Hsu, MD, MAS
Cardiac Electrophysiology, Division of Cardiology
University of California, San Diego (UCSD)
• MedicalResearch.com: What are the main findings of the study?
• Dr. Hsu: We found that the prevalence of cardiac perforation during modern day ICD implantation is 0.14%.
• We also found that specific patient and implanter characteristics predict cardiac perforation risk: older age, female sex, left
bundle branch block, worsened heart failure class, higher left ventricular ejection fraction, and non-single chamber ICD
implant are associated with a greater odds of perforation, whereas atrial fibrillation, diabetes, previous cardiac bypass
surgery, and higher implanter procedural volume are associated with a lower odds of perforation.
• It appears that cardiac perforation from ICD implantation is associated with a substantially increased risk of other major in-
hospital complications, prolonged hospitalization, and death.
• In this large, national sample of first-time ICD recipients, cardiac perforation occurred in 625 out of 440,251 patients
(0.14%). We identified several patient and implanter characteristics that predicted cardiac perforation risk. After
multivariable adjustment, older age, female sex, left bundle branch block, worsened heart failure class, higher left
ventricular ejection fraction, and non-single chamber ICD implant were associated with a greater odds of cardiac
perforation. Conversely, atrial fibrillation, diabetes, previous cardiac bypass surgery, and higher implanter procedural volume
were associated with a lower odds of perforation (all p values <0.05). Patients who experienced cardiac perforation had a
substantially increased risk of adverse events both before and after adjustment for potential confounders, including a
greater than 26-fold increased odds of any other associated major complication, 16-fold increased odds of prolonged
hospital stay > 3 days, and 15-fold increased odds of in-hospital death.
Read the rest of the interview on MedicalResearch.com

• MedicalResearch.com: Were any of the findings unexpected?
• Dr. Hsu: It was somewhat surprising that a higher LVEF was associated with an increased odds of cardiac
perforation. It is speculative to say that perhaps more forceful contractions of the heart muscle against
the lead tip may predispose to cardiac perforation. Therefore, more research in this area is necessary.
• MedicalResearch.com: What should clinicians and patients take away from this study?
• Dr. Hsu: Increased risks from cardiac perforation from ICD implantation have important ramifications
relevant to patients and practicing physicians, particularly as such major complications and longer hospital
stays likely adversely affect patient quality of life and translate into increased healthcare utilization and
costs. If indeed cardiac perforation is at the core of the majority of acute complications that occur in new
ICD implants and the lead characteristics influence that risk, these data may inform lead manufacturers to
be even more vigilant in assuring the safety of lead implant procedures. Additionally, knowledge that
cardiac perforation is associated with a considerably increased risk of adverse events may allow for more
aggressive treatment in those who experience the complication to avert further morbidity and
mortality. By distinguishing easily recognizable predictors of cardiac perforation identified in this study,
implanters may be better able to counsel patients regarding their risks, better able to quantify that risk,
and may alter their approach (such as placing fewer total leads) in those most vulnerable. Therefore our
study findings would be relevant to ICD implanters and patients undergoing this cardiovascular procedure.

• MedicalResearch.com: What further research do you recommend as a result of your study?
• Dr. Hsu: Further research into the mechanisms of novel predictors found to be associated
with cardiac perforation in our study is warranted, particularly regarding the association of
LBBB and increased LVEF with a higher cardiac perforation risk, as well as the association of
atrial fibrillation and diabetes with a lower cardiac perforation risk.
• Specifically, now that these covariates have been identified, other device registries as well as
prospective studies might consider special efforts to make sure these covariates are included
on case report forms.
• Citation:
• Cardiac Perforation From Implantable Cardioverter-Defibrillator Lead Placement: Insights
From the National Cardiovascular Data Registry
• Jonathan C. Hsu, Paul D. Varosy, Haikun Bao, Thomas A. Dewland, Jeptha P. Curtis, and
Gregory M. Marcus
• Circ Cardiovasc Qual Outcomes. 2013;CIRCOUTCOMES.113.000299published online before
print September 3 2013, doi:10.1161/CIRCOUTCOMES.113.000299

Cardiac Surgery: How Do Short Vacation Breaks by Surgeons Affect Patient Outcomes?
MedicalResearch.com Interview with:
Marco D. Huesch, MBBS, Ph.D.
Assistant professor at the USC Sol Price School of Public Policy
Adjunct professor with Duke’s School of Medicine and Fuqua School of Business.
• Answer: This study asked whether ‘learning by doing’ works backwards too, as
‘forgetting by not doing’. In an nutshell, the answer is ‘no’ among the Californian
cardiac surgeons I examined with short breaks of around a month.
• Answer: The noted British surgeon James Paget pointed out more than a century
ago that a physician “that ceases to gain knowledge is always losing it.” I
hypothesized that at the patient-level, having a surgeon who had not performed
cardiac bypass surgery in the calendar month before the month of the patient’s
operation, would be associated with slightly longer stays and slightly worse in-
hospital and 30-day mortality. However, this was not supported by my analysis of
nearly 60,000 patients over a three-year period in California.

Cardiac Surgery: How Do Short Vacation Breaks by Surgeons Affect Patient Outcomes?
Marco D. Huesch, MBBS, Ph.D.
Assistant professor at the USC Sol Price School of Public Policy
Adjunct professor with Duke’s School of Medicine and Fuqua School of Business.
• MedicalResearch.com: What should clinicians and patients take away from your report?
• Answer: My findings suggest that either down time does not have significant adverse impacts on surgeon
performance, or such down time has countervailing effects. In the latter interpretation, any adverse
impact on manual dexterity or familiarity with operating room team members through absence may be
balanced by the generally positive impacts of vacation time. In the former interpretation, well-practiced
technical and planning tasks retain their familiarity or may be quickly recovered on re-appearance in the
operating room. Those are both reassuring findings for patients and their clinicians, which ideally future
research can continue to confirm.
• MedicalResearch.com: What recommendations do you have for future research as a result of this study?
• Answer: There are many problems in healthcare that are complex to deal with; conversely there are many
more far simpler problems. If human capital – the degradable experience that a medical professional
builds through practice – actually decays in some noticeable way after breaks in practice, then this would
be a relatively simple and uncontroversial problem to deal with. Changes in staffing, in training, in
coverage and in scheduling could address such a problem relatively easily. Future research should build on
this small study of mine, and other studies (noticeably by Jason Hockenberry in Atlanta), to explore such
human capital dynamics and their effect on patient outcomes.
• Citation:
• Huesch, M. D. (2013), The Impact of Short Breaks From Cardiac Surgery on Mortality and Stay Length in
California. Journal for Healthcare Quality. doi: 10.1111/jhq.12018

Rhabdomyolysis: Risk Prediction Score for Kidney Failure or Mortality
Gearoid M. McMahon, MB, BCh
Renal Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston,
Massachusetts Framingham Heart Study, National Heart, Lung, and Blood Institute, and Center for Population Studies, Framingham,
• Answer: This study examined the incidence, causes and outcomes of rhabdomyolysis in two large
University Teaching hospitals. Rhabdomyolysis is a characterized by an increase in serum creatine
phosphokinase (CPK) and results from muscle damage from a variety of causes. The most important
complication of rhabdomyolysis is acute kidney injury which can result in a need for dialysis. Using a series
of laboratory and clinical variables that are readily available on admission, we constructed a risk score that
can predict with some accuracy the likelihood that a patient with rhabdomyolysis might die or need
dialysis during an admission. The final variables included in the model were age, gender, the cause of
rhabdomyolysis and the admission CPK, creatinine, phosphate, bicarbonate and calcium. One of the
advantages of this study was, because we had access to data from two institutions, we were able to derive
the risk score in one hospital and confirm its accuracy in the second institution.
•
MedicalResearch.com: Were any of the findings unexpected?
• Answer: In the past, it has been assumed that the degree of elevation of the CPK was a marker of severity
of muscle damage and was therefore the most important factor in determining prognosis. However, we
found that the initial CPK level was a poor predictor of outcomes. Instead, the most important
determinants of a poor outcome were advanced age, the cause of rhabdomyolysis and the admission
levels of phosphate and creatinine.

Rhabdomyolysis: Risk Prediction Score for Kidney Failure or Mortality
Gearoid M. McMahon, MB, BCh
Renal Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston,
Massachusetts Framingham Heart Study, National Heart, Lung, and Blood Institute, and Center for Population Studies, Framingham,
• Answer: Using the risk calculator, patients with rhabdomyolysis can be stratified on
admission into higher and lower risk categories. This could allow clinicians to be less
aggressive with therapy in lower risk patients and thus potentially reduce the cost of these
admissions.
• MedicalResearch.com: What recommendations do you have for future research as a result
of this study?
• Answer: Although this study was conducted in two institutions, these are large, tertiary
facilities and it is uncertain whether or not this risk score would definitely be applicable
outside this setting. It would be important validate the score in different settings – smaller
hospitals and in the community.
• Citation:
• A Risk Prediction Score for Kidney Failure or Mortality in Rhabdomyolysis
• Gearoid M. McMahon, MB, BCh; Xiaoxi Zeng, MD; Sushrut S. Waikar, MD, MPH
JAMA Intern Med. 2013;():-. doi:10.1001/jamainternmed.2013.9774.

Your Blood Pressure Affected by Spouse’s Social Network
MedicalResearch.com Interview with: Bert Uchino PhD
Department of Psychology and Health Psychology Program
University of Utah, Salt Lake City, Utah,
• Dr. Uchino: The main findings from our paper is that independent of one’s own social
network quality, the quality of a spouse’s social network was related to daily life ambulatory
blood pressure (ABP) levels. More specifically, the more supportive (positive) ties, and the
less aversive (negative) or ambivalent (both positive and negative) ties in a spouse’s social
network, the lower was one’s own ABP. In addition, looking at the social networks of
couples as a whole showed that couples who combined had more supportive ties and less
aversive or ambivalent ties showed lower ABP.
•
• Dr. Uchino: These findings were not unexpected given that prior work by researchers such as
Dr. Repetti at UCLA has shown that social interactions outside of the marriage can “spillover”
and create problems at home (e.g., negative mood, social withdrawal). However, it is the
only study that we know of that extends such processes to potential health outcomes given
that some of the differences that emerged met or exceeded cut-offs for “normal” ABP.

Your Blood Pressure Affected by Spouse’s Social Network
MedicalResearch.com Interview with: Bert Uchino PhD
Department of Psychology and Health Psychology Program
University of Utah, Salt Lake City, Utah,
• Dr. Uchino: There is now a large epidemiological literature showing that relationships quality can influence health-relevant
biological processes (e.g., blood pressure, inflammation) as well as mortality as shown by the recent meta-analysis by Dr.
Holt-Lunstad at Brigham Young University. Just as some physicians ask patients about their stress or depression levels and
the importance of managing it – similar issues can be asked about one’s relationships. For instance, it brings up the
possibility of screening patients and their spouses for the quality of their relationships. For patients, I believe that it
highlights the fact that the quality of our relationship has a real impact on how our body is functioning. It also underscores
the importance of taking time to cultivate our relationships and make time for those individuals who are truly sources of
support and perhaps minimize contact or try to resolve the more negative relationships in their lives.
• Dr. Uchino: This research has some overlap with the ideas of Dr. Christakis at Harvard University on social contagion. In his
seminal work, obesity is linked up to 2 to 3 degrees of network separation. It makes me wonder how far these relationship
quality influences on ABP extend along the social networks of our friends and family and so on. Similarly, do these
processes also influence the health trajectory of children whose parents have poor quality relationships? Finally, one of the
most pressing issues is to uncover the mechanisms responsible for these links. We discussed a few (e.g., emotional spillover,
defensive concern etc.) but future work will be needed to flush out these possibilities.
• Citation:
• The Quality of Spouses’ Social Networks Contributes to Each Other’s Cardiovascular Risk
Bert N. Uchino mail, Timothy W. Smith, McKenzie Carlisle, Wendy C. Birmingham, Kathleen C. Light
26 Jul 2013 PLoS ONE
doi:10.1371/journal.pone.0069809

Stuttering: What is the Natural History?
Professor Sheena Reilly PhD FASSA
Associate Director, Clinical and Public Health Research
Murdoch Childrens Research Institute Professor of Speech Pathology
Department of Paediatrics, University of Melbourn Royal Children’s Hospital
Flemington Road Parkville Victoria 3052 Australia
• Prof. Reilly: Stuttering was more common than previously thought. The cumulative incidence
of stuttering by four years old was 11%, which is more than twice what has previously been
reported. Developmental stuttering was associated with better language development, non-
verbal skills with no identifiable effect on the child’s mental health or temperament by four
years of age.
• Prof. Reilly: The two main findings that surpassed us were that so many in our study of over
1600 children, started to stutter (11%) by 4 years of age, yet very few of these had recovered
in the first 12 months after onset.
We were also surprised to find the children who had stuttered had better receptive and
expressive language skills.
• Prof. Reilly: Stuttering is very common in preschoolers. Children who stutter in the preschool
years perform well in many other developmental domains during this time.

Stuttering: What is the Natural History?
Professor Sheena Reilly PhD FASSA
Associate Director, Clinical and Public Health Research
Murdoch Childrens Research Institute Professor of Speech Pathology
Department of Paediatrics, University of Melbourn Royal Children’s Hospital
Flemington Road Parkville Victoria 3052 Australia
• MedicalResearch.com: What recommendations do you have for future research as a result of this
study?
• Prof. Reilly: First it would be great for someone to replicate our findings and second our goal is to
see if we can determine whether there are factors that help predict whether children recover from
or persist with stuttering
• Lead researcher, Professor Sheena Reilly said parents could be happy in knowing that they can take
a ‘watch and wait’ approach to their child’s stuttering. “Current best practice recommends waiting
for 12 months before commencing treatment, unless the child is distressed, there is parental
concern, or the child becomes reluctant to communicate. on these findings
there wasn’t any evidence that watching and waiting would do any harm to their child’s language
skills or social and emotional development” she said.
• Due to the low rates of recovery in the study, researchers were unable to determine what predicts
which kids will recover from stuttering, but say this will be the focus of research moving forward
• Citation:
• Natural History of Stuttering to 4 Years of Age: A Prospective Community-Based Study
Sheena Reilly, Mark Onslow, Ann Packman, Eileen Cini, Laura Conway, Obioha C. Ukoumunne, Edith
L. Bavin, Margot Prior, Patricia Eadie, Susan Block, and Melissa Wake
• Pediatrics peds.2012-3067; published ahead of print August 26, 2013, doi:10.1542/peds.2012-3067

ACL Injuries and Landing Strategies
Marc F. Norcross, PhD, ATC
Assistant Professor
School of Biological & Population Health Sciences, Exercise & Sport Science Program
College of Public Health and Human Sciences
Oregon State University Corvallis, OR 97331
• Dr. Norcross: In the scientific community, there remains considerable disagreement over which direction
of knee loading is most responsible for causing an anterior cruciate ligament (ACL) injury event. Many
researchers tend to fall into one of three “camps” in which they believe quadriceps loading (sagittal plane),
“knock-kneed” landing (frontal plane), or twisting (transverse plane) is the essential factor in the injury
mechanism. However, we know from cadaver studies that combined loading from all of these different
planes puts the most strain on the ACL. We found that men and women are equally likely to use a sagittal
plane landing strategy that we believe increases the risk for ACL injury. However, females were about 3.6
times more likely than males to use a higher risk frontal plane landing strategy. This suggests that the
increased likelihood of greater frontal plane loading in women coupled with the equal likelihood of using a
high-risk sagittal plane strategy is likely at least partly responsible for women’s 2-6 times greater risk for
ACL injury.
• Dr. Norcross: We expected that the same individuals who use a high-risk sagittal plane landing strategy
would also be the ones to use a high-risk frontal plane landing strategy. However, we did not find any
relationship between the sagittal and frontal plane landing strategies of individuals in this study. Given
our findings, we proposed that individuals at the greatest risk for ACL injury are likely to be the ones who
land using a high-risk sagittal plane and a high-risk frontal plane landing strategy. This is because the way
in which these individuals move is likely consistently placing greater combined loading on the ACL. So,
when they perform a difficult or very explosive task, it could result in an excessively high load that may
cause the ligament to fail.

ACL Injuries and Landing Strategies
Marc F. Norcross, PhD, ATC
Assistant Professor
School of Biological & Population Health Sciences, Exercise & Sport Science Program
College of Public Health and Human Sciences
Oregon State University Corvallis, OR 97331
Dr. Norcross: It is important to think about the total package related to landing technique and
not just one aspect like being “knock-kneed” or stiff.
of this study?
• Dr. Norcross: The use of currently available ACL injury intervention programs are a great way
to teach safer landing strategies and have been shown in controlled studies to reduce the risk
for ACL injury. However, in my opinion, we must improve the way in which these programs
are packaged so that there is widespread implementation by coaches and health care
professionals. Until we do so, I believe that we are going to continue to face an uphill battle
in reducing the ACL injury rate at the population level.
• Citation:
• Ankle-Dorsiflexion Range of Motion and Landing Biomechanics
Chun-Man Fong, LAT, ATC; J. Troy Blackburn, PhD, ATC; Marc F. Norcross, MA, ATC; Melanie
McGrath, PhD, ATC; Darin A. Padua, PhD, ATC

Female Physicians Continue to Earn Less than Male Physicians
Seth A. Seabury, PhD
Department of Emergency Medicine, University of Southern California, Los Angeles Leonard D. Schaeffer Center for Health Policy and
Economics, University of Southern California, Los Angeles
• Dr. Seabury: We studied the trends in the earnings of male and female physicians in the US from 1987-
2010 using nationally representative data from the Current Population Survey (CPS). We found that, while
the number of female physicians grew significantly, male physicians continue to have significantly higher
earnings than female physicians. The difference in the median earnings of male physicians compared to
female physicians actually increased from $33,840 in 1987-1990 to $56,019 in 2006-2010, though the
difference across years was not statistically significant. Our approach controlled for differences in hours
worked, so earnings gap was not driven by differences in work hours, though it could be explained by
other factors we did not observe in our data (e.g., specialty choice).
• Looking at other occupations in the US health care industry, the male-female earnings gap was smaller for
pharmacists and registered nurses and decreased over time, but was large and increased for physicians
assistants. On the other hand, our numbers indicate that outside of the health care industry, the male-
female earnings gap fell by more than 45%. Even though significant gender inequality persists across the
US, female physicians do not appear to have benefited from the relative gains that female workers outside
the health care industry have.
• Dr. Seabury: Other recent studies have indicated that earnings differences persist between male and
female physicians, so it wasn’t necessarily surprising that we found a gap from 2006-2010. However, the
size of the gap, and the fact that the gap had failed to close significantly in more than 20 years even
though earnings equality outside the health care industry has improved a great deal, was surprising to us.

Female Physicians Continue to Earn Less than Male Physicians
Seth A. Seabury, PhD
Department of Emergency Medicine, University of Southern California, Los Angeles Leonard D. Schaeffer Center for Health Policy and
Economics, University of Southern California, Los Angeles
• Dr. Seabury: While efforts to increase the number of female physicians have been at least
partially successful, the earnings of female physicians lag behind those of male physicians by
a significant margin, and there has been no improvement over the last 20+ years. While the
root cause of this inequality is unclear, more needs to be done to ensure that female
physicians receive equal opportunities for specialty choice and career advancement as do
male physicians.
• Citation:
• Seabury SA, Chandra A, Jena AB. Trends in the Earnings of Male and Female Health Care
Professionals in the United States, 1987 to 2010. JAMA Intern Med. 2013;():-.
doi:10.1001/jamainternmed.2013.8519.

HIV Prevention: Using Social Networking
Sean D. Young, PhD, MS
Assistant Professor In-Residence Center for Behavioral and Addiction Medicine Department of Family Medicine
University of California, Los Angeles
• Dr. Young: Here’s the main take-home point:
• There is a lot of excitement about the possibility of using technologies, big data, and mHealth
to improve health outcomes and change behavior. However,
• 1) little work has been done on this topic using sound research methods (for example, studies
have asked people to report whether a technology changed behavior rather than objectively
measuring whether it actually changed behavior.
• 2) technologies have not been shown to create sustainable behavior change (i.e., the effects
go away with time), and 3) it is unclear whether the people who really need to change
behavior and improve health would use these technologies as intended.
• Results are below. Study findings suggest that it is possible to use technologies to create
sustainable health behavior change, however, only if the approach integrates the science
behind how to change behavior. We validated that our approach combining behavioral
science and social media can create sustainable health behavior change.

• Press Release:
• Social Networking Technologies as an Emerging Tool for HIV Prevention: A Cluster
Randomized Trial
• Contact: Enrique Rivero (erivero@mednet.ucla.edu)
• Behavioral psychology + social media = A scientifically-proven approach to increase HIV
testing and prevention behaviors
• Technique may also apply to other diseases, prevention efforts
• Can social media and online communities be used to create sustainable health behavior
change?
• A new UCLA study published Sept. 3 in the peer reviewed journal Annals of Internal Medicine
finds that combining behavioral science with social media/online communities can lead to
sustainable health behavior change. The authors’ evidence-based approach for using social
media and online communities not only leads to increased HIV testing and encourages
significant behavior change among high risk groups, but also turns out to be one of the best
HIV-prevention and testing approaches on the Internet.

• And it’s not just applicable to HIV prevention efforts, said Sean D. Young, assistant professor of family medicine
and director of innovation for the center for behavior and addiction medicine at the David Geffen School of
Medicine at UCLA and the study’s lead investigator. We found similar effects for general health and well-being.
Because our approach combines behavioral psychology with social technologies, these methods might be used to
change health behaviors across a variety of diseases.
• The authors found that people in the study were highly engaged and maintained active participation in the study.
“Internet HIV prevention interventions and mobile health applications have had very high dropout rates and
problems getting people engaged, and this effect is even more pronounced among high-risk groups such as
minority populations and men who have sex with men,” Young said. “However, our approach appeared to
overcome these issues and changed behavior.”
• The study is published Sept. 3 in the peer reviewed journal Annals of Internal Medicine.
• A previous study published in February, also led by Young, found that social media could be useful in HIV and STD
prevention efforts by increasing conversations about HIV prevention.
• The researchers recruited 112 men who have sex with men either through banner ads placed on social networking sites such as
Facebook, through a Facebook fan page with study information, through banner ads and posts on Craigslist, and from venues such as
bars, schools, gyms and community organizations in Los Angeles. Of the participants, 60 percent were African American, 28 percent
were Latino, 11 percent were white and 2 percent were Asian.
• Each was randomly assigned to either an HIV group or a general health group on Facebook, the latter serving as the control, and then
randomly assigned to two peer leaders within their groups. Participants were under no obligation to engage with peer leaders or other
participants or to even remain members of their respective Facebook groups. They were also allowed to adjust their Facebook settings
in order to control the amount of personal information they shared with other group members.
• Throughout the study, participants were able to request and receive home-based HIV self-testing kits. At baseline and again at 12
weeks, participants completed a 92-item survey that included questions about Internet and social media usage, including their use to
discuss health and sexual risk behaviors; general health behavior like exercise and nutrition; and sex and sexual health behaviors
including HIV testing and treatment. Among other things, the researchers looked for evidence of behavior change, such as reduction of
sexual partners, and requests for home-based HIV test kits with follow-ups to obtain test results.

• Among the findings:
• 95 percent of the intervention participants voluntarily communicated on Facebook, along with 73 percent of the controls
• 44 percent (25 of 57) of the intervention group requested the testing kits, compared with 20 percent (11 of 55) of the
controls
• Nine of the 57 intervention group participants took and mailed back the test kits to receive their results, compared with 2 of
the 55 control group members, suggesting a greater likelihood that their approach can successfully lead one to take an HIV
test.
• The intervention group members chatted and sent personal messages with much higher frequency than did the control
group members
• African American and Latino men who have sex with men, who are at higher risk for becoming infected with HIV compared
with the rest of the population, find social networks to be an acceptable platform for HIV prevention
• African Americans and Latinos also find home-based tests to be an acceptable HIV testing method
• Retention at follow-up was more than 93 percent, in contrast to the high dropout rates from other Internet-based HIV-
prevention interventions.
• The researchers note some limitations to the study. Among them are that they used only two Facebook communities per
condition, meaning these methods should be tested with more people before implementing them . In addition, no best
practices regarding the use of social networking for HIV communication have been established.
• The next step will be to assess how this method might generalize to other populations, diseases, and prevention efforts,
Young said. “We have created a potential paradigm for health behavior change using new social technologies,” he said. “We
are beginning to explore this approach in other areas.”
• Study co-authors are William G. Cumberland, Sung-Jae Lee, Devan Jaganath, Greg Szekeres, and Thomas Coates, all of UCLA.
• Grants from The National Institute of Mental Health (K01 MH090884), the UCLA Center for HIV Identification, Prevention
and Treatment Services (CHIPTS), and the UCLA AIDS Institute funded this study.

Spontaneous Renal Artery Dissection: Characteristics, Course, Associations
Afshinnia, Farsad, M.D., M.S.
Research Fellow and Clinical Lecturer
Department of Nephrology
University of Michigan Health System
• Answer: Spontaneous Renal Artery Dissection (SRAD) is most commonly observed in middle
aged individuals. Although SRAD can have no association with other comorbidities at the
time of presentation, we have noticed association with a number of systemic disorders such
as hypertension, cancer, congestive heart failure, and rheumatologic diseases. In particular
clustering of Fibromascular dysplasia (FMD), Ehlers-Danlos syndrome, poly arteritis nodosa,
Poland syndrome, and nail patella syndrome in our patients has been striking. The most
commonly observed presenting symptom is sudden onset severe flank pain which may be
spontaneous or following physical stress. Other presenting features may include uncontrolled
hypertension, groin and/or testicular pain, headache, nausea, vomiting, fever, dysuria,
hematuria and blurry vision.
• Answer: Association with a cluster of systemic disorders in our observation was quite
unexpected and striking. Although uncontrolled hypertension at presentation may be
reflection of pain or Renin-Angiotensin-Aldosterone System (RAAS) activation due to
disrupted renal blood flow, history of longstanding hypertension even prior to dissection may
reflect underlying vascular disorders such as FMD.

Spontaneous Renal Artery Dissection: Characteristics, Course, Associations
Afshinnia, Farsad, M.D., M.S.
Research Fellow and Clinical Lecturer
Department of Nephrology
University of Michigan Health System
• Answer: For patients: If sudden onset severe unremitting flank pain is experienced patients should
seek urgent medical attention. Upon confirmation of SRAD, avoidance of strenuous physical
activities such as heavy weight lifting is advised as recurrence of SRAD is not uncommon. Control of
hypertension as a modifiable risk factor may protect against recurrence of SRAD.
• For physicians: Radiographic imaging should confirm the diagnosis once SRAD is suspected.
Confirmation is made by conventional renal artery angiography, CT angiogram or Magnetic
Resonance Angiography (MRA). Presence of SRAD should draw physician’s attention to possible
presence of other systemic disorders, and initiation of appropriate work up. Treatment options
include supportive medical treatment (such as control of pain, blood pressure, management of
coexistent symptoms ± anticoagulation), endovascular radiographic interventions (such as stenting),
and surgical repair (including vascular reconstruction, anastomosis, and nephrectomy). Choice of
therapy is individualized and is determined by severity and extent of dissection. Long term
prognosis is a function of underlying comorbid conditions, although with appropriate medical or
surgical management, long-term clinical outcome may appear favorable.
study?
• Answer: SRAD may present sporadically. It may also be complication of other rare diseases. Our
study besides several other case series and reports has suggested some of these rare diseases.
However, foundation of consortium of SRAD allowing global registry of this entity may provide
opportunity for its better understanding by shedding more light to its hidden aspects.

Postmenopausal Women: Impact Brisk Walking
Pascale Mauriège, PhD, Division of Kinesiology
PEPS, Room 2148, Laval University, Québec, Canada G1K 7P4
Answer:
• 1) The impact of a 4-month brisk walking program (3 sessions/week of 45-min walking at
60% of heart rate reserve) on postmenopausal moderately obese (BMI=29-35 kg/m2)
women’s perceived health, and more particularly the perceived ideal weight and stress level.
• 2) The existence of a relationship between improvements in perceived ideal weight and fat
mass reduction in the walking group.
• 3) The lack of non respondents to our novel self-administered Short Perceived Health
Questionnaire (SPHQ) that was completed within 2-3 min by all participant.
• 4) The good reproductibility for five of six items of the SHPQ, and the validation of three
questions against generic tools.
• MedicalResearch.com: Were any of the findings unexpected ?
• Answer:
• The relationship between some items of perceived health and body composition, but also
the reliability, the reproductibility and the good acceptance of the SPHQ.

Postmenopausal Women: Impact Brisk Walking
Pascale Mauriège, PhD, Division of Kinesiology
PEPS, Room 2148, Laval University, Québec, Canada G1K 7P4
• Answer:
• A brisk walking program exerts a favourable impact on cardiorespiratory fitness, and body composition (body weight and fat mass
losses, as well as waist girth reduction), but also on perceived health. Although being less studied, this aspect is of importance as it is
related to wellness’ participants.
• Our data may encourage patients to engage in a brisk walking program, because of their multiple effects (physiological, morphological
and psychological).
• Furthermore, brisk walking is the most common feasible form of aerobic exercise for middle-aged women because of its safety (low risk
of injuries), popularity (low cost) and accessibility to all public.
• In summary, a brisk walking program increases fitness and wellness in postmenopausal women.
• Answer:
• Additional studies are needed
• to more accurately examine the relationships between changes in perceived health and those in body fatness and/or cardiorespiratory
fitness after endurance training.
• to continue the validation of the SPHQ agains other generic tools
• to extend the SHPQ to the overall population (as for example, premenopausal women, men, and individuals of non French origin).
• Citation:
• Impact of brisk walking on perceived health evaluated by a novel short questionnaire in sedentary and moderately obese
postmenopausal women.
• Garnier S, Gaubert I, Joffroy S, Auneau G, Mauriège P.
• From the 1Faculty of Sport Sciences and Human Kinetics, Université P. Sabatier, Toulouse, France; and 2Fédération Française
d’Éducation Physique et de Gymnastique Volontaire, Paris, France.
Menopause. 2013 Feb 4. [Epub ahead of print]

CVD Risk: Metabolic Health, not BMI, determined risk in young women
Dr Søren Skøtt Andersen and Dr Michelle Schmiegelow
Study done in collaboration between Roskilde University Hospital
and Gentofte University Hospital in Denmark
• Answer: The main finding of this study of young women was that a body mass index above or
equal to 25 kg/m2 in metabolically healthy women was not associated with an increased risk
of cardiovascular events (myocardial infarction or ischemic stroke) within 5 years of follow-
up. A BMI >= 25 kg/m2 in women with any metabolic disorder was associated with a 4-fold
significant increased risk of the end-point. As increasing BMI is strongly associated with risk
of developing metabolic disorders, the key message of this study is to stress the importance
of preventing the development of metabolic disorders in overweight/obese women during
this possible “window of opportunity”.
• Answer: We found it somewhat surprising that we were able to prove an association
between metabolic unhealth and risk of cardiovascular events in a population of women as
young as ours (median age only 31 years) within only 5 years of follow-up.

CVD Risk: Metabolic Health, not BMI, determined risk in young women
Dr Søren Skøtt Andersen and Dr Michelle Schmiegelow
Study done in collaboration between Roskilde University Hospital
and Gentofte University Hospital in Denmark
• MedicalResearch.com: What should clinicians and patients take away from this study?
• Answer: We hope that these results will raise awareness of the importance for clinicians to
motivate overweight/obese young women to change their lifestyle (dietary habits, physical
activity etc) in order to prevent the development of metabolic disorders and this advice
should be offered at a young age.
• MedicalResearch.com: What further research do you recommend as a result of your study?
• Answer: The findings of our study should be investigated in other populations such as men,
and more elderly populations.
• Press Release:
• Metabolically healthy women have same CVD risk regardless of BMI
• Topics: Cardiovascular Disease Prevention – Risk Assessment and Management

Acute Pericarditis: Study of Colchicine for Treatment and Prevention
MedicalResearch.com Interview with:Massimo Imazio, MD, FESC
Dipartimento di Cardiologia/Cardiology Department
Maria Vittoria Hospital-ASLTO2
via Cibrario 72 10141 Torino, Italy
• Dr. Imazio: In a multicenter, double-blind trial, eligible adults with acute pericarditis
(idiopathic/viral, post-pericardiotomy syndromes and pericarditis related to a systemic
inflammatory disease) were randomly assigned to receive either colchicine (at a dose of 0.5 mg
twice daily for 3 months for patients weighing >70 kg or 0.5 mg once daily for patients weighing ≤70
kg) or placebo in addition to conventional anti-inflammatory therapy with aspirin or ibuprofen. The
primary study outcome was incessant or recurrent pericarditis.
• After a mean follow-up of 22 months (minimum 18 months) the primary outcome occurred in 20
patients (16.7%) in the colchicine group and 45 patients (37.5%) in the placebo group (relative risk
reduction in the colchicine group, 0.56; 95% confidence interval, 0.30 to 0.72; number needed to
treat, 4; P<0.001).
• Dr. Imazio: Colchicine is able to halve recurrences also in the setting of acute pericarditis as well as
after a first recurrence of pericarditis (CORP trial result. Annals of Internal Medicine 2011).
Moreover colchicine may also reduce pericarditis-related hospitalizations and may contribute to
reduce management costs.
• Dr. Imazio: Most treatments are empirical in the setting of pericarditis. At present, colchicine is the
most studied drug in this field, and we have enough evidence (an open label randomised trial, the
COPE trial and a multicenter double blind randomised trial-present ICAP study), in my view, to
support its use in acute pericarditis (first episode) as well as for the first recurrence of pericarditis
after the index attack as supported by the previously published CORP trial.

Acute Pericarditis: Study of Colchicine for Treatment and Prevention
MedicalResearch.com Interview with:Massimo Imazio, MD, FESC
Dipartimento di Cardiologia/Cardiology Department
Maria Vittoria Hospital-ASLTO2
via Cibrario 72 10141 Torino, Italy
• Dr. Imazio: We still need additional evidence in patients with multiple recurrences but data from the CORP-2 trial will be available soon
next year and will address this remaining issue.
• The best treatment length is unknown and we may speculate that longer treatments (>3 months) may further reduce the proportion of
recurrences during follow-up. Additional research may be needed on this issue.
• Moreover we need basic research to better address the mechanism of colchicine action in acute and recurrent pericarditis.
• Current guidelines recommend colchicine doses of 2 mg per day for 1 to 2 days, followed by a maintenance dose of 1 mg per day
18. However, lower doses may improve patient compliance and be equally efficacious.
• The COPE, CORE, and CORP trials used a maintenance dose of 0.5 mg
twice daily, which was reduced to 0.5 mg daily in patients weighing less than 70 kg. In our study, a loading dose was not given, and
patients had similar side effects in the colchicine and placebo
groups, a finding that supports the use of a weight-adjusted maintenance dose without any loading dose.
•
• As final comments, I would like to add that a number of limitations of our study should be considered. Our findings might not be
generalizable to other clinical conditions or other patient
populations; in this regard, we excluded patients with elevated levels of aminotransferases, creatinine, or troponin and those with liver
disease, myopathy, blood dyscrasias, or inflammatory
bowel disease. Our results should not be applied to women who are pregnant or lactating or to children. We also excluded patients with
bacterial or neoplastic pericarditis.
• Of note, colchicine is not approved for the prevention of recurrent pericarditis in North America or Europe, and its use as such is off-
label. Our limited sample size might have precluded the identification of rare adverse effects.
• Citation:
• Massimo Imazio, M.D., Antonio Brucato, M.D., Roberto Cemin, M.D., Stefania Ferrua, M.D., Stefano Maggiolini, M.D., Federico Beqaraj,
M.D., Daniela Demarie, M.D., Davide Forno, M.D., Silvia Ferro, M.D., Silvia Maestroni, M.D., Riccardo Belli, M.D., Rita Trinchero, M.D.,
David H. Spodick, M.D., and Yehuda Adler, M.D. for the ICAP Investigators
• NEJM: September 1, 2013DOI: 10.1056/NEJMoa1208536

Endocarditis: Hospitalizations and Mortality Trends
Behnood Bikdeli, MD
Yale/YNHH Center for Outcomes Research and Evaluation
One Church St, Suite 200 New Haven CT 0651
• MedicalResearch.com: What are the main findings of the study? 
• Dr. Bikdeli: We determined the trends in hospitalizations and mortality from endocarditis among US older adults from 1999
to 2010. Endocarditis is the most serious cardiovascular infection and our study that had a very large sample, signified the
high burden of endocarditis in this time period.
• Further, as a secondary question, we compared the trends in hospitalizations and outcomes before versus after 2007, a year
in which the American Heart Association (AHA) made a very radical change in its recommendations. The 2007 AHA
recommendations narrowed the indications for use of antibiotics to prevent endocarditis. Many people were concerned that
after such recommendations, the rates of endocarditis might increase remarkably. Our study did not show a consistent
increase in hospitalizations or outcomes after 2007. What is unique about our study is that we demonstrated these trends to
be consistent after adjustments for demographic changes over time. Moreover, we demonstrated that the adjusted
mortality rates did not show a consistent increase after 2007, when the AHA guidelines recommended restricted antibiotic
prophylaxis for endocarditis.
• MedicalResearch.com: Were any of the findings unexpected? 
• Dr. Bikdeli: Yes, in fact we observed a consistent decline in endocarditis hospitalization rates from 2006-2010. This
interesting finding warrants further investigation. One possible explanation could the concerted efforts that have been used
for reducing the rates of catheter-associated bloodstream infections.
• Another surprising finding was the consistently higher rates of endocarditis and worse outcomes for black patients. This
issue also requires more in-depth research.

Endocarditis: Hospitalizations and Mortality Trends
Behnood Bikdeli, MD
Yale/YNHH Center for Outcomes Research and Evaluation
One Church St, Suite 200 New Haven CT 0651
• MedicalResearch.com: What should clinicians and patients take away from your report? 
• Dr. Bikdeli: This is a very important question. We caution against under or over interpretations from our findings. First, as I said earlier,
our study shows that the burden of endocarditis among elderly Medicare beneficiaries is very high, with a third of patients dying one
year from diagnosis.
• Second, we did not observe a consistent increase in hospitalization rates after 2007, when the AHA recommended for restrictive use of
antibiotic prophylaxis. Our investigation was not a comparative effectiveness study to prove the non-inferiority of restrictive
prophylaxis. However, the trends that we observed, as well as a few studies from the US, UK, and France, do not show a change in
pattern of endocarditis hospitalizations after recommendations for restrictive antibiotic use.
• Clinicians should consider the risks and benefits of prophylaxis on a case-by-case basis and should share the information with their
patients for appropriate decision making. My personal opinion is that widespread antibiotic prophylaxis would not have a big beneficial
impact, and is not free from adverse effects. Nevertheless, there may be several instances in which antibiotic prophylaxis for
endocarditis is reasonable.
• Dr. Bikdeli: With regard to antibiotic prophylaxis for endocarditis, one would ideally want to see comparative effectiveness studies (e.g.
randomized controlled trials). However, widespread antibiotic prophylaxis, most probably, has a small effect size. Therefore, a
randomized trial to test its efficacy might require around 50,000 patients, make it extremely unlikely to happen in near future. What I
expect to be helpful is continued surveillance investigations, similar to our study. Also, we certainly need to further investigate better
therapeutic options for management of endocarditis, and would also need to address the disparities for high-risk subgroups, such as
blacks.
• Citation:
• Trends in Hospitalization Rates and Outcomes of Endocarditis among Medicare Beneficiaries
Behnood Bikdeli, MD; Yun Wang, PhD; Nancy Kim, MD, PhD; Mayur M. Desai, PhD, MPH; Vincent Quagliarello, MD; Harlan M.
Krumholz, MD, SM
• J Am Coll Cardiol. 2013;():. doi:10.1016/j.jacc.2013.07.071

Gestational Diabetes: Associated with Low Pre-Pregnancy Adiponectin Levels
Monique Hedderson, PhD
Research Scientist
Kaiser Permanente Northern California Oakland, CA 94612
• Dr. Hedderson: It is fascinating to discover that metabolic abnormalities appear to be
present, even years before pregnancy, in a large proportion of women who develop
gestational diabetes. The findings from this study emphasize the importance of the pre-
pregnancy period in future pregnancy outcomes.
• Dr. Hedderson: The magnitude of the findings were a surprise. Overweight or obese
women with lower than average levels of adiponectin were found to be seven times
more likely to develop the condition than women of average BMI with normal
adiponectin levels. It is rare to find an association that strong. We also found that
women who were normal weight but had lower than average levels of adiponectin had
a 3.5 fold increased risk of GDM. This is important because although we know obesity is
one of the strongest risk factors for GDM, less is known about risk factors among
normal weight women who develop GDM. It was also surprising that the association
between adiponectin and GDM risk was independent of other known risk factors for
GDM, including measures of insulin resistance. This suggests that it may be acting
through a unique mechanism.

Gestational Diabetes: Associated with Low Pre-Pregnancy Adiponectin Levels
Monique Hedderson, PhD
Research Scientist
Kaiser Permanente Northern California Oakland, CA 94612
• Dr. Hedderson: I think clinicians need to be aware of the importance of the pre-pregnancy period. With the current obesity
epidemic, more than 30% of women are entering pregnancy overweight or obese. We know know obesity is associated with
several pregnancy complications, including gestational diabetes, and most women retain excess weight after pregnancy.
There is a growing body of evidence to suggest that achieving a health body weight before pregnancy would reduce a
number of pregnancy complications, including gestational diabetes.
• Dr. Hedderson: There is scientific evidence that weight loss and certain dietary factors may increase adiponectin levels.
However, more research is needed to determine the best strategies to improve adiponectin levels. Lifestyle intervention
studies designed to prevent diabetes by decreasing dietary fat intake and increasing physical activity have been shown to be
extremely effective at reducing the risk of diabetes in at risk populations. It is likely that similar interventions in young,
reproductive aged women would be effective at reducing gestational diabetes, but more studies are needed to confirm the
effectiveness in younger populations.
Citation:
• Low Prepregnancy Adiponectin Concentrations Are Associated With a Marked Increase in Risk for Development of
Gestational Diabetes Mellitus
• Monique M. Hedderson, Jeanne Darbinian, Peter J. Havel, Charles P. Quesenberry, Sneha Sridhar, Samantha Ehrlich, and
Assiamira Ferrara
• Diabetes Care published ahead of print August 29, 2013, doi:10.2337/dc13-0389

Nerve Block after Surgery Reduced Narcotic Usage, Shortened Hospital Stays
Conor P. Delaney, MD MCh PhD FRCSI FACS FASCRS
The Jeffrey L. Ponsky Professor of Surgical Education | Chief, Division of Colorectal Surgery | Vice-Chair, Department of Surgery | Director,
CWRU Center for Skills and Simulation | Surgical Director, Digestive Health Institute | University Hospitals Case Medical Center | Case
Western Reserve University | 11100 Euclid Avenue Cleveland, OH 44106-5047
• Answer: Our goal was to see whether the transversus abdominis plane (TAP) block reduced complications and shortened the hospital
stay of patients undergoing colorectal operations. The TAP block is a nerve block injection given at the conclusion of the operation
which reduces pain in the operative area. Results showed that the mean hospital stay dropped to less than 2.5 days after the surgical
procedure, significantly lower than the 3.7 days which the University Hospitals Case Medical Center Care pathway had already
described for more than 1,000 consecutive patients. In our new study, we employed the TAP block and the Enhanced Recovery
Pathway (ERP) on 100 patients. We found that 27 patients went home the next day and another 35 went home 48 hours after their
operations. That is considerably better than the five or six days patients usually stay in the hospital after laparoscopic colorectal
procedures, and certainly better than nine days often seen after an open operation. With a third of patients leaving the day after
colorectal resection, we feel these results are significant.
• We also found that the TAP block allows patients to bypass or at least reduce the amount of narcotics they are often given after an
operation. Though narcotics can help reduce pain, these agents also can slow down recovery. The TAP block wears off just in time for
patients to skip the worst of the pain that occurs immediately after the operation, and the block does not appear to pose any significant
risks to patients.
• MedicalResearch.com:  Were any of the findings unexpected?
• Answer: The old thinking was that if patients went home early, they have a higher chance of readmission, but the data continue to
show that is not the case. Patients who went home earliest had the lowest readmission rate. Although my group has seen this in
previous studies, the new study affirms those findings. There were no mortalities, and patients who stayed longer in hospital tended to
have more complications.
• Of the eight patients with complications, such as urinary tract infections, gastrointestinal bleeds or small bowel obstructions, only two
of this group were discharged within 48 hours. Those patients who had complications or required a longer stay were probably more
high-risk patients anyway, because of advanced age or additional health conditions. Standardized criteria for discharge from hospital
also play an important role in these results.

Nerve Block after Surgery Reduced Narcotic Usage, Shortened Hospital Stays
Conor P. Delaney, MD MCh PhD FRCSI FACS FASCRS
The Jeffrey L. Ponsky Professor of Surgical Education | Chief, Division of Colorectal Surgery | Vice-Chair, Department of Surgery | Director,
CWRU Center for Skills and Simulation | Surgical Director, Digestive Health Institute | University Hospitals Case Medical Center | Case
Western Reserve University | 11100 Euclid Avenue Cleveland, OH 44106-5047
• Answer: I predict that Enhanced Recovery Pathways (ERP) will become standard practice for colorectal surgical patients in the next five
years, although some health care organizations are already using them to a variable extent. The ERP protocol counters traditional
conventions about how patients should prepare for, and recover from, colorectal operations. These standardized steps—which have
been shown to speed recovery and improve outcomes—include letting patients eat the day after the procedure instead of waiting
several days, encouraging them to walk around after procedures instead of staying in bed, optimizing analgesia, and controlling
intravenous fluid volumes.
• Using a TAP block to reduce hospital stay and narcotics use also has implications for reducing health care costs. In addition to the cost of
each day in hospital, painkillers and other medications for colorectal surgical patients can cost many hundreds of dollars for each
patient. The TAP block costs just $20 per patient. There are so many things we have to be careful of and cost is one of them. This is a
low cost way to help patients feel better and recover sooner.
• However, TAP blocks in the ERP protocol will require more evidence from further studies, such as a randomized clinical trial.
• Answer: The next step is a randomized clinical trial. In fact, my research team has already initiated a randomized double-blinded trial to
compare a group of colorectal surgical patients who receive the TAP block with another group who will not.
• If things continue to go well, my expectation is that we’ll eventually be giving the TAP to everyone, because it helps with reducing the
pain. As quality and outcomes improve, we will also continue to see an increasing percentage of patients who are fit to be discharged
the day after colorectal resection.
• Citation:
• Outcomes of Discharge after Elective Laparoscopic Colorectal Surgery with Transversus Abdominis Plane Blocks and Enhanced
Recovery Pathway
• Favuzza J, Delaney CP.
• Division of Colorectal Surgery, University Hospitals Case Medical Center, Cleveland, OH.
J Am Coll Surg. 2013 Sep;217(3):503-6. doi: 10.1016/j.jamcollsurg.2013.03.030. Epub 2013 Jun 28.

Mental Health Disorders and Risk of Shortened Lifespan
MedicalResearch.com Interview with: Arif Khan, MD
Medical Director, Northwest Clinical Research Center
Adjunct Professor of Psychiatry Duke University Medical Center and
Christine Khan, Psychiatric Nurse
Northwest Clinical Research Center Bellevue, WA 98007
• MedicalResearch.com: What are the main findings of your study?
• The original idea set in early 20th century that psychiatric patients discharged from mental hospitals had a shortened life span or faced
early death was supported by this analysis of psychiatric patients participating in research trials for new medications. There was no
increased risk of early death or shortened life span for participating in these research clinical trials.
• Life span shortening or increased risk of early death is highest among patients with schizophrenia, followed by patients with major
mood disorders such as Bipolar Mood Disorder and Major Depression.
• Such a decrease in life span or increased risk of early death not seen among patients with anxiety disorders and adult ADHD.
• 40% of increased early death risk was due to suicide among patients with schizophrenia and major mood disorders.
• Even after taking out the risk associated with suicide, the increased early death risk or shortened life span was two-fold or higher
among patients with schizophrenia and major mood disorders compared to general population and mostly due to heart attacks and
strokes and similar illnesses.
• This shortening of life span or an increase in early death could not be fully accounted for by poor medical care or ongoing severe
medical illnesses as such patients were not included in these research trials and good quality medical care was provided during trial
participation.
• There was definite evidence that treatment with medication compared to the placebo or ‘sugar pill’, if anything mitigated this risk of
early death or shortened life span, although the reason for such finding is unknown at present. The only exception was the class of
medications such as Elavil and Tofranil which are not commonly used nowadays.
• Lastly, it is likely that psychiatric illnesses are associated with inherent risk of brain, heart and other organ abnormalities and thus carry
serious risk of early death such as the risk seen in patients with high blood pressure or high cholesterol.
• Citation:
• Khan A, Faucett J, Morrison S, Brown WA. Comparative Mortality Risk in Adult Patients With Schizophrenia, Depression, Bipolar
Disorder, Anxiety Disorders, and Attention-Deficit/Hyperactivity Disorder Participating in Psychopharmacology Clinical Trials. JAMA
Psychiatry. 2013;():-. doi:10.1001/jamapsychiatry.2013.149.

Coronary Angiography: Vitamin C and Protection Against Contrast-Induced Kidney Disease
Umar Sadat, MD, PhD
Addenbrooke’s Hospital
Cambridge, United Kingdom
• Dr. Sadat: Vitamin C offers significant nephroprotection against contrast induced-acute kidney injury (CI-AKI) in patients undergoing coronary
angiography.
Patients receiving Vitamin C were observed to have 33% less risk of CI-AKI compared to those receiving placebo or other treatment.
• Dr. Sadat: The robustness of this meta-analysis was evident at every step, which though unexpected was very reassuring too. This makes the results
of this meta-analysis very reliable.
• Dr. Sadat: Although most clinical trials have investigated the use of N-acetylcysteine against CI-AKI, there is lack of convincing and consistent
evidence about its use. Although our meta analysis is the first ever pooled analysis of randomized controlled trials assessing nephroprotective role of
vitamin C against CI-AKI, the robustness of our meta analysis should encourage clinicians to use this pharmacological agent to protect against CI-AKI
in patients undergoing contrast media-enhanced radiological procedures, particularly in those with pre existing renal impairment.
• For patients, our results may be very reassuring and encouraging in that vitamin C can protect their kidneys from dye-induced kidney damage,
particularly when there is pre existing impairment of kidney functions.
• Dr. Sadat: Future studies should aim at investigating the underlying mechanisms involved in the nephroprotective role of vitamin C against CI-AKI.
• Our meta-analysis included patients who were undergoing coronary angiography. Future studies may include patients undergoing peripheral
angiography such as patients with peripheral vascular disease, or patients undergoing endovascular aortic procedures such as endovascular aortic
aneurysm repair (EVAR).
• All such future studies should be adequately powered and use validated biomarkers of renal injury, rather than use non-validated renal biomarkers-
changes in which may not translate into clinically relevant outcomes.
•
• Citation:
• Does ascorbic acid protect against contrast induced- acute kidney injury in patients undergoing coronary angiography – a systematic review with
meta-analysis of randomized controlled trials.
• Umar Sadat, MD, PhD; Ammara Usman, MB BS, MBA; Jonathan H. Gillard, MD, FRCR; Jonathan R. Boyle, MD, FRCS

Rheumatoid Arthritis: Nurse-Led Care Effectiveness and Patient Satisfaction
Mwidimi Ndosi, PhD, MSc, BSc (Hons), RN.
Academic & Clinical Unit for Musculoskeletal Nursing (ACUMeN)
Leeds Institute of Rheumatic and Musculoskeletal Medicine
University of Leeds England
• Answer: The aims of this study was to determine the clinical and cost-effectiveness of nurse-
led care for people with rheumatoid arthritis.
• The main findings were:
• (i) Patients seeing clinical nurse specialists for their rheumatoid arthritis follow-up care
do not get an inferior treatment.
(ii) Nurse-led care is safe and in some aspects presents added value to patients
(iii) Nurse-led care represents good value for money in terms of disease management
for people with RA.
• Answer: It was expected that nurse-led care would be associated with greater patient
satisfaction as this has been shown in other chronic diseases.
• It was however surprising to see that patients under nurse-led care saw greater improvement
in their disease activity, despite making fewer medication changes than rheumatologist-led
care.

Rheumatoid Arthritis: Nurse-Led Care Effectiveness and Patient Satisfaction
Mwidimi Ndosi, PhD, MSc, BSc (Hons), RN.
Academic & Clinical Unit for Musculoskeletal Nursing (ACUMeN)
Leeds Institute of Rheumatic and Musculoskeletal Medicine
University of Leeds England
• MedicalResearch.com: This was a pragmatic trial, assessing the effectiveness of an established practice in the UK and this
report provides a robust evidence of its effectiveness. Since in rheumatology, nurse-led care follows a ‘complementary
model’, patients are likely to get additional benefits and this model of care should be given a serious consideration in other
chronic conditions.
• Answer: Since the future of care for people with rheumatic diseases is likely to involve more multidisciplinary collaboration,
further research is should look into ways this model of care can achieve better outcomes with more efficiency in different
subgroups of patients.
• Citation:
• The outcome and cost-effectiveness of nurse-led care in people with rheumatoid arthritis: a multicentre randomised
controlled trial
• Mwidimi Ndosi, Martyn Lewis, Claire Hale, Helen Quinn, Sarah Ryan, Paul Emery,
Howard Bird, Jackie Hill
• Ann Rheum Dis annrheumdis-2013-203403Published Online First: 27 August 2013 doi:10.1136/annrheumdis-2013-203403

Type 2 Diabetes: Fruit and Fruit Juice Consumption
MEDICALRESEARCH.COM: INTERVIEW WITH: Qi Sun, MD ScD
Assistant Professor of Medicine
Channing Division of Network Medicine
Brigham and Women’s Hospital and Harvard Medical School, Assistant Professor
Department of Nutrition, Harvard School of Public Health , Boston, MA 02115
• MEDICALRESEARCH.COM: What are the main findings of the study?
• Response: We have three major findings.
• First, we found that total fruit consumption was consistently associated with lower risk of developing type 2 diabetes in these large
scale studies among U.S. men and women.
• Second, we found that different individual fruits were differentially associated with diabetes risk. For example, higher intakes of
blueberries, grapes or raisins, apples or pears are particularly associated with a lower diabetes risk.
• Last, we found that fruit juice was associated with a higher diabetes risk, and replacing fruit juices with whole fruits will likely lead to
reduced diabetes risk.
• MEDICALRESEARCH.COM: Were any of the findings unexpected?
• QS: One of the study hypotheses is that fruits with high glycemic index or glycemic load are less beneficial than fruits with lower values
of these indices. However, our data do not suggest that the glycemic properties of fruits play an important role in the associations with
diabetes.
• MEDICALRESEARCH.COM: What should clinicians and patients take away from your report?
• QS: Our findings endorse the recommendation on increasing whole fruits consumption, rather than fruit juices, in diabetes prevention.
However, whether patients of diabetes should also maintain or increase fruit consumption was not addressed in this study.
• MEDICALRESEARCH.COM: What recommendations do you have for future research as a result of this study?
• QS: Future studies are needed to shed light on the mechanisms underlying our findings that consumption of certain fruits is particularly
beneficial on lowering diabetes risk. For example, it is interesting to understand whether the polyphenol contents of a specific fruit
determine its association with diabetes risk. In addition, it is important to extend this research to other populations, such as diabetes
patients, and to other diseases, such as heart disease and cancer.
• Citation:
• Fruit consumption and risk of type 2 diabetes: results from three prospective longitudinal cohort studies
• Isao Muraki research fellow , Fumiaki Imamura investigator scientist , JoAnn E Manson professor of medicine , Frank B Hu professor of
nutrition and epidemiology , Walter C Willett professor of epidemiology and nutrition , Rob M van Dam associate professor ,
Qi Sun assistant professor
• BMJ 2013;347:f5001 doi: 10.1136/bmj.f5001

Diabetes Complicates Surgical Recovery
MedicalResearch.com Interview with: Ta-Liang Chen, MD, PhD
Graduate Institute of Clinical Medical Science,
China Medical University, Taichung, Taiwan
• Reply: Diabetes increases postoperative 30-day mortality, complications, and medical expenditures in patients undergoing
in-hospital noncardiac surgeries.
• Reply: Diabetes-related eye involvement, peripheral circulatory disorder, ketoacidosis, renal manifestations, and coma
complicated postoperative mortality.
• Reply: Perioperative assessment, high quality of care and family support are needed for this specific population. Medical
resources should be appropriately allocated to patients with diabetes and coexisting medical conditions when they undergo
noncardiac surgeries.
• Reply: Future researches need to investigate the impact of preoperative medication, and fasting glucose level on the adverse
events after non-cardiac surgeries.
• Citation:
• Adverse Outcomes After Noncardiac Surgery in Patients With Diabetes: A nationwide population-based retrospective cohort
study Diabetes Care published ahead of print August 29, 2013, doi:10.2337/dc13-0770
• Chun-Chieh Yeh, Chien-Chang Liao, Yi-Cheng Chang, Long-Bin Jeng, Horng-Ren Yang, Chun-Chuan Shih, and Ta-Liang Chen

Alzheimer Disease: Homozygous Genetic Loci Identified
MedicalResearch.com Interview with: Ekaterina Rogaeva, PhD
Tanz Centre for Research in Neurodegenerative Diseases, University of Toronto, Toronto, Ontario, Canada
Tanz Centre for Research in Neurodegenerative Diseases, University of Toronto, Toronto, Ontario, CanadaDepartment of Medicine
, University of Toronto, Toronto, Ontario, CanadaCambridge Institute for Medical Research and Department of Clinical Neurosciences,
University of Cambridge, Cambridge, England
• Answer: We tested the hypothesis that late-onset Alzheimer disease (AD) might be in part
explained by the homozygosity of unknown loci. In a genome-wide study of a Caribbean
Hispanic population with noticeable inbreeding and high risk of AD we assessed the presence
of long runs of homozygosity (ROHs) – regions where the alleles inherited from both parents
are identical. Our results suggest the existence of recessive AD loci, since the mean length of
the ROH per person was significantly longer in AD cases versus controls, and this association
was stronger in familial AD.
• The association of ROHs with AD could either reflect the cumulative risk effects of multiple
ROHs or the contribution of specific loci harboring recessive mutations in a subset of AD
patients. To address the latter possibility we identified overlapping ROH segments (consensus
regions) and calculated the case/control ratio for each of 1,415 consensus regions. The most
significant association with AD was observed for two genes: EXOC4, encoding a component
of the exocyst complex involved in the trafficking of the NMDA receptor; and CTNNA3,
encoding alpha catenin interacting with PSEN1 (known AD gene).
• Answer: Thus far, all known causal AD genes (APP, PSEN1 and PSEN2) are responsible for an
autosomal dominant inheritance of disease For the first time we showed that autosomal
recessive inheritance could also contribute to AD, when one copy of a mutant allele cause

Alzheimer Disease: Homozygous Genetic Loci Identified
MedicalResearch.com Interview with: Ekaterina Rogaeva, PhD
Tanz Centre for Research in Neurodegenerative Diseases, University of Toronto, Toronto, Ontario, Canada
Tanz Centre for Research in Neurodegenerative Diseases, University of Toronto, Toronto, Ontario, CanadaDepartment of Medicine
, University of Toronto, Toronto, Ontario, CanadaCambridge Institute for Medical Research and Department of Clinical Neurosciences,
University of Cambridge, Cambridge, England
• Answer: Knowledge about the genetics of AD is important to manage the challenges of aging
populations, since it is the most prevalent form of dementia. The results of our ROH-study is
especially important for clinicians assessing AD patients from regions where consanguineous
marriages are frequently practised (e.g. the Middle East) or from populations with a noticeable
degree of inbreeding (e.g. Caribbean Hispanics). Families with both history of AD and an inbred
background should be included in genetic studies to search for recessive defects as described
above.
study?
• Answer: Future studies would require the analysis of large independent and relatively inbred data
sets that might confirm the loci detected in our study and/or reveal novel recessive AD genes. In
order to characterize the molecular defects underlying AD, the first step is to conduct deep
sequencing of the top significant loci in a subset of samples with ROHs overlapping EXOC4 and
CTNNA3 loci, followed-up by segregation studies in AD families and the assessment of potential
pathological mutations in different ethnic groups.
• Citation:
• Evidence of Recessive Alzheimer Disease Loci in a Caribbean Hispanic Data Set Genome-wide
Survey of Runs of HomozygosityGhani M, Sato C, Lee JH, et al. Evidence of Recessive Alzheimer
Disease Loci in a Caribbean Hispanic Data Set: Genome-wide Survey of Runs of Homozygosity.
JAMA Neurol. 2013;():-. doi:10.1001/jamaneurol.2013.3545.

Breast Cancer Risk: Increased by Pre- First Pregnancy Alcohol Intake
MedicalResearch.com Interview with: Ying Liu, MD, PhD
Instructor, Division of Public Health Sciences
Department of Surgery
Washington University School of Medicine
St. Louis, MO 63110
• Answer: Alcohol intake between menarche (first menstrual period) and first pregnancy was consistently associated with
increased risks of breast cancer and proliferative benign breast disease. For every 10 gram/day alcohol intake (approximately
a drink a day) during this specific time period, the risk for breast cancer increased by 11% and the risk for proliferative
benign breast disease increased by 16%.
• Answer: The adverse effect of pre-pregnancy alcohol intake on breast cancer risk was stronger as the time period between
menarche and first pregnancy lengthened.
• Answer: Young women should reduce their alcohol drinking to less than one drink a day, especially during this critical time
period, as a key tool to reduce their breast cancer risk.
• Answer: Future work is needed to resolve what accounts for this association and what we could do to counteract the
adverse effect of pre-pregnancy drinking on breast cancer risk.
• Citation:
• Alcohol Intake Between Menarche and First Pregnancy: A Prospective Study of Breast Cancer Risk
Ying Liu, Graham A. Colditz,, Bernard Rosner, Catherine S. Berkey, Laura C. Collins, Stuart J. Schnitt, James L. Connolly, Wendy
Y. Chen, Walter C. Willett, and Rulla M. Tamimi
• Alcohol Intake Between Menarche and First Pregnancy: A Prospective Study of Breast Cancer Risk JNCI J Natl Cancer Inst first
published online August 28, 2013 doi:10.1093/jnci/djt213

Depression: Association with Low Physical Activity, Prolonged Sitting
Jannique van Uffelen, PhD, MSc (epidemiology),
MSc (human movement sciences), BHealth
Senior Research Fellow Active Ageing
INSTITUTE OF SPORT, EXERCISE & ACTIVE LIVING (ISEAL)
VICTORIA UNIVERSITY
• Answer: We examined the link between sitting-time and physical activity with current and future depressive symptoms in
8,950 mid aged women, who participated in the Australian Longitudinal Study on Women’s Health.
• Both high sitting-time and low physical activity levels were associated with higher risk of current depressive symptoms, and
in combination, the risk further increased. Compared with women sitting ≤4 hours/day and meeting the physical activity
recommendations of at least 150 minutes of moderate intensity activity per week, women who sat >7 hrs/day and who did
no physical activity were three times as likely to have depressive symptoms. However, only lack of physical activity was
associated with increased risk of future depressive symptoms, irrespective of sitting-time. Women who did no physical
activity were 26% more likely to have future depressive symptoms than women meeting physical activity recommendations.
• Depressive symptoms did not predict changes in sitting-time. However, compared with women without symptoms, women
with depressive symptoms were 20% less likely to increase their physical activity levels over time. This suggests a vicious
circle whereby inactive women are more likely to have future depressive symptoms and those with depressive symptoms
are less likely to increase their activity levels.
• Answer: An interesting finding in our study was that sitting-time was associated with current depressive symptoms, but not
with future symptoms. There are several potential explanations for this, which are described in more detail in the article. A
particularly interesting explanation is the potential of reverse causality. Fatigue and loss of energy are common depressive
symptoms and it could therefore be the case that, instead of high sitting-time causing depressive symptoms, depressive
symptoms cause high sitting-time. Although this seems to be a logical explanation, we did not find evidence for reverse
causation in our study.

Depression: Association with Low Physical Activity, Prolonged Sitting
Jannique van Uffelen, PhD, MSc (epidemiology),
MSc (human movement sciences), BHealth
Senior Research Fellow Active Ageing
INSTITUTE OF SPORT, EXERCISE & ACTIVE LIVING (ISEAL)
VICTORIA UNIVERSITY
• Answer: Based on the findings of our study, lifestyle interventions to alleviate current depressive symptoms and prevent
future symptoms should include strategies to increase activity levels commensurate with meeting the physical activity
recommendations for public health. These recommendations indicate that , to promote and maintain health, adults should
do a minimum of 30 minutes of moderate intensity aerobic activity on 5 days per week, or 20 minutes of vigorous intensity
aerobic activity on 3 days per week, or any combination of moderate and vigorous intensity activity to meet the minimum
activity level. Lifestyle interventions could also include strategies to reduce sitting-time to alleviate current symptoms, which
is in line with common practice to reduce behavioural inactivity in the treatment of depression.
• Answer: More prospective studies are needed to clarify the association between sitting-time and depressive symptoms over
time and to further examine the direction of the association. Furthermore, as there are indications that the association
between sedentary behaviour and mental health differs by domain, such as occupational sitting or leisure time sitting, the
link between domain specific sitting time and depressive symptoms is a direction for future research.
• For a 6 minute video cast of the paper, please see: http://www.scivee.tv/node/60419
•
• Citation:
• Sitting-Time, Physical Activity, and Depressive Symptoms in Mid-Aged Women
• Jannique G.Z. van Uffelen, Yolanda R. van Gellecum, Nicola W. Burton, Geeske Peeters, Kristiann C. Heesch, Wendy J. Brown
• American Journal of Preventive Medicine – September 2013 (Vol. 45, Issue 3, Pages 276-281, DOI:
10.1016/j.amepre.2013.04.009

Rheumatoid Arthritis: Are Two Drugs Better than One?
Dr. Janet E Pope
Division of Rheumatology, Department of Medicine
The University of Western Ontario, St Joseph’s Health Centre
268 Grosvenor Street, London, ON, Canada N6A 4V2
• Dr. Pope: We performed a RCT of patients who were stable for 6 months of etanercept
added to methotrexate (inadequate responders to Mtx) who were randomized to stopping
Mtx or continuing Mtx to determine if in the next 6 months (and later as the trial continues)
the response rate would be the same if Mtx was discontinued. Overall, Mtx + etanercept was
not statistically equivalent to etanercept alone (ie non-inferiority did not occur); implying 6
months after stopping Mtx, the etanercept patients on monotherapy performed slightly less
well than those on combination therapy.
• In a pre-specified subset analysis, both patients who started in lower DAS28; and/or were in a
low DAS28 at 6 months seemed to do equally well if Mtx was stopped or continued, but if not
in a low DAS28 at 6 months, stopping Mtx on average slightly worsened the DAS28.
• Dr. Pope: Yes and no. Most studies have shown that two drugs are better than one in RA. This
seems to be the case in the CAMEO trial, but if in a low disease state, this likely can be
maintained for at least another 6 months after Mtx is discontinued. We are looking at a
longer durability of response and drop out rate for those in each treatment group to see if in
the long term (as may be found in some registries), Mtx is better for less drop out over time.

Rheumatoid Arthritis: Are Two Drugs Better than One?
Dr. Janet E Pope
Division of Rheumatology, Department of Medicine
The University of Western Ontario, St Joseph’s Health Centre
268 Grosvenor Street, London, ON, Canada N6A 4V2
• Dr. Pope: If in a low disease state in RA with Mtx and etanercept, perhaps Mtx can be
stopped but if not in remission or a low disease state Mtx should not be stopped. We can’t
answer about lowering Mtx or lowering etanercept as that was not part of this study.
of this study?
• Dr. Pope: It would be interesting to answer the above questions (dose reduction of one drug
or the other) and we will look at retention in the study (both drop outs and maintaining
response) in the two groups for another 12 months and we have the pharmacogenomics on
the patients to determine if there are certain genes that predispose to more or less retention
for both treatment arms.
• Citation:
• The Canadian Methotrexate and Etanercept Outcome Study: a randomised trial of
discontinuing versus continuing methotrexate after 6 months of etanercept and
methotrexate therapy in rheumatoid arthritis Janet E Pope, Boulos Haraoui, J Carter Thorne,
Andrew Vieira, Melanie Poulin-Costello, Edward C Keystone
• Ann Rheum Dis annrheumdis-2013-203684Published Online First: 26 August 2013
doi:10.1136/annrheumdis-2013-203684

Pregnancy: Birth Defects Risks with Oral Fluconazole
Ms. Mølgaard-Nielsen
Statens Serum Institut
Copenhagen S, Denmark
• Answer: Use of oral fluconazole during early pregnancy did not increase the risk of birth
defects overall in common therapeutic doses. We also looked at 15 individual birth defects of
previous concern and oral fluconazole was not associated with an increased risk for 14 of
these birth defects. However, we did see an increase in the risk of tetralogy of Fallot, an
uncommon congenital heart defect, but the number of exposed cases was few.
• Answer: In 2011, the U.S. Food and Drug Administration, FDA, issued a warning on the
teratogenic risk associated with fluconazole based on birth defects seen in 5 infants whose
mothers had been treated with high- and long-term doses during pregnancy due to severe
fungal infections. Similar defects had been observed in animal studies. With the use of the
unique Danish national registries, we identified all pregnant women in Denmark in the period
1996-2011 and conducted the largest study ever examining the association between
fluconazole in common therapeutic doses and birth defects. Our findings were not
unexpected, but still, a large comprehensive study was necessary to address any concerns
that the teratogenic effects seen for high- and long term fluconazole doses translated into similar effects for common
therapeutic use.

Pregnancy: Birth Defects Risks with Oral Fluconazole
Ms. Mølgaard-Nielsen
Statens Serum Institut
Copenhagen S, Denmark
• Answer: Many pregnant women suffer from vaginal candidiasis, which is the most common
clinical indication for use of oral fluconazole. First-line treatment for vaginal candidiasis
during pregnancy is vaginal preparations of topical azole antifungal drugs because of their
minimal systemic absorption. However, in cases when topical treatment is ineffective this
study provides comprehensive safety information and may help inform clinical decisions
when treatment with oral fluconazole is considered in pregnancy. Furthermore, pregnant
women can be reassured since this study does not support a teratogenic effect of fluconazole
used in common therapeutic doses during pregnancy.
of this study?
• Answer: In our study, the increased risk of tetralogy of Fallot is based on only 7 cases born of
mothers using fluconazole, and we therefore suggest that this association needs to be
confirmed in another and preferably larger study before anything certain can be concluded.
• Citation:
• Use of Oral Fluconazole during Pregnancy and the Risk of Birth Defects
• Ditte Mølgaard-Nielsen, M.Sc., Björn Pasternak, M.D., Ph.D., and Anders Hviid, Dr.Med.Sci.
• N Engl J Med 2013; 369:830-839August 29, 2013DOI: 10.1056/NEJMoa1301066

Kaiser’s Hypertension Program Dramatically Improves Blood Pressure Control in Large Population
MedicalResearch.com Interview with: Dr. Marc Jaffe, MD
Clinical Leader, Kaiser Northern California Cardiovascular Risk Reduction Program
Clinical Leader, Kaiser National Integrated Cardiovascular Health (ICVH) Guideline Development Group
Associate Clinical Professor of Medicine, UCSF Endocrinology and Internal Medicine
Kaiser South San Francisco Medical Center South San Francisco, California 94080
• Dr. Jaffe: In 2001, we set out to improve blood pressure control in among Kaiser Permanente (KP) members in Northern
California, and we ended up creating one of the largest, community-based hypertension programs in the nation. The paper
published in JAMA explores how we combined a number of innovations, including a patient registry, single-pill combination
therapy drugs and more, to nearly double blood pressure control rates.
• If you had told us at the onset that blood pressure control among members would be more than 80 percent, and it was
actually almost 90 percent in 2011, we wouldn’t have believed you. These results are truly incredible. During the study
period, hypertension control increased by more than 35 percent from 43.6 percent to 80.4 percent in Kaiser Permanente
Northern California between 2001 and 2009. In contrast, the national mean control rate increased from 55.4 percent to 64.1
percent during that period.
• Dr. Jaffe: There is hope for patients with hypertension to get their blood pressure under control, especially if their health
care providers follow some of the steps outlined in our paper. This model is replicable, and we published this article in JAMA
so other hospitals and health systems could implement elements of this system that was so successful for us. Perhaps by
following these methods, clinicians can improve blood pressure control nationwide.
• Dr. Jaffe: We hope other hospitals and health systems will try out the elements that were successful for us with this program
as well as other strategies and report on their own results so the health care system as a whole can benefit.
• Citation:
• Jaffe MG, Lee GA, Young JD, Sidney S, Go AS. Improved Blood Pressure Control Associated With a Large-Scale
Hypertension Program. JAMA. 2013;310(7):699-705. doi:10.1001/jama.2013.108769.

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