Reuters Health

(Reuters Health) - Some cancer patients may turn down care that could ease their pain and improve their quality of life because they think this type of "palliative" treatment amounts

to giving up and simply waiting to die, a small Canadian study suggests.

Even though the World Health Organization recommends early palliative care for patients living with any serious illness, negative attitudes among patients and family caregivers often lead them to reject this option, researchers note in the Canadian Medical Association Journal.

"Patients and caregivers in our study saw palliative care as being equated with death, loss of hope, dependency, and going into places you never get out of again," said lead study author Dr. Camilla Zimmermann, head of the division of palliative care at the University Health Network in Toronto.

"This is in stark contrast with the actual definition of palliative care, which is interdisciplinary care that provides quality of life for patients with any serious illness and their families, and that is provided throughout the course of the illness rather than only at the end of life," Zimmermann added by email.

Zimmermann and colleagues interviewed 48 cancer patients and 23 of their family caregivers in cases when life expectancy was six to 24 months.

The researchers randomly assigned 26 patients to receive palliative care in addition to standard cancer care, while another 22 patients had only standard care.

Twenty-two patients in the palliative care group and 20 in the control group were receiving chemotherapy.

Over four months, patients in the palliative care group had at least monthly palliative care clinic visits, while those in the standard care group didn't receive any formal interventions. Caregivers could attend clinic visits for the palliative care participants, but they weren't required to do so.

Patients were typically in their early to mid 60s. Most were married and had at least some education beyond high school.

Most family caregivers were spouses, but a few were children or other relatives.

Initial perceptions of palliative care were similar in both groups - patients generally thought this was done only for the dying. While patients in both groups thought of palliative care

as providing comfort, they also associated it with giving up on treatment.

Once some patients received palliative care, however, their thinking shifted. Some patients now saw this as a way to live life to the fullest despite the terminal diagnosis, while others

suggested that doctors might have better luck renaming this as something other than "palliative care."

Calling palliative care providers "pain specialists" because they treat discomfort and focus on quality of life would make this sound more appealing and less frightening, some patients

said after getting this type of care.

But in the control group, without any experience with palliative care during the study, patients didn't see the point of renaming it because they thought it would still carry the stigma of giving up and waiting to die.

"Palliative care should not be framed as a last resort option," said Dr. Anthony Caprio, a geriatrician and hospice and palliative medicine physician at Carolinas HealthCare System in

North Carolina.

"These `nothing left to do' conversations often frame palliative care as a way to help people die comfortably, rather than an approach to care that allows them to live with the highest quality of life for as long as possible," said Caprio, who wrote an editorial that was published with the study.

Using different language in discussions with patients can make a big difference, Caprio added.

"I often describe palliative care as an extra layer of support," Caprio said. "Who wouldn't want more support, especially during a difficult illness?"

(Reuters Health) - Some cancer patients may turn down care that could ease their pain and improve their quality of life because they think this type of "palliative" treatment amounts

to giving up and simply waiting to die, a small Canadian study suggests.

Even though the World Health Organization recommends early palliative care for patients living with any serious illness, negative attitudes among patients and family caregivers often lead them to reject this option, researchers note in the Canadian Medical Association Journal.

"Patients and caregivers in our study saw palliative care as being equated with death, loss of hope, dependency, and going into places you never get out of again," said lead study author Dr. Camilla Zimmermann, head of the division of palliative care at the University Health Network in Toronto.

"This is in stark contrast with the actual definition of palliative care, which is interdisciplinary care that provides quality of life for patients with any serious illness and their families, and that is provided throughout the course of the illness rather than only at the end of life," Zimmermann added by email.

Zimmermann and colleagues interviewed 48 cancer patients and 23 of their family caregivers in cases when life expectancy was six to 24 months.

The researchers randomly assigned 26 patients to receive palliative care in addition to standard cancer care, while another 22 patients had only standard care.

Twenty-two patients in the palliative care group and 20 in the control group were receiving chemotherapy.

Over four months, patients in the palliative care group had at least monthly palliative care clinic visits, while those in the standard care group didn't receive any formal interventions. Caregivers could attend clinic visits for the palliative care participants, but they weren't required to do so.

Patients were typically in their early to mid 60s. Most were married and had at least some education beyond high school.

Most family caregivers were spouses, but a few were children or other relatives.

Initial perceptions of palliative care were similar in both groups - patients generally thought this was done only for the dying. While patients in both groups thought of palliative care

as providing comfort, they also associated it with giving up on treatment.

Once some patients received palliative care, however, their thinking shifted. Some patients now saw this as a way to live life to the fullest despite the terminal diagnosis, while others

suggested that doctors might have better luck renaming this as something other than "palliative care."

Calling palliative care providers "pain specialists" because they treat discomfort and focus on quality of life would make this sound more appealing and less frightening, some patients

said after getting this type of care.

But in the control group, without any experience with palliative care during the study, patients didn't see the point of renaming it because they thought it would still carry the stigma of giving up and waiting to die.

"Palliative care should not be framed as a last resort option," said Dr. Anthony Caprio, a geriatrician and hospice and palliative medicine physician at Carolinas HealthCare System in

North Carolina.

"These `nothing left to do' conversations often frame palliative care as a way to help people die comfortably, rather than an approach to care that allows them to live with the highest quality of life for as long as possible," said Caprio, who wrote an editorial that was published with the study.

Using different language in discussions with patients can make a big difference, Caprio added.

"I often describe palliative care as an extra layer of support," Caprio said. "Who wouldn't want more support, especially during a difficult illness?"

(Reuters Health) - Some cancer patients may turn down care that could ease their pain and improve their quality of life because they think this type of "palliative" treatment amounts

to giving up and simply waiting to die, a small Canadian study suggests.

Even though the World Health Organization recommends early palliative care for patients living with any serious illness, negative attitudes among patients and family caregivers often lead them to reject this option, researchers note in the Canadian Medical Association Journal.

"Patients and caregivers in our study saw palliative care as being equated with death, loss of hope, dependency, and going into places you never get out of again," said lead study author Dr. Camilla Zimmermann, head of the division of palliative care at the University Health Network in Toronto.

"This is in stark contrast with the actual definition of palliative care, which is interdisciplinary care that provides quality of life for patients with any serious illness and their families, and that is provided throughout the course of the illness rather than only at the end of life," Zimmermann added by email.

Zimmermann and colleagues interviewed 48 cancer patients and 23 of their family caregivers in cases when life expectancy was six to 24 months.

The researchers randomly assigned 26 patients to receive palliative care in addition to standard cancer care, while another 22 patients had only standard care.

Twenty-two patients in the palliative care group and 20 in the control group were receiving chemotherapy.

Over four months, patients in the palliative care group had at least monthly palliative care clinic visits, while those in the standard care group didn't receive any formal interventions. Caregivers could attend clinic visits for the palliative care participants, but they weren't required to do so.

Patients were typically in their early to mid 60s. Most were married and had at least some education beyond high school.

Most family caregivers were spouses, but a few were children or other relatives.

Initial perceptions of palliative care were similar in both groups - patients generally thought this was done only for the dying. While patients in both groups thought of palliative care

as providing comfort, they also associated it with giving up on treatment.

Once some patients received palliative care, however, their thinking shifted. Some patients now saw this as a way to live life to the fullest despite the terminal diagnosis, while others

suggested that doctors might have better luck renaming this as something other than "palliative care."

Calling palliative care providers "pain specialists" because they treat discomfort and focus on quality of life would make this sound more appealing and less frightening, some patients

said after getting this type of care.

But in the control group, without any experience with palliative care during the study, patients didn't see the point of renaming it because they thought it would still carry the stigma of giving up and waiting to die.

"Palliative care should not be framed as a last resort option," said Dr. Anthony Caprio, a geriatrician and hospice and palliative medicine physician at Carolinas HealthCare System in

North Carolina.

"These `nothing left to do' conversations often frame palliative care as a way to help people die comfortably, rather than an approach to care that allows them to live with the highest quality of life for as long as possible," said Caprio, who wrote an editorial that was published with the study.

Using different language in discussions with patients can make a big difference, Caprio added.

"I often describe palliative care as an extra layer of support," Caprio said. "Who wouldn't want more support, especially during a difficult illness?"

NEW YORK (Reuters Health) - A breakfast rich in whey protein may help people with type 2 diabetes manage their illness better, new research from Israel suggests.

"Whey protein, a byproduct of cheese manufacturing, lowers postprandial glycemia more than other protein sources," said lead author Dr. Daniela Jakubowicz from Wolfson Medical Center at Tel Aviv University."

We found that in type 2 diabetes, increasing protein content at breakfast has a greater impact on weight loss, glycated hemoglobin (HbA1C), satiety and postprandial glycemia when the protein source is whey protein, compared with other protein sources, such as eggs, tuna and soy," she told Reuters Health by email.

Dr. Jakubowicz and her group presented their findings April 1 at ENDO 2016, the annual meeting of the Endocrine Society, in Boston.

They randomly assigned 48 overweight and obese patients with type 2 diabetes to one of three isocaloric diets. Over 12 weeks, everyone ate a large breakfast, a medium-sized lunch and a small dinner, but the amount and source of each group's breakfast proteins differed.

At breakfast, the 17 participants in the whey group ate 36 g of protein as part of a whey protein shake consisting of 40% carbohydrate, 40% protein and 20% fat. The 16 participants in the high-protein group ate 36 g of protein in the form of eggs, tuna and cheese (40% carbs; 40% protein; 20% fat). The 15 in the high-carbohydrate group ate 13 g of protein in ready-to-eat cereals (65% carbs; 15% protein; 20% fat).

All three diets included a 660 kcal breakfast, a 567 cal lunch and a 276 cal dinner, with the same composition at lunch and dinner.

After 12 weeks, the participants in the whey protein group lost the most weight (7.6 kg vs. 6.1 kg for participants in the high-protein group and 3.5 kg for those in the high-carbohydrate group (p<0.0001).

Participants on the whey protein diet were less hungry during the day and had lower glucose spikes after meals compared with those on the other two diets.

The drop in HbA1C was 11.5% in the whey group, 7.7% in the protein group and 4.6% in the carbohydrate group (p<0.0001). Compared with the carbohydrate group, the percentage drop in HbA1c was greater by 41% in the protein group and by 64% in the whey group (p<0.0001).

"Whey protein was consumed only at breakfast; however, the improvement of glucose, insulin and glucagon-like peptide 1 (GLP-1) was also observed after lunch and dinner. The mechanism of this persistent beneficial effect of whey protein needs further research," Dr. Jakubowicz said.

Co-author Dr. Julio Wainstein, also at Wolfson Medical Center, added by email, "Usually, patients with type 2 diabetes are treated with a combination of several antidiabetic drugs to achieve adequate glucose regulation and decrease HbA1c. Whey protein should be considered an important adjuvant in the management of type 2 diabetes."

"Furthermore," Dr. Wainstein added, "it is possible that by adding whey protein to the diet, glucose regulation might be achieved with less medication, which is a valuable advantage in type 2 diabetes treatment."

The study had no commercial funding, and the authors declared no conflicts of interest.

NEW YORK (Reuters Health) - A breakfast rich in whey protein may help people with type 2 diabetes manage their illness better, new research from Israel suggests.

"Whey protein, a byproduct of cheese manufacturing, lowers postprandial glycemia more than other protein sources," said lead author Dr. Daniela Jakubowicz from Wolfson Medical Center at Tel Aviv University."

We found that in type 2 diabetes, increasing protein content at breakfast has a greater impact on weight loss, glycated hemoglobin (HbA1C), satiety and postprandial glycemia when the protein source is whey protein, compared with other protein sources, such as eggs, tuna and soy," she told Reuters Health by email.

Dr. Jakubowicz and her group presented their findings April 1 at ENDO 2016, the annual meeting of the Endocrine Society, in Boston.

They randomly assigned 48 overweight and obese patients with type 2 diabetes to one of three isocaloric diets. Over 12 weeks, everyone ate a large breakfast, a medium-sized lunch and a small dinner, but the amount and source of each group's breakfast proteins differed.

At breakfast, the 17 participants in the whey group ate 36 g of protein as part of a whey protein shake consisting of 40% carbohydrate, 40% protein and 20% fat. The 16 participants in the high-protein group ate 36 g of protein in the form of eggs, tuna and cheese (40% carbs; 40% protein; 20% fat). The 15 in the high-carbohydrate group ate 13 g of protein in ready-to-eat cereals (65% carbs; 15% protein; 20% fat).

All three diets included a 660 kcal breakfast, a 567 cal lunch and a 276 cal dinner, with the same composition at lunch and dinner.

After 12 weeks, the participants in the whey protein group lost the most weight (7.6 kg vs. 6.1 kg for participants in the high-protein group and 3.5 kg for those in the high-carbohydrate group (p<0.0001).

Participants on the whey protein diet were less hungry during the day and had lower glucose spikes after meals compared with those on the other two diets.

The drop in HbA1C was 11.5% in the whey group, 7.7% in the protein group and 4.6% in the carbohydrate group (p<0.0001). Compared with the carbohydrate group, the percentage drop in HbA1c was greater by 41% in the protein group and by 64% in the whey group (p<0.0001).

"Whey protein was consumed only at breakfast; however, the improvement of glucose, insulin and glucagon-like peptide 1 (GLP-1) was also observed after lunch and dinner. The mechanism of this persistent beneficial effect of whey protein needs further research," Dr. Jakubowicz said.

Co-author Dr. Julio Wainstein, also at Wolfson Medical Center, added by email, "Usually, patients with type 2 diabetes are treated with a combination of several antidiabetic drugs to achieve adequate glucose regulation and decrease HbA1c. Whey protein should be considered an important adjuvant in the management of type 2 diabetes."

"Furthermore," Dr. Wainstein added, "it is possible that by adding whey protein to the diet, glucose regulation might be achieved with less medication, which is a valuable advantage in type 2 diabetes treatment."

The study had no commercial funding, and the authors declared no conflicts of interest.

NEW YORK (Reuters Health) - A breakfast rich in whey protein may help people with type 2 diabetes manage their illness better, new research from Israel suggests.

"Whey protein, a byproduct of cheese manufacturing, lowers postprandial glycemia more than other protein sources," said lead author Dr. Daniela Jakubowicz from Wolfson Medical Center at Tel Aviv University."

We found that in type 2 diabetes, increasing protein content at breakfast has a greater impact on weight loss, glycated hemoglobin (HbA1C), satiety and postprandial glycemia when the protein source is whey protein, compared with other protein sources, such as eggs, tuna and soy," she told Reuters Health by email.

Dr. Jakubowicz and her group presented their findings April 1 at ENDO 2016, the annual meeting of the Endocrine Society, in Boston.

They randomly assigned 48 overweight and obese patients with type 2 diabetes to one of three isocaloric diets. Over 12 weeks, everyone ate a large breakfast, a medium-sized lunch and a small dinner, but the amount and source of each group's breakfast proteins differed.

At breakfast, the 17 participants in the whey group ate 36 g of protein as part of a whey protein shake consisting of 40% carbohydrate, 40% protein and 20% fat. The 16 participants in the high-protein group ate 36 g of protein in the form of eggs, tuna and cheese (40% carbs; 40% protein; 20% fat). The 15 in the high-carbohydrate group ate 13 g of protein in ready-to-eat cereals (65% carbs; 15% protein; 20% fat).

All three diets included a 660 kcal breakfast, a 567 cal lunch and a 276 cal dinner, with the same composition at lunch and dinner.

After 12 weeks, the participants in the whey protein group lost the most weight (7.6 kg vs. 6.1 kg for participants in the high-protein group and 3.5 kg for those in the high-carbohydrate group (p<0.0001).

Participants on the whey protein diet were less hungry during the day and had lower glucose spikes after meals compared with those on the other two diets.

The drop in HbA1C was 11.5% in the whey group, 7.7% in the protein group and 4.6% in the carbohydrate group (p<0.0001). Compared with the carbohydrate group, the percentage drop in HbA1c was greater by 41% in the protein group and by 64% in the whey group (p<0.0001).

"Whey protein was consumed only at breakfast; however, the improvement of glucose, insulin and glucagon-like peptide 1 (GLP-1) was also observed after lunch and dinner. The mechanism of this persistent beneficial effect of whey protein needs further research," Dr. Jakubowicz said.

Co-author Dr. Julio Wainstein, also at Wolfson Medical Center, added by email, "Usually, patients with type 2 diabetes are treated with a combination of several antidiabetic drugs to achieve adequate glucose regulation and decrease HbA1c. Whey protein should be considered an important adjuvant in the management of type 2 diabetes."

"Furthermore," Dr. Wainstein added, "it is possible that by adding whey protein to the diet, glucose regulation might be achieved with less medication, which is a valuable advantage in type 2 diabetes treatment."

The study had no commercial funding, and the authors declared no conflicts of interest.

NEW YORK (Reuters Health) - Low-income adults in the U.S. likely benefited if their states expanded Medicaid in 2014 under the Affordable Care Act, suggests a new study.

Researchers found increased rates of insurance coverage, healthcare use, and chronic disease diagnoses among low-income adults in states that expanded access to the government-funded health insurance program.

"It looks like there is better medical care for these adults," said lead author Dr. Laura Wherry, of the David Geffen School of Medicine at the University of California, Los Angeles.

A key provision of the Affordable Care Act (ACA), sometimes referred to as Obamacare, was to force states to expand their Medicaid programs by 2014. But with a Supreme Court decision allowing states to opt out of the expansion, only 26 states actually expanded their Medicaid programs.

For the new study, the researchers analyzed 2010-2014 survey data collected from low-income U.S. adults ages 19 to 64.

In the pre-expansion era, from 2010-2013, about 33% had no insurance in states that ultimately expanded Medicaid, compared to about 42% in states that opted out of expansion, according to an article online April 18 in Annals of Internal Medicine.

In 2014, those rates fell to about 18% in states that expanded Medicaid andabout 34% in states that didn't.

Overall, the uninsured rate fell by about 7 percentage points more in states that expanded Medicaid than in those that didn't.

States with expanded Medicaid coverage also had a larger increase in the proportion of people who thought their insurance coverage improved over the previous year.

Additionally, there was evidence that people in states with expanded Medicaid programs were using their coverage, because they had larger increases in interactions with general physicians and overnight hospital stays.

There were also more diagnoses of diabetes and high cholesterol in states with expanded Medicaid programs.

Gaining insurance likely leads to more screening for these conditions, and more diagnoses may lead to early treatment and important downstream health effects, Dr. Jeffrey Kullgren wrote in an editorial.

The new study shows what's happening in states that expand Medicaid and "what is foregone by states that reject the ACA's opportunity to expand Medicaid," write Kullgren, of the University of Michigan Medical School and the Veterans Affairs Ann Arbor Health System.

While the new study did not show that people felt healthier in expanded-Medicaid states, Dr. Wherry said it may be too early to see changes in that measure.

"I think long-term follow up will be very important," she said. The results help confirm the value of the ACA for people who obtain this coverage, said Dr. John McDonough, who worked on the ACA but was not involved with the new study.

He said the new findings likely won't convince reluctant states to expand their Medicaid programs, however.

"It's not about evidence at this point," said Dr. McDonough, who is a professor at the Harvard T.H. Chan School of Public Health in Boston. "It's about a political fear over Obamacare that at this point is not influenceable by meaningful evidence."

The authors reported no funding or disclosures.

NEW YORK (Reuters Health) - Low-income adults in the U.S. likely benefited if their states expanded Medicaid in 2014 under the Affordable Care Act, suggests a new study.

Researchers found increased rates of insurance coverage, healthcare use, and chronic disease diagnoses among low-income adults in states that expanded access to the government-funded health insurance program.

"It looks like there is better medical care for these adults," said lead author Dr. Laura Wherry, of the David Geffen School of Medicine at the University of California, Los Angeles.

A key provision of the Affordable Care Act (ACA), sometimes referred to as Obamacare, was to force states to expand their Medicaid programs by 2014. But with a Supreme Court decision allowing states to opt out of the expansion, only 26 states actually expanded their Medicaid programs.

For the new study, the researchers analyzed 2010-2014 survey data collected from low-income U.S. adults ages 19 to 64.

In the pre-expansion era, from 2010-2013, about 33% had no insurance in states that ultimately expanded Medicaid, compared to about 42% in states that opted out of expansion, according to an article online April 18 in Annals of Internal Medicine.

In 2014, those rates fell to about 18% in states that expanded Medicaid andabout 34% in states that didn't.

Overall, the uninsured rate fell by about 7 percentage points more in states that expanded Medicaid than in those that didn't.

States with expanded Medicaid coverage also had a larger increase in the proportion of people who thought their insurance coverage improved over the previous year.

Additionally, there was evidence that people in states with expanded Medicaid programs were using their coverage, because they had larger increases in interactions with general physicians and overnight hospital stays.

There were also more diagnoses of diabetes and high cholesterol in states with expanded Medicaid programs.

Gaining insurance likely leads to more screening for these conditions, and more diagnoses may lead to early treatment and important downstream health effects, Dr. Jeffrey Kullgren wrote in an editorial.

The new study shows what's happening in states that expand Medicaid and "what is foregone by states that reject the ACA's opportunity to expand Medicaid," write Kullgren, of the University of Michigan Medical School and the Veterans Affairs Ann Arbor Health System.

While the new study did not show that people felt healthier in expanded-Medicaid states, Dr. Wherry said it may be too early to see changes in that measure.

"I think long-term follow up will be very important," she said. The results help confirm the value of the ACA for people who obtain this coverage, said Dr. John McDonough, who worked on the ACA but was not involved with the new study.

He said the new findings likely won't convince reluctant states to expand their Medicaid programs, however.

"It's not about evidence at this point," said Dr. McDonough, who is a professor at the Harvard T.H. Chan School of Public Health in Boston. "It's about a political fear over Obamacare that at this point is not influenceable by meaningful evidence."

The authors reported no funding or disclosures.

NEW YORK (Reuters Health) - Low-income adults in the U.S. likely benefited if their states expanded Medicaid in 2014 under the Affordable Care Act, suggests a new study.

Researchers found increased rates of insurance coverage, healthcare use, and chronic disease diagnoses among low-income adults in states that expanded access to the government-funded health insurance program.

"It looks like there is better medical care for these adults," said lead author Dr. Laura Wherry, of the David Geffen School of Medicine at the University of California, Los Angeles.

A key provision of the Affordable Care Act (ACA), sometimes referred to as Obamacare, was to force states to expand their Medicaid programs by 2014. But with a Supreme Court decision allowing states to opt out of the expansion, only 26 states actually expanded their Medicaid programs.

For the new study, the researchers analyzed 2010-2014 survey data collected from low-income U.S. adults ages 19 to 64.

In the pre-expansion era, from 2010-2013, about 33% had no insurance in states that ultimately expanded Medicaid, compared to about 42% in states that opted out of expansion, according to an article online April 18 in Annals of Internal Medicine.

In 2014, those rates fell to about 18% in states that expanded Medicaid andabout 34% in states that didn't.

Overall, the uninsured rate fell by about 7 percentage points more in states that expanded Medicaid than in those that didn't.

States with expanded Medicaid coverage also had a larger increase in the proportion of people who thought their insurance coverage improved over the previous year.

Additionally, there was evidence that people in states with expanded Medicaid programs were using their coverage, because they had larger increases in interactions with general physicians and overnight hospital stays.

There were also more diagnoses of diabetes and high cholesterol in states with expanded Medicaid programs.

Gaining insurance likely leads to more screening for these conditions, and more diagnoses may lead to early treatment and important downstream health effects, Dr. Jeffrey Kullgren wrote in an editorial.

The new study shows what's happening in states that expand Medicaid and "what is foregone by states that reject the ACA's opportunity to expand Medicaid," write Kullgren, of the University of Michigan Medical School and the Veterans Affairs Ann Arbor Health System.

While the new study did not show that people felt healthier in expanded-Medicaid states, Dr. Wherry said it may be too early to see changes in that measure.

"I think long-term follow up will be very important," she said. The results help confirm the value of the ACA for people who obtain this coverage, said Dr. John McDonough, who worked on the ACA but was not involved with the new study.

He said the new findings likely won't convince reluctant states to expand their Medicaid programs, however.

"It's not about evidence at this point," said Dr. McDonough, who is a professor at the Harvard T.H. Chan School of Public Health in Boston. "It's about a political fear over Obamacare that at this point is not influenceable by meaningful evidence."

The authors reported no funding or disclosures.

(Reuters Health) - When it comes to urgent medical problems like ankle injuries or suspected strep, virtual MDs may be no match for the real thing, a new U.S. study suggests.

Researchers enlisted 67 volunteers to test out how well eight popular virtual visit companies diagnosed these problems and four other common medical issues - sore throat, sinus infection, low back pain, and urinary tract infection.

About one in four patients got the wrong diagnosis or none at all from the virtual visits, the study found. What's more, virtual doctors followed standard protocols for diagnosing and treating these problems only 54% of the time.

"One of the more surprising findings of the study was the universally low rate of testing when it was needed," said lead researcher Dr. Adam Schoenfeld, of the University of California, San Francisco.

"We don't know why, but it may reflect the challenges of ordering or following up on tests performed near where the patient lives but far from where the doctor is, or concern about the costs to the patient of additional testing," Schoenfeld added by email.

Virtual visits using videoconferences, phone calls and web chats are becoming a more common way for patients to seek urgent care because it can save the inconvenience of a clinic visit or provide access to care when people can't get an appointment with their regular doctor.

Some insurers are starting to pay for virtual visits in certain situations, making this option more viable for patients who worry about costs.

For the current study, Schoenfeld and colleagues trained volunteers to act as if they had common acute medical problems and then sent them to virtual doctors provided by companies including Ameridoc, Amwell, Consult a Doctor, Doctor on Demand, MDAligne, MDLIVE, MeMD and NowClinic.

Altogether, the volunteers completed 599 virtual visits in 2013 and 2014.

The companies varied in how well they followed treatment guidelines, with standard care given anywhere from 34 to 66% of the time across the eight websites, the researchers report in JAMA Internal Medicine April 4.

Mode of communication - such as web chat or videoconference - didn't appear to influence how often treatment guidelines were

followed.

Virtual doctors got complete histories and did thorough exams anywhere from 52% to 82% of the time.   Virtual visits resulted in correct diagnoses anywhere from 65% to 94% of the time.

Often, virtual doctors failed to order urine tests needed to assess urinary tract infections, or to request images needed to diagnoses ankle pain, for example, and antibiotics were often prescribed inappropriately.

One limitation of the study is that the researchers only looked at virtual visits, so they couldn't compare these online doctors' visits to what might have happened with in-person clinical exams.

Still, it's possible that at least some of the variation in quality of care was the result of the remote visits, said Dr. Jeffrey Linder, a researcher at Brigham and Women's Hospital and Harvard Medical School who co-authored an editorial accompanying the study.

"There is a built-in barrier to getting testing, which led to worse care for ankle pain and recurrent urinary tract infections - for which the doctors should have ordered a test - and better care for low back pain - for which doctors should not have ordered a test," Linder said by email.

In an ideal world, patients would be able to have occasional virtual visits with their primary care providers, who know their medical histories, said Dr. David Levine, co-author of the editorial and also a researcher at Brigham and Women's and Harvard.

Although virtual urgent care and in-person urgent care have not been compared head-to-head, virtual urgent care has its downsides - indirect physical exam, difficult access to testing, and unclear follow-up," Levine said by email. "While the quality of care is not perfect anywhere, a patient's primary care doctor should be a person's first point of contact."

(Reuters Health) - When it comes to urgent medical problems like ankle injuries or suspected strep, virtual MDs may be no match for the real thing, a new U.S. study suggests.

Researchers enlisted 67 volunteers to test out how well eight popular virtual visit companies diagnosed these problems and four other common medical issues - sore throat, sinus infection, low back pain, and urinary tract infection.

About one in four patients got the wrong diagnosis or none at all from the virtual visits, the study found. What's more, virtual doctors followed standard protocols for diagnosing and treating these problems only 54% of the time.

"One of the more surprising findings of the study was the universally low rate of testing when it was needed," said lead researcher Dr. Adam Schoenfeld, of the University of California, San Francisco.

"We don't know why, but it may reflect the challenges of ordering or following up on tests performed near where the patient lives but far from where the doctor is, or concern about the costs to the patient of additional testing," Schoenfeld added by email.

Virtual visits using videoconferences, phone calls and web chats are becoming a more common way for patients to seek urgent care because it can save the inconvenience of a clinic visit or provide access to care when people can't get an appointment with their regular doctor.

Some insurers are starting to pay for virtual visits in certain situations, making this option more viable for patients who worry about costs.

For the current study, Schoenfeld and colleagues trained volunteers to act as if they had common acute medical problems and then sent them to virtual doctors provided by companies including Ameridoc, Amwell, Consult a Doctor, Doctor on Demand, MDAligne, MDLIVE, MeMD and NowClinic.

Altogether, the volunteers completed 599 virtual visits in 2013 and 2014.

The companies varied in how well they followed treatment guidelines, with standard care given anywhere from 34 to 66% of the time across the eight websites, the researchers report in JAMA Internal Medicine April 4.

Mode of communication - such as web chat or videoconference - didn't appear to influence how often treatment guidelines were

followed.

Virtual doctors got complete histories and did thorough exams anywhere from 52% to 82% of the time.   Virtual visits resulted in correct diagnoses anywhere from 65% to 94% of the time.

Often, virtual doctors failed to order urine tests needed to assess urinary tract infections, or to request images needed to diagnoses ankle pain, for example, and antibiotics were often prescribed inappropriately.

One limitation of the study is that the researchers only looked at virtual visits, so they couldn't compare these online doctors' visits to what might have happened with in-person clinical exams.

Still, it's possible that at least some of the variation in quality of care was the result of the remote visits, said Dr. Jeffrey Linder, a researcher at Brigham and Women's Hospital and Harvard Medical School who co-authored an editorial accompanying the study.

"There is a built-in barrier to getting testing, which led to worse care for ankle pain and recurrent urinary tract infections - for which the doctors should have ordered a test - and better care for low back pain - for which doctors should not have ordered a test," Linder said by email.

In an ideal world, patients would be able to have occasional virtual visits with their primary care providers, who know their medical histories, said Dr. David Levine, co-author of the editorial and also a researcher at Brigham and Women's and Harvard.

Although virtual urgent care and in-person urgent care have not been compared head-to-head, virtual urgent care has its downsides - indirect physical exam, difficult access to testing, and unclear follow-up," Levine said by email. "While the quality of care is not perfect anywhere, a patient's primary care doctor should be a person's first point of contact."

(Reuters Health) - When it comes to urgent medical problems like ankle injuries or suspected strep, virtual MDs may be no match for the real thing, a new U.S. study suggests.

Researchers enlisted 67 volunteers to test out how well eight popular virtual visit companies diagnosed these problems and four other common medical issues - sore throat, sinus infection, low back pain, and urinary tract infection.

About one in four patients got the wrong diagnosis or none at all from the virtual visits, the study found. What's more, virtual doctors followed standard protocols for diagnosing and treating these problems only 54% of the time.

"One of the more surprising findings of the study was the universally low rate of testing when it was needed," said lead researcher Dr. Adam Schoenfeld, of the University of California, San Francisco.

"We don't know why, but it may reflect the challenges of ordering or following up on tests performed near where the patient lives but far from where the doctor is, or concern about the costs to the patient of additional testing," Schoenfeld added by email.

Virtual visits using videoconferences, phone calls and web chats are becoming a more common way for patients to seek urgent care because it can save the inconvenience of a clinic visit or provide access to care when people can't get an appointment with their regular doctor.

Some insurers are starting to pay for virtual visits in certain situations, making this option more viable for patients who worry about costs.

For the current study, Schoenfeld and colleagues trained volunteers to act as if they had common acute medical problems and then sent them to virtual doctors provided by companies including Ameridoc, Amwell, Consult a Doctor, Doctor on Demand, MDAligne, MDLIVE, MeMD and NowClinic.

Altogether, the volunteers completed 599 virtual visits in 2013 and 2014.

The companies varied in how well they followed treatment guidelines, with standard care given anywhere from 34 to 66% of the time across the eight websites, the researchers report in JAMA Internal Medicine April 4.

Mode of communication - such as web chat or videoconference - didn't appear to influence how often treatment guidelines were

followed.

Virtual doctors got complete histories and did thorough exams anywhere from 52% to 82% of the time.   Virtual visits resulted in correct diagnoses anywhere from 65% to 94% of the time.

Often, virtual doctors failed to order urine tests needed to assess urinary tract infections, or to request images needed to diagnoses ankle pain, for example, and antibiotics were often prescribed inappropriately.

One limitation of the study is that the researchers only looked at virtual visits, so they couldn't compare these online doctors' visits to what might have happened with in-person clinical exams.

Still, it's possible that at least some of the variation in quality of care was the result of the remote visits, said Dr. Jeffrey Linder, a researcher at Brigham and Women's Hospital and Harvard Medical School who co-authored an editorial accompanying the study.

"There is a built-in barrier to getting testing, which led to worse care for ankle pain and recurrent urinary tract infections - for which the doctors should have ordered a test - and better care for low back pain - for which doctors should not have ordered a test," Linder said by email.

In an ideal world, patients would be able to have occasional virtual visits with their primary care providers, who know their medical histories, said Dr. David Levine, co-author of the editorial and also a researcher at Brigham and Women's and Harvard.

Although virtual urgent care and in-person urgent care have not been compared head-to-head, virtual urgent care has its downsides - indirect physical exam, difficult access to testing, and unclear follow-up," Levine said by email. "While the quality of care is not perfect anywhere, a patient's primary care doctor should be a person's first point of contact."

NEW YORK (Reuters Health) - Edoxaban (Savaysa, Daiichi-Sankyo) shows advantages over warfarin in long-term treatment of patients with venous thromboembolism (VTE), according to a post-hoc analysis of multinational trial data.

As Dr. Gary Raskob told Reuters Health by email, "Our results indicate that once-daily edoxaban provides an effective

and more convenient alternative to warfarin, with lower major bleeding risk, for patients who require extended treatment

beyond three months to prevent recurrent venous thromboembolism."

In a March 22 online paper in the Lancet Haematology, Dr.Raskob, of the University of Oklahoma, Oklahoma City, and colleagues note that guidelines recommend anticoagulant treatment for at least three months. However, "The risk of recurrence is substantial for patients with unprovoked venous thromboembolism or continuing risk factors and many of these

patients need extended anticoagulation therapy beyond three months."

To shed more light on longer term effects, the team examined outcome after three to 12 months in 3,633 patients treated with heparin and edoxaban and 3,594 treated with heparin and warfarin who took part in a randomized, double-blind trial. Median treatment duration was close to 9 months.

At three months, recurrent VTE was seen in 1.1% of the edoxaban group and 1.2% of the warfarin patients. At three to six months, the corresponding proportions were 0.7% and 0.5%. At more than six but less than 12 months, they were 0.2% and 0.8%.

Among other findings was that the cumulative incidence of major bleeding was 0.3% in the edoxaban-treated group and 0.7%

in the warfarin-treated patients. Intention-to-treat analysis gave similar results to these per-protocol findings.

Use of edoxaban, Dr. Raskob concluded, "may enable more patients to stay on extended anticoagulant treatment and help reduce the burden from recurrent venous thromboembolism."

Commenting on the findings by email, Dr. Jerrold H. Levy, coauthor of an accompanying editorial, told Reuters Health, "This post-hoc analysis reports that edoxaban is an alternative to warfarin for extended use in the secondary prevention of venous thromboembolism."

Dr. Levy, of Duke University Hospital, Durham, North Carolina, concluded, "The only other study where a direct oral anticoagulant was compared with warfarin for extended use in this setting was the RE-MEDY trial that compared dabigatran with warfarin in patients for six to 36 months and found dabigatran was similar to warfarin for efficacy with a lower incidence of clinically relevant major bleeding."

This study was funded by Daiichi-Sankyo.  Dr. Raskob received fees from the company during the study. Other coauthors

also have ties to the company and a number are employees of Daiichi-Sankyo.

NEW YORK (Reuters Health) - Edoxaban (Savaysa, Daiichi-Sankyo) shows advantages over warfarin in long-term treatment of patients with venous thromboembolism (VTE), according to a post-hoc analysis of multinational trial data.

As Dr. Gary Raskob told Reuters Health by email, "Our results indicate that once-daily edoxaban provides an effective

and more convenient alternative to warfarin, with lower major bleeding risk, for patients who require extended treatment

beyond three months to prevent recurrent venous thromboembolism."

In a March 22 online paper in the Lancet Haematology, Dr.Raskob, of the University of Oklahoma, Oklahoma City, and colleagues note that guidelines recommend anticoagulant treatment for at least three months. However, "The risk of recurrence is substantial for patients with unprovoked venous thromboembolism or continuing risk factors and many of these

patients need extended anticoagulation therapy beyond three months."

To shed more light on longer term effects, the team examined outcome after three to 12 months in 3,633 patients treated with heparin and edoxaban and 3,594 treated with heparin and warfarin who took part in a randomized, double-blind trial. Median treatment duration was close to 9 months.

At three months, recurrent VTE was seen in 1.1% of the edoxaban group and 1.2% of the warfarin patients. At three to six months, the corresponding proportions were 0.7% and 0.5%. At more than six but less than 12 months, they were 0.2% and 0.8%.

Among other findings was that the cumulative incidence of major bleeding was 0.3% in the edoxaban-treated group and 0.7%

in the warfarin-treated patients. Intention-to-treat analysis gave similar results to these per-protocol findings.

Use of edoxaban, Dr. Raskob concluded, "may enable more patients to stay on extended anticoagulant treatment and help reduce the burden from recurrent venous thromboembolism."

Commenting on the findings by email, Dr. Jerrold H. Levy, coauthor of an accompanying editorial, told Reuters Health, "This post-hoc analysis reports that edoxaban is an alternative to warfarin for extended use in the secondary prevention of venous thromboembolism."

Dr. Levy, of Duke University Hospital, Durham, North Carolina, concluded, "The only other study where a direct oral anticoagulant was compared with warfarin for extended use in this setting was the RE-MEDY trial that compared dabigatran with warfarin in patients for six to 36 months and found dabigatran was similar to warfarin for efficacy with a lower incidence of clinically relevant major bleeding."

This study was funded by Daiichi-Sankyo.  Dr. Raskob received fees from the company during the study. Other coauthors

also have ties to the company and a number are employees of Daiichi-Sankyo.

NEW YORK (Reuters Health) - Edoxaban (Savaysa, Daiichi-Sankyo) shows advantages over warfarin in long-term treatment of patients with venous thromboembolism (VTE), according to a post-hoc analysis of multinational trial data.

As Dr. Gary Raskob told Reuters Health by email, "Our results indicate that once-daily edoxaban provides an effective

and more convenient alternative to warfarin, with lower major bleeding risk, for patients who require extended treatment

beyond three months to prevent recurrent venous thromboembolism."

In a March 22 online paper in the Lancet Haematology, Dr.Raskob, of the University of Oklahoma, Oklahoma City, and colleagues note that guidelines recommend anticoagulant treatment for at least three months. However, "The risk of recurrence is substantial for patients with unprovoked venous thromboembolism or continuing risk factors and many of these

patients need extended anticoagulation therapy beyond three months."

To shed more light on longer term effects, the team examined outcome after three to 12 months in 3,633 patients treated with heparin and edoxaban and 3,594 treated with heparin and warfarin who took part in a randomized, double-blind trial. Median treatment duration was close to 9 months.

At three months, recurrent VTE was seen in 1.1% of the edoxaban group and 1.2% of the warfarin patients. At three to six months, the corresponding proportions were 0.7% and 0.5%. At more than six but less than 12 months, they were 0.2% and 0.8%.

Among other findings was that the cumulative incidence of major bleeding was 0.3% in the edoxaban-treated group and 0.7%

in the warfarin-treated patients. Intention-to-treat analysis gave similar results to these per-protocol findings.

Use of edoxaban, Dr. Raskob concluded, "may enable more patients to stay on extended anticoagulant treatment and help reduce the burden from recurrent venous thromboembolism."

Commenting on the findings by email, Dr. Jerrold H. Levy, coauthor of an accompanying editorial, told Reuters Health, "This post-hoc analysis reports that edoxaban is an alternative to warfarin for extended use in the secondary prevention of venous thromboembolism."

Dr. Levy, of Duke University Hospital, Durham, North Carolina, concluded, "The only other study where a direct oral anticoagulant was compared with warfarin for extended use in this setting was the RE-MEDY trial that compared dabigatran with warfarin in patients for six to 36 months and found dabigatran was similar to warfarin for efficacy with a lower incidence of clinically relevant major bleeding."

This study was funded by Daiichi-Sankyo.  Dr. Raskob received fees from the company during the study. Other coauthors

also have ties to the company and a number are employees of Daiichi-Sankyo.

NEW YORK (Reuters Health) - Ten-year results from a comparison of coronary-artery bypass grafting (CABG) with medical therapy alone has found that bypass lowers the odds of cardiovascular death by about nine percentage points in people with ischemic cardiomyopathy.

The 16% reduction in the death rate meant volunteers who received bypass grafting typically lived nearly a year and a half longer than those who received optimal nonsurgical therapy.

The findings are based on a study population of 1,212 patients with an ejection fraction of 35% or less who received bypass grafts between 2002 and 2007.

Death from any cause, the primary endpoint, occurred in 66.1% of the control patients and 58.9% of the bypass recipients (p=0.02).

When the researchers looked exclusively at cardiovascular deaths, the rates were 49.3% in the medical-therapy group and 40.5% in the group receiving bypass in addition to standard medical care (p=0.006).

The combined odds of hospitalization or death from any cause were also lower with bypass.

For death or hospitalization for cardiovascular causes, there was a 10.4 percentage point difference (p<0.001). For death or hospitalization for heart failure, the difference was 8.6 points (p<0.002). It was for 6.4 percentage points for death or hospitalization for any cause (p=0.001).

Results from the study, known as STICHES, were released April 3 at the American College of Cardiology annual scientific session in Chicago and online by the New England Journal of Medicine.

Bypass grafting "was associated with more favorable results than medical therapy alone across all clinically relevant long-term outcomes we evaluated," said the team, led by Dr. Eric Velazquez of the Duke Clinical Research Institute at Duke University, Durham, North Carolina.

The trends "resulted from a persistent and perhaps increasing effect size over time," they said. "Thus, it appears that the operative risk associated with CABG is offset by a durable effect that translates into increasing clinical benefit to at least 10 years."

Coronary artery disease kills more than 538,000 people in the United States each year. Most of the studies establishing the benefits of bypass grafting were done more than 40 years ago.

The initial version of the new study was known as STICH and it followed patients at 99 sites in 22 countries for a median of just over four and a half years. It found no significant difference between the two treatments when it came to the rate of death from any cause. However, bypass recipients were less likely to die from a cardiovascular event or to die from any cause or be hospitalized for cardiovascular causes.

STICHES extends those results to 10 years and found that any-cause death became significant.

Median survival was 7.73 years with bypass and 6.29 years without. The researchers calculated that the number needed to treat to prevent one death was 14 patients. The number needed to prevent one death from a cardiovascular cause was 11.

Other secondary measures were the rates of death combined with specific cardiovascular events. Once again, they consistently found a benefit for bypass.

There was a 15.8 percentage point difference for any cause of death or revascularization (p<0.001). For death or nonfatal myocardial infarction the difference was 6.3 points and it was for 7.2 percentage points for death or nonfatal stroke (both p=0.03).

Among the 610 people originally assigned to the bypass group, 9% did not receive a graft before the end of the trial. In the 602 assigned to medical therapy alone, 19.8% underwent bypass surgery. Eleven percent had it within the first year.

In an accompanying editorial, Drs. Robert Guyton and Andrew Smith of Emory University in Atlanta, wrote, "The STICHES 10-year results firmly extend the survival benefit of CABG in patients with advanced coronary artery disease to patients with heart failure and severe ischemic cardiomyopathy. These findings should prompt strong consideration of coronary bypass as an addition to medical therapy in shared decision making with these patients."

The National Heart Lung and Blood Institute funded this research. Two coauthors reported disclosures.

NEW YORK (Reuters Health) - Ten-year results from a comparison of coronary-artery bypass grafting (CABG) with medical therapy alone has found that bypass lowers the odds of cardiovascular death by about nine percentage points in people with ischemic cardiomyopathy.

The 16% reduction in the death rate meant volunteers who received bypass grafting typically lived nearly a year and a half longer than those who received optimal nonsurgical therapy.

The findings are based on a study population of 1,212 patients with an ejection fraction of 35% or less who received bypass grafts between 2002 and 2007.

Death from any cause, the primary endpoint, occurred in 66.1% of the control patients and 58.9% of the bypass recipients (p=0.02).

When the researchers looked exclusively at cardiovascular deaths, the rates were 49.3% in the medical-therapy group and 40.5% in the group receiving bypass in addition to standard medical care (p=0.006).

The combined odds of hospitalization or death from any cause were also lower with bypass.

For death or hospitalization for cardiovascular causes, there was a 10.4 percentage point difference (p<0.001). For death or hospitalization for heart failure, the difference was 8.6 points (p<0.002). It was for 6.4 percentage points for death or hospitalization for any cause (p=0.001).

Results from the study, known as STICHES, were released April 3 at the American College of Cardiology annual scientific session in Chicago and online by the New England Journal of Medicine.

Bypass grafting "was associated with more favorable results than medical therapy alone across all clinically relevant long-term outcomes we evaluated," said the team, led by Dr. Eric Velazquez of the Duke Clinical Research Institute at Duke University, Durham, North Carolina.

The trends "resulted from a persistent and perhaps increasing effect size over time," they said. "Thus, it appears that the operative risk associated with CABG is offset by a durable effect that translates into increasing clinical benefit to at least 10 years."

Coronary artery disease kills more than 538,000 people in the United States each year. Most of the studies establishing the benefits of bypass grafting were done more than 40 years ago.

The initial version of the new study was known as STICH and it followed patients at 99 sites in 22 countries for a median of just over four and a half years. It found no significant difference between the two treatments when it came to the rate of death from any cause. However, bypass recipients were less likely to die from a cardiovascular event or to die from any cause or be hospitalized for cardiovascular causes.

STICHES extends those results to 10 years and found that any-cause death became significant.

Median survival was 7.73 years with bypass and 6.29 years without. The researchers calculated that the number needed to treat to prevent one death was 14 patients. The number needed to prevent one death from a cardiovascular cause was 11.

Other secondary measures were the rates of death combined with specific cardiovascular events. Once again, they consistently found a benefit for bypass.

There was a 15.8 percentage point difference for any cause of death or revascularization (p<0.001). For death or nonfatal myocardial infarction the difference was 6.3 points and it was for 7.2 percentage points for death or nonfatal stroke (both p=0.03).

Among the 610 people originally assigned to the bypass group, 9% did not receive a graft before the end of the trial. In the 602 assigned to medical therapy alone, 19.8% underwent bypass surgery. Eleven percent had it within the first year.

In an accompanying editorial, Drs. Robert Guyton and Andrew Smith of Emory University in Atlanta, wrote, "The STICHES 10-year results firmly extend the survival benefit of CABG in patients with advanced coronary artery disease to patients with heart failure and severe ischemic cardiomyopathy. These findings should prompt strong consideration of coronary bypass as an addition to medical therapy in shared decision making with these patients."

The National Heart Lung and Blood Institute funded this research. Two coauthors reported disclosures.

NEW YORK (Reuters Health) - Ten-year results from a comparison of coronary-artery bypass grafting (CABG) with medical therapy alone has found that bypass lowers the odds of cardiovascular death by about nine percentage points in people with ischemic cardiomyopathy.

The 16% reduction in the death rate meant volunteers who received bypass grafting typically lived nearly a year and a half longer than those who received optimal nonsurgical therapy.

The findings are based on a study population of 1,212 patients with an ejection fraction of 35% or less who received bypass grafts between 2002 and 2007.

Death from any cause, the primary endpoint, occurred in 66.1% of the control patients and 58.9% of the bypass recipients (p=0.02).

When the researchers looked exclusively at cardiovascular deaths, the rates were 49.3% in the medical-therapy group and 40.5% in the group receiving bypass in addition to standard medical care (p=0.006).

The combined odds of hospitalization or death from any cause were also lower with bypass.

For death or hospitalization for cardiovascular causes, there was a 10.4 percentage point difference (p<0.001). For death or hospitalization for heart failure, the difference was 8.6 points (p<0.002). It was for 6.4 percentage points for death or hospitalization for any cause (p=0.001).

Results from the study, known as STICHES, were released April 3 at the American College of Cardiology annual scientific session in Chicago and online by the New England Journal of Medicine.

Bypass grafting "was associated with more favorable results than medical therapy alone across all clinically relevant long-term outcomes we evaluated," said the team, led by Dr. Eric Velazquez of the Duke Clinical Research Institute at Duke University, Durham, North Carolina.

The trends "resulted from a persistent and perhaps increasing effect size over time," they said. "Thus, it appears that the operative risk associated with CABG is offset by a durable effect that translates into increasing clinical benefit to at least 10 years."

Coronary artery disease kills more than 538,000 people in the United States each year. Most of the studies establishing the benefits of bypass grafting were done more than 40 years ago.

The initial version of the new study was known as STICH and it followed patients at 99 sites in 22 countries for a median of just over four and a half years. It found no significant difference between the two treatments when it came to the rate of death from any cause. However, bypass recipients were less likely to die from a cardiovascular event or to die from any cause or be hospitalized for cardiovascular causes.

STICHES extends those results to 10 years and found that any-cause death became significant.

Median survival was 7.73 years with bypass and 6.29 years without. The researchers calculated that the number needed to treat to prevent one death was 14 patients. The number needed to prevent one death from a cardiovascular cause was 11.

Other secondary measures were the rates of death combined with specific cardiovascular events. Once again, they consistently found a benefit for bypass.

There was a 15.8 percentage point difference for any cause of death or revascularization (p<0.001). For death or nonfatal myocardial infarction the difference was 6.3 points and it was for 7.2 percentage points for death or nonfatal stroke (both p=0.03).

Among the 610 people originally assigned to the bypass group, 9% did not receive a graft before the end of the trial. In the 602 assigned to medical therapy alone, 19.8% underwent bypass surgery. Eleven percent had it within the first year.

In an accompanying editorial, Drs. Robert Guyton and Andrew Smith of Emory University in Atlanta, wrote, "The STICHES 10-year results firmly extend the survival benefit of CABG in patients with advanced coronary artery disease to patients with heart failure and severe ischemic cardiomyopathy. These findings should prompt strong consideration of coronary bypass as an addition to medical therapy in shared decision making with these patients."

The National Heart Lung and Blood Institute funded this research. Two coauthors reported disclosures.

(Reuters Health) - Elderly patients with hip fractures may get better care at smaller hospitals, a new study suggests. Seniors with hip fractures waited longer for surgery and were more likely to be rehospitalized if they were treated at a major trauma center than if they went to a smaller emergency room, researchers found.

Seniors in level 1 trauma centers were also more likely to develop blood clots in their legs, compared to their peers who were treated in settings designed for less serious injuries, the researchers reported March 11 in the journal Medical Care.

Level 1 trauma centers have the resources to treat very serious injuries, said lead author Dr. David Metcalfe of Brigham and Women's Hospital in Boston.

"However, because they care for the most complex patients, these hospitals are often very busy. There is therefore a risk that some groups of patients might be disadvantaged or 'lost' in the system," Metcalfe told Reuters Health by email.

For example, patients with multiple injuries or bones breaking through skin may be treated before seniors with hip fractures.

Each year in the U.S. alone, more than 250,000 people aged 65 and older are hospitalized for hip fractures, according to the Centers for Disease Control and Prevention.

The study team used statewide data from California on 91,401 seniors hospitalized between 2007 and 2011. All were over age 65 and had surgery for hip fractures.

Overall, 6% were treated at a level 1 trauma center, 18% at a level 2 trauma center and 70% in a non-trauma center.

On average, patients stayed in the hospital for five days and waited one day for surgery.

Patients in level 1 trauma centers stayed for one day longer than those in the other settings and waited nearly eight hours longer for surgery.

Seniors treated at level 1 centers were 62% more likely to be readmitted to the hospital within a month of their surgery than seniors treated in level 2 or non-trauma settings.Seniors were also 32% more likely to develop blood clots in their legs at level 1 centers.

Patients at level 2 trauma centers had the same outcomes as those at non-trauma centers, the authors found. There was no difference between any of the groups in risk of death, bed sores, or pneumonia, however.

"We now know that it is important to treat patients with hip fractures as quickly as possible," said Metcalfe, noting that older adults who wait too long for treatment may be at risk for bed sores, blood clots, and lung infections.

"The concern is that this delay will lead to increasing length of stay in hospital as well as increased complications for the patients because they spend longer in bed waiting for surgery," said Dr. Chris Gooding, a surgeon at Addenbrookes Hospital, a level 1 trauma center in Cambridge, UK. Gooding was not involved in the study.

"This is an important subject as in developed countries we have an aging population and as a result we are seeing increasing numbers of patients with hip fractures," Gooding told Reuters Health by email.

At the same time, Gooding noted, there are also a growing number of level 1 trauma centers.

"One of the best ways to help these patients is to get their operation done quickly so that they can start walking again and return to their own homes as soon as possible," Metcalfe advised.

(Reuters Health) - Elderly patients with hip fractures may get better care at smaller hospitals, a new study suggests. Seniors with hip fractures waited longer for surgery and were more likely to be rehospitalized if they were treated at a major trauma center than if they went to a smaller emergency room, researchers found.

Seniors in level 1 trauma centers were also more likely to develop blood clots in their legs, compared to their peers who were treated in settings designed for less serious injuries, the researchers reported March 11 in the journal Medical Care.

Level 1 trauma centers have the resources to treat very serious injuries, said lead author Dr. David Metcalfe of Brigham and Women's Hospital in Boston.

"However, because they care for the most complex patients, these hospitals are often very busy. There is therefore a risk that some groups of patients might be disadvantaged or 'lost' in the system," Metcalfe told Reuters Health by email.

For example, patients with multiple injuries or bones breaking through skin may be treated before seniors with hip fractures.

Each year in the U.S. alone, more than 250,000 people aged 65 and older are hospitalized for hip fractures, according to the Centers for Disease Control and Prevention.

The study team used statewide data from California on 91,401 seniors hospitalized between 2007 and 2011. All were over age 65 and had surgery for hip fractures.

Overall, 6% were treated at a level 1 trauma center, 18% at a level 2 trauma center and 70% in a non-trauma center.

On average, patients stayed in the hospital for five days and waited one day for surgery.

Patients in level 1 trauma centers stayed for one day longer than those in the other settings and waited nearly eight hours longer for surgery.

Seniors treated at level 1 centers were 62% more likely to be readmitted to the hospital within a month of their surgery than seniors treated in level 2 or non-trauma settings.Seniors were also 32% more likely to develop blood clots in their legs at level 1 centers.

Patients at level 2 trauma centers had the same outcomes as those at non-trauma centers, the authors found. There was no difference between any of the groups in risk of death, bed sores, or pneumonia, however.

"We now know that it is important to treat patients with hip fractures as quickly as possible," said Metcalfe, noting that older adults who wait too long for treatment may be at risk for bed sores, blood clots, and lung infections.

"The concern is that this delay will lead to increasing length of stay in hospital as well as increased complications for the patients because they spend longer in bed waiting for surgery," said Dr. Chris Gooding, a surgeon at Addenbrookes Hospital, a level 1 trauma center in Cambridge, UK. Gooding was not involved in the study.

"This is an important subject as in developed countries we have an aging population and as a result we are seeing increasing numbers of patients with hip fractures," Gooding told Reuters Health by email.

At the same time, Gooding noted, there are also a growing number of level 1 trauma centers.

"One of the best ways to help these patients is to get their operation done quickly so that they can start walking again and return to their own homes as soon as possible," Metcalfe advised.

(Reuters Health) - Elderly patients with hip fractures may get better care at smaller hospitals, a new study suggests. Seniors with hip fractures waited longer for surgery and were more likely to be rehospitalized if they were treated at a major trauma center than if they went to a smaller emergency room, researchers found.

Seniors in level 1 trauma centers were also more likely to develop blood clots in their legs, compared to their peers who were treated in settings designed for less serious injuries, the researchers reported March 11 in the journal Medical Care.

Level 1 trauma centers have the resources to treat very serious injuries, said lead author Dr. David Metcalfe of Brigham and Women's Hospital in Boston.

"However, because they care for the most complex patients, these hospitals are often very busy. There is therefore a risk that some groups of patients might be disadvantaged or 'lost' in the system," Metcalfe told Reuters Health by email.

For example, patients with multiple injuries or bones breaking through skin may be treated before seniors with hip fractures.

Each year in the U.S. alone, more than 250,000 people aged 65 and older are hospitalized for hip fractures, according to the Centers for Disease Control and Prevention.

The study team used statewide data from California on 91,401 seniors hospitalized between 2007 and 2011. All were over age 65 and had surgery for hip fractures.

Overall, 6% were treated at a level 1 trauma center, 18% at a level 2 trauma center and 70% in a non-trauma center.

On average, patients stayed in the hospital for five days and waited one day for surgery.

Patients in level 1 trauma centers stayed for one day longer than those in the other settings and waited nearly eight hours longer for surgery.

Seniors treated at level 1 centers were 62% more likely to be readmitted to the hospital within a month of their surgery than seniors treated in level 2 or non-trauma settings.Seniors were also 32% more likely to develop blood clots in their legs at level 1 centers.

Patients at level 2 trauma centers had the same outcomes as those at non-trauma centers, the authors found. There was no difference between any of the groups in risk of death, bed sores, or pneumonia, however.

"We now know that it is important to treat patients with hip fractures as quickly as possible," said Metcalfe, noting that older adults who wait too long for treatment may be at risk for bed sores, blood clots, and lung infections.

"The concern is that this delay will lead to increasing length of stay in hospital as well as increased complications for the patients because they spend longer in bed waiting for surgery," said Dr. Chris Gooding, a surgeon at Addenbrookes Hospital, a level 1 trauma center in Cambridge, UK. Gooding was not involved in the study.

"This is an important subject as in developed countries we have an aging population and as a result we are seeing increasing numbers of patients with hip fractures," Gooding told Reuters Health by email.

At the same time, Gooding noted, there are also a growing number of level 1 trauma centers.

"One of the best ways to help these patients is to get their operation done quickly so that they can start walking again and return to their own homes as soon as possible," Metcalfe advised.

NEW YORK (Reuters Health) - The prevalence of antibiotic resistance in pediatric urinary tract infection (UTI) has reached such high levels in many countries that existing empiric therapies may no longer be effective, researchers from UK report."

Prevalence of resistance to commonly prescribed antibiotics in primary care in children with urinary tract infections caused by E. coli is high, and there was remarkable variability in E. coli resistance among countries in the study, particularly in countries outside the OECD (Organization for Economic Cooperation and Development), where one possible explanation is the availability of antibiotics over the counter," Ashley Bryce from the University of Bristol in the U.K. and Dr. Céire E. Costelloe from Imperial College London told Reuters Health in a joint email.

"This could render some antibiotics ineffective as first-line treatments for urinary tract infection," they said.

E. coli is responsible for more than 80% of all UTIs and is also the most common cause of bacteremia and foodborne infections and one cause of meningitis in neonates.

Bryce, Dr. Costelloe, and colleagues investigated the prevalence of resistance in community-acquired E. coli UTI to the most commonly prescribed antibiotics given to children in primary care in their systematic review of 58 published reports.

For all antibiotics tested, the prevalence of antibiotic resistance was higher in non-OECD countries than in OECD countries, the team reports in an article online March 15 in The BMJ.

The prevalence of resistance was highest for ampicillin, ranging from 41% in Switzerland to 100% in Ghana and Nigeria.

Resistance to co-trimoxazole and trimethoprim was 30% in OECD countries and 67% in Saudi Arabia, the only non-OECD country for which rates were available.

Pooled prevalences of resistance to ciprofloxacin and ceftazidime were around 2% in OECD countries but over 26% in non-OECD countries.

For all time periods analyzed, the odds of resistance were greater in children exposed to antibiotics than in those who were unexposed.

"The Infectious Diseases Society of America (IDSA) in collaboration with the European Society for Microbiology and Infectious Diseases (ESCMID) recommend that an antibiotic should be selected for first line empirical treatment of urinary tract infection only if the local prevalence of resistance is less than 20%," the researchers note.

"According to these guidelines, our review suggests ampicillin, co-trimoxazole, and trimethoprim are no longer suitable first line treatment options for urinary tract infection in many OECD countries and that as a result many guidelines, such as those published by the National Institute for Health and Care Excellence (NICE), might need updating," they write. "In non-OECD countries, resistance to all first line antibiotics specified for urinary tract infections was in excess of 20%, suggesting that choices of first line treatment might need to be re-evaluated in less well developed countries."

"We are not able to advise clinicians on which antibiotic is best to prescribe as this often depends on the individual case," Bryce and Dr. Costelloe said. "Clinicians should, however, adhere to local or national guidelines wherever possible, which is why it is of great importance that such guidelines are kept up to date and reflect current resistance rates."

"Clinicians may also wish to consider the antibiotic history of the child when they present to primary care with symptoms of an infection, especially in light of the suggestion of our results that previous treatment with an antibiotic is associated with resistance to that same antibiotic, and that this association may be present up to 6 months post treatment," they added.

Dr. Grant Russell from Monash University in Melbourne, Australia, wrote an editorial accompanying the report. He told Reuters Health by email, "I found the extent of the resistance (and the fact that it covered all of the regularly used empiric antibiotics) both concerning and surprising. The fact that choices are diminishing is disturbing, and the fact that the situation is dire in the developing world is deeply troubling."

"We need to do what we can do to prevent bacterial infections, and when treating them to consider that effective antibiotics are a finite resource," he said. "We all have a responsibility in attempting to conserve that resource."

"No new classes of antibiotics have been developed in the last 30 years - this and the dire situation in both the developed and the developing world suggests that the 'global problem' of antibiotic resistance is going to become more and more of an issue in years and decades to come," Dr. Russell concluded.

NEW YORK (Reuters Health) - The prevalence of antibiotic resistance in pediatric urinary tract infection (UTI) has reached such high levels in many countries that existing empiric therapies may no longer be effective, researchers from UK report."

Prevalence of resistance to commonly prescribed antibiotics in primary care in children with urinary tract infections caused by E. coli is high, and there was remarkable variability in E. coli resistance among countries in the study, particularly in countries outside the OECD (Organization for Economic Cooperation and Development), where one possible explanation is the availability of antibiotics over the counter," Ashley Bryce from the University of Bristol in the U.K. and Dr. Céire E. Costelloe from Imperial College London told Reuters Health in a joint email.

"This could render some antibiotics ineffective as first-line treatments for urinary tract infection," they said.

E. coli is responsible for more than 80% of all UTIs and is also the most common cause of bacteremia and foodborne infections and one cause of meningitis in neonates.

Bryce, Dr. Costelloe, and colleagues investigated the prevalence of resistance in community-acquired E. coli UTI to the most commonly prescribed antibiotics given to children in primary care in their systematic review of 58 published reports.

For all antibiotics tested, the prevalence of antibiotic resistance was higher in non-OECD countries than in OECD countries, the team reports in an article online March 15 in The BMJ.

The prevalence of resistance was highest for ampicillin, ranging from 41% in Switzerland to 100% in Ghana and Nigeria.

Resistance to co-trimoxazole and trimethoprim was 30% in OECD countries and 67% in Saudi Arabia, the only non-OECD country for which rates were available.

Pooled prevalences of resistance to ciprofloxacin and ceftazidime were around 2% in OECD countries but over 26% in non-OECD countries.

For all time periods analyzed, the odds of resistance were greater in children exposed to antibiotics than in those who were unexposed.

"The Infectious Diseases Society of America (IDSA) in collaboration with the European Society for Microbiology and Infectious Diseases (ESCMID) recommend that an antibiotic should be selected for first line empirical treatment of urinary tract infection only if the local prevalence of resistance is less than 20%," the researchers note.

"According to these guidelines, our review suggests ampicillin, co-trimoxazole, and trimethoprim are no longer suitable first line treatment options for urinary tract infection in many OECD countries and that as a result many guidelines, such as those published by the National Institute for Health and Care Excellence (NICE), might need updating," they write. "In non-OECD countries, resistance to all first line antibiotics specified for urinary tract infections was in excess of 20%, suggesting that choices of first line treatment might need to be re-evaluated in less well developed countries."

"We are not able to advise clinicians on which antibiotic is best to prescribe as this often depends on the individual case," Bryce and Dr. Costelloe said. "Clinicians should, however, adhere to local or national guidelines wherever possible, which is why it is of great importance that such guidelines are kept up to date and reflect current resistance rates."

"Clinicians may also wish to consider the antibiotic history of the child when they present to primary care with symptoms of an infection, especially in light of the suggestion of our results that previous treatment with an antibiotic is associated with resistance to that same antibiotic, and that this association may be present up to 6 months post treatment," they added.

Dr. Grant Russell from Monash University in Melbourne, Australia, wrote an editorial accompanying the report. He told Reuters Health by email, "I found the extent of the resistance (and the fact that it covered all of the regularly used empiric antibiotics) both concerning and surprising. The fact that choices are diminishing is disturbing, and the fact that the situation is dire in the developing world is deeply troubling."

"We need to do what we can do to prevent bacterial infections, and when treating them to consider that effective antibiotics are a finite resource," he said. "We all have a responsibility in attempting to conserve that resource."

"No new classes of antibiotics have been developed in the last 30 years - this and the dire situation in both the developed and the developing world suggests that the 'global problem' of antibiotic resistance is going to become more and more of an issue in years and decades to come," Dr. Russell concluded.

NEW YORK (Reuters Health) - The prevalence of antibiotic resistance in pediatric urinary tract infection (UTI) has reached such high levels in many countries that existing empiric therapies may no longer be effective, researchers from UK report."

Prevalence of resistance to commonly prescribed antibiotics in primary care in children with urinary tract infections caused by E. coli is high, and there was remarkable variability in E. coli resistance among countries in the study, particularly in countries outside the OECD (Organization for Economic Cooperation and Development), where one possible explanation is the availability of antibiotics over the counter," Ashley Bryce from the University of Bristol in the U.K. and Dr. Céire E. Costelloe from Imperial College London told Reuters Health in a joint email.

"This could render some antibiotics ineffective as first-line treatments for urinary tract infection," they said.

E. coli is responsible for more than 80% of all UTIs and is also the most common cause of bacteremia and foodborne infections and one cause of meningitis in neonates.

Bryce, Dr. Costelloe, and colleagues investigated the prevalence of resistance in community-acquired E. coli UTI to the most commonly prescribed antibiotics given to children in primary care in their systematic review of 58 published reports.

For all antibiotics tested, the prevalence of antibiotic resistance was higher in non-OECD countries than in OECD countries, the team reports in an article online March 15 in The BMJ.

The prevalence of resistance was highest for ampicillin, ranging from 41% in Switzerland to 100% in Ghana and Nigeria.

Resistance to co-trimoxazole and trimethoprim was 30% in OECD countries and 67% in Saudi Arabia, the only non-OECD country for which rates were available.

Pooled prevalences of resistance to ciprofloxacin and ceftazidime were around 2% in OECD countries but over 26% in non-OECD countries.

For all time periods analyzed, the odds of resistance were greater in children exposed to antibiotics than in those who were unexposed.

"The Infectious Diseases Society of America (IDSA) in collaboration with the European Society for Microbiology and Infectious Diseases (ESCMID) recommend that an antibiotic should be selected for first line empirical treatment of urinary tract infection only if the local prevalence of resistance is less than 20%," the researchers note.

"According to these guidelines, our review suggests ampicillin, co-trimoxazole, and trimethoprim are no longer suitable first line treatment options for urinary tract infection in many OECD countries and that as a result many guidelines, such as those published by the National Institute for Health and Care Excellence (NICE), might need updating," they write. "In non-OECD countries, resistance to all first line antibiotics specified for urinary tract infections was in excess of 20%, suggesting that choices of first line treatment might need to be re-evaluated in less well developed countries."

"We are not able to advise clinicians on which antibiotic is best to prescribe as this often depends on the individual case," Bryce and Dr. Costelloe said. "Clinicians should, however, adhere to local or national guidelines wherever possible, which is why it is of great importance that such guidelines are kept up to date and reflect current resistance rates."

"Clinicians may also wish to consider the antibiotic history of the child when they present to primary care with symptoms of an infection, especially in light of the suggestion of our results that previous treatment with an antibiotic is associated with resistance to that same antibiotic, and that this association may be present up to 6 months post treatment," they added.

Dr. Grant Russell from Monash University in Melbourne, Australia, wrote an editorial accompanying the report. He told Reuters Health by email, "I found the extent of the resistance (and the fact that it covered all of the regularly used empiric antibiotics) both concerning and surprising. The fact that choices are diminishing is disturbing, and the fact that the situation is dire in the developing world is deeply troubling."

"We need to do what we can do to prevent bacterial infections, and when treating them to consider that effective antibiotics are a finite resource," he said. "We all have a responsibility in attempting to conserve that resource."

"No new classes of antibiotics have been developed in the last 30 years - this and the dire situation in both the developed and the developing world suggests that the 'global problem' of antibiotic resistance is going to become more and more of an issue in years and decades to come," Dr. Russell concluded.

(Reuters Health) - Women who develop diabetes while pregnant may be at elevated risk of also developing a dangerous build up of fat in their livers when they reach middle age, according to a new analysis.

The common risk factor for both gestational diabetes and non-alcoholic fatty liver disease, researchers say, is trouble making or using the hormone insulin to manage blood sugar, known as insulin resistance.

"We hope that early identification can promote healthy lifestyle changes that prevent or slow disease progression," said lead author Dr. Veeral Ajmera of the University of California, San Francisco.

"Pregnancy stresses the body in many ways, one of which is the ability to manage blood sugar," Ajmera said by email. "During pregnancy a woman's body becomes more resistant to insulin, which is the hormone required to decrease the blood sugar."

Insulin resistance is also "central to development of non-alcoholic fatty liver disease," which affects 20 percent to 30 percent of adults in the western world, the study team writes in The American Journal of Gastroenterology. Non-alcoholic fatty liver disease is the most common chronic liver disease in the United States.

Fatty liver disease is often diagnosed later in life, Ajmera told Reuters Health. So the researchers used long-term data to see if diabetes during pregnancy made a woman more likely to develop fatty liver disease 25 years later.

The researchers analyzed information about 1,115 black and white women recruited between 1985-1986 in four cities across the United States who gave birth to at least one child.

The participants did not have diabetes before becoming pregnant and the study excluded people who had liver issues related to alcohol, HIV, hepatitis or medications.

At the start of the study, women reported on whether they first experienced diabetes during pregnancy, and researchers confirmed the diagnosis with blood test results. Twenty-five years later, the women received more blood tests as well as CT scans of their livers to check if they had fatty liver disease.

At the beginning of the study, 124 women reported that they developed diabetes while they were pregnant. These women were more likely than those who did not experience gestational diabetes to be overweight. They also had higher degrees of insulin resistance when they were younger as well as at the 25-year follow up.

The women who experienced diabetes during pregnancy were also more likely to have developed diabetes again at some point in the following 25 years.

Overall, 75 women were diagnosed with non-alcoholic fatty liver disease when they were middle aged. Women who had diabetes during pregnancy were more than twice as likely as those who didn't to later develop fatty liver disease.

After researchers adjusted for diabetes that some women experienced outside of pregnancy, the risk of non-alcoholic fatty liver disease was still 50 percent higher for women who had gestational diabetes compared to those who didn't.

Fatty liver disease can have grave health effects and can even lead to cirrhosis, a condition that causes liver damage and possible failure, said Simon Taylor-Robinson, a professor of medicine at Imperial College London in the U.K. who wasn't involved in the study.

He advocates changes in diet to avoid the insulin resistance that leads to diabetes and fatty liver disease. "Many women are obese - so it is a matter of reducing weight and eating sensibly," he said.

Taylor-Robinson recommends eating fewer carbohydrates, more proteins and vegetables, and in particular, avoiding large amounts of fruit juice, which can contain a lot of sugar.

Ajmera also advised lifestyle changes, especially adding exercise. "We recommend either aerobic or resistance training for 30 minutes five times per week," he said.

"There are consequences to obesity and this includes cirrhosis, liver cancer and heart disease," Taylor-Robinson said. "Those people who become diabetic during pregnancy have strong risks of developing these complications later in life if attention isn't given to weight, diet and exercise."

(Reuters Health) - Women who develop diabetes while pregnant may be at elevated risk of also developing a dangerous build up of fat in their livers when they reach middle age, according to a new analysis.

The common risk factor for both gestational diabetes and non-alcoholic fatty liver disease, researchers say, is trouble making or using the hormone insulin to manage blood sugar, known as insulin resistance.

"We hope that early identification can promote healthy lifestyle changes that prevent or slow disease progression," said lead author Dr. Veeral Ajmera of the University of California, San Francisco.

"Pregnancy stresses the body in many ways, one of which is the ability to manage blood sugar," Ajmera said by email. "During pregnancy a woman's body becomes more resistant to insulin, which is the hormone required to decrease the blood sugar."

Insulin resistance is also "central to development of non-alcoholic fatty liver disease," which affects 20 percent to 30 percent of adults in the western world, the study team writes in The American Journal of Gastroenterology. Non-alcoholic fatty liver disease is the most common chronic liver disease in the United States.

Fatty liver disease is often diagnosed later in life, Ajmera told Reuters Health. So the researchers used long-term data to see if diabetes during pregnancy made a woman more likely to develop fatty liver disease 25 years later.

The researchers analyzed information about 1,115 black and white women recruited between 1985-1986 in four cities across the United States who gave birth to at least one child.

The participants did not have diabetes before becoming pregnant and the study excluded people who had liver issues related to alcohol, HIV, hepatitis or medications.

At the start of the study, women reported on whether they first experienced diabetes during pregnancy, and researchers confirmed the diagnosis with blood test results. Twenty-five years later, the women received more blood tests as well as CT scans of their livers to check if they had fatty liver disease.

At the beginning of the study, 124 women reported that they developed diabetes while they were pregnant. These women were more likely than those who did not experience gestational diabetes to be overweight. They also had higher degrees of insulin resistance when they were younger as well as at the 25-year follow up.

The women who experienced diabetes during pregnancy were also more likely to have developed diabetes again at some point in the following 25 years.

Overall, 75 women were diagnosed with non-alcoholic fatty liver disease when they were middle aged. Women who had diabetes during pregnancy were more than twice as likely as those who didn't to later develop fatty liver disease.

After researchers adjusted for diabetes that some women experienced outside of pregnancy, the risk of non-alcoholic fatty liver disease was still 50 percent higher for women who had gestational diabetes compared to those who didn't.

Fatty liver disease can have grave health effects and can even lead to cirrhosis, a condition that causes liver damage and possible failure, said Simon Taylor-Robinson, a professor of medicine at Imperial College London in the U.K. who wasn't involved in the study.

He advocates changes in diet to avoid the insulin resistance that leads to diabetes and fatty liver disease. "Many women are obese - so it is a matter of reducing weight and eating sensibly," he said.

Taylor-Robinson recommends eating fewer carbohydrates, more proteins and vegetables, and in particular, avoiding large amounts of fruit juice, which can contain a lot of sugar.

Ajmera also advised lifestyle changes, especially adding exercise. "We recommend either aerobic or resistance training for 30 minutes five times per week," he said.

"There are consequences to obesity and this includes cirrhosis, liver cancer and heart disease," Taylor-Robinson said. "Those people who become diabetic during pregnancy have strong risks of developing these complications later in life if attention isn't given to weight, diet and exercise."

(Reuters Health) - Women who develop diabetes while pregnant may be at elevated risk of also developing a dangerous build up of fat in their livers when they reach middle age, according to a new analysis.

The common risk factor for both gestational diabetes and non-alcoholic fatty liver disease, researchers say, is trouble making or using the hormone insulin to manage blood sugar, known as insulin resistance.

"We hope that early identification can promote healthy lifestyle changes that prevent or slow disease progression," said lead author Dr. Veeral Ajmera of the University of California, San Francisco.

"Pregnancy stresses the body in many ways, one of which is the ability to manage blood sugar," Ajmera said by email. "During pregnancy a woman's body becomes more resistant to insulin, which is the hormone required to decrease the blood sugar."

Insulin resistance is also "central to development of non-alcoholic fatty liver disease," which affects 20 percent to 30 percent of adults in the western world, the study team writes in The American Journal of Gastroenterology. Non-alcoholic fatty liver disease is the most common chronic liver disease in the United States.

Fatty liver disease is often diagnosed later in life, Ajmera told Reuters Health. So the researchers used long-term data to see if diabetes during pregnancy made a woman more likely to develop fatty liver disease 25 years later.

The researchers analyzed information about 1,115 black and white women recruited between 1985-1986 in four cities across the United States who gave birth to at least one child.

The participants did not have diabetes before becoming pregnant and the study excluded people who had liver issues related to alcohol, HIV, hepatitis or medications.

At the start of the study, women reported on whether they first experienced diabetes during pregnancy, and researchers confirmed the diagnosis with blood test results. Twenty-five years later, the women received more blood tests as well as CT scans of their livers to check if they had fatty liver disease.

At the beginning of the study, 124 women reported that they developed diabetes while they were pregnant. These women were more likely than those who did not experience gestational diabetes to be overweight. They also had higher degrees of insulin resistance when they were younger as well as at the 25-year follow up.

The women who experienced diabetes during pregnancy were also more likely to have developed diabetes again at some point in the following 25 years.

Overall, 75 women were diagnosed with non-alcoholic fatty liver disease when they were middle aged. Women who had diabetes during pregnancy were more than twice as likely as those who didn't to later develop fatty liver disease.

After researchers adjusted for diabetes that some women experienced outside of pregnancy, the risk of non-alcoholic fatty liver disease was still 50 percent higher for women who had gestational diabetes compared to those who didn't.

Fatty liver disease can have grave health effects and can even lead to cirrhosis, a condition that causes liver damage and possible failure, said Simon Taylor-Robinson, a professor of medicine at Imperial College London in the U.K. who wasn't involved in the study.

He advocates changes in diet to avoid the insulin resistance that leads to diabetes and fatty liver disease. "Many women are obese - so it is a matter of reducing weight and eating sensibly," he said.

Taylor-Robinson recommends eating fewer carbohydrates, more proteins and vegetables, and in particular, avoiding large amounts of fruit juice, which can contain a lot of sugar.

Ajmera also advised lifestyle changes, especially adding exercise. "We recommend either aerobic or resistance training for 30 minutes five times per week," he said.

"There are consequences to obesity and this includes cirrhosis, liver cancer and heart disease," Taylor-Robinson said. "Those people who become diabetic during pregnancy have strong risks of developing these complications later in life if attention isn't given to weight, diet and exercise."

(Reuters Health) - Over the last 40 years, heart disease rates have dropped in the U.S. overall, but the changes varied widely by region, with the highest rates of the disease shifting from the Northeast to the South, researchers say.

"The consistent progression southward over the past few decades suggests that the pattern is not random - and could be attributed to geographic differences in prevention and treatment opportunities," said lead author Michele Casper of the CDC's Division for Heart Disease and Stroke Prevention in Atlanta, Georgia.

"Identifying those counties and regions with the greatest burden of mortality is a necessary first step to target appropriate resources that will ultimately reduce death rates," Casper told Reuters Health by email.

The researchers used data on heart disease deaths among people age 35 and over in the U.S. collected in two year intervals, between 1973 and 2010, from more than 3,000 counties of the 48 contiguous states.

Every county saw a decline in heart disease deaths. The average decline across the U.S. was 61%, but some counties only saw a decline of 9% while others cut heart disease deaths by 83%.

At the beginning of the study, heart disease deaths were most common in the Northeast through Appalachia and into the Midwest. Coastal North Carolina, South Carolina and Georgia also had high rates.

Most counties with the lowest death rates were located in the West, with some low-rate counties also scattered in Alabama, Florida and Mississippi.

By 2010, most high-rate counties were still in the eastern half of the country, but in the South, rather than in the North, with some parts of New England becoming pockets with lower death rates.

Declines were slowest in counties in Alabama, Mississippi, Louisiana, Arkansas, Oklahoma and parts of Texas, the authors reported in a paper scheduled for publication in Circulation.

Since the 1970s, national attention on the dangers of cigarette smoking and uncontrolled high blood pressure has led to a significant decline in deaths from coronary heart disease and myocardial infarction, but "heart disease" includes other conditions, such as heart failure, which have not decreased as much, said Dr. Donald A. Barr of Stanford University School of Medicine in California, who wrote an editorial accompanying the new study.

Comparable data for heart failure (associated with diabetes, obesity and underlying hypertension) has not been coming down as fast, Barr told Reuters Health by phone. He noted that heart failure is projected to increase over the next couple of decades, while coronary heart disease is expected to decline.

Heart failure disproportionately affects low-income Americans and African Americans, he said. "These at-risk populations are found in a somewhat higher proportion in those southeastern states."

"Combining heart failure and coronary heart disease under the global term 'heart disease' combines good news with not so good news," Barr said.

There were still meaningful declines in heart disease deaths in the South, Casper noted.

"Heart disease-related deaths are largely preventable, and with targeted public health efforts, it's possible to alleviate much of the heavy burden of this disease and close the geographic gap in declining heart disease death rates," Casper said.

"With collaboration, government agencies, medical care organizations, community groups, businesses and other organizations can provide more local opportunities for physical activity, as well as access to smoke-free spaces, affordable healthy foods, quality healthcare and social and economic well-being," Casper said.

(Reuters Health) - Over the last 40 years, heart disease rates have dropped in the U.S. overall, but the changes varied widely by region, with the highest rates of the disease shifting from the Northeast to the South, researchers say.

"The consistent progression southward over the past few decades suggests that the pattern is not random - and could be attributed to geographic differences in prevention and treatment opportunities," said lead author Michele Casper of the CDC's Division for Heart Disease and Stroke Prevention in Atlanta, Georgia.

"Identifying those counties and regions with the greatest burden of mortality is a necessary first step to target appropriate resources that will ultimately reduce death rates," Casper told Reuters Health by email.

The researchers used data on heart disease deaths among people age 35 and over in the U.S. collected in two year intervals, between 1973 and 2010, from more than 3,000 counties of the 48 contiguous states.

Every county saw a decline in heart disease deaths. The average decline across the U.S. was 61%, but some counties only saw a decline of 9% while others cut heart disease deaths by 83%.

At the beginning of the study, heart disease deaths were most common in the Northeast through Appalachia and into the Midwest. Coastal North Carolina, South Carolina and Georgia also had high rates.

Most counties with the lowest death rates were located in the West, with some low-rate counties also scattered in Alabama, Florida and Mississippi.

By 2010, most high-rate counties were still in the eastern half of the country, but in the South, rather than in the North, with some parts of New England becoming pockets with lower death rates.

Declines were slowest in counties in Alabama, Mississippi, Louisiana, Arkansas, Oklahoma and parts of Texas, the authors reported in a paper scheduled for publication in Circulation.

Since the 1970s, national attention on the dangers of cigarette smoking and uncontrolled high blood pressure has led to a significant decline in deaths from coronary heart disease and myocardial infarction, but "heart disease" includes other conditions, such as heart failure, which have not decreased as much, said Dr. Donald A. Barr of Stanford University School of Medicine in California, who wrote an editorial accompanying the new study.

Comparable data for heart failure (associated with diabetes, obesity and underlying hypertension) has not been coming down as fast, Barr told Reuters Health by phone. He noted that heart failure is projected to increase over the next couple of decades, while coronary heart disease is expected to decline.

Heart failure disproportionately affects low-income Americans and African Americans, he said. "These at-risk populations are found in a somewhat higher proportion in those southeastern states."

"Combining heart failure and coronary heart disease under the global term 'heart disease' combines good news with not so good news," Barr said.

There were still meaningful declines in heart disease deaths in the South, Casper noted.

"Heart disease-related deaths are largely preventable, and with targeted public health efforts, it's possible to alleviate much of the heavy burden of this disease and close the geographic gap in declining heart disease death rates," Casper said.

"With collaboration, government agencies, medical care organizations, community groups, businesses and other organizations can provide more local opportunities for physical activity, as well as access to smoke-free spaces, affordable healthy foods, quality healthcare and social and economic well-being," Casper said.

(Reuters Health) - Over the last 40 years, heart disease rates have dropped in the U.S. overall, but the changes varied widely by region, with the highest rates of the disease shifting from the Northeast to the South, researchers say.

"The consistent progression southward over the past few decades suggests that the pattern is not random - and could be attributed to geographic differences in prevention and treatment opportunities," said lead author Michele Casper of the CDC's Division for Heart Disease and Stroke Prevention in Atlanta, Georgia.

"Identifying those counties and regions with the greatest burden of mortality is a necessary first step to target appropriate resources that will ultimately reduce death rates," Casper told Reuters Health by email.

The researchers used data on heart disease deaths among people age 35 and over in the U.S. collected in two year intervals, between 1973 and 2010, from more than 3,000 counties of the 48 contiguous states.

Every county saw a decline in heart disease deaths. The average decline across the U.S. was 61%, but some counties only saw a decline of 9% while others cut heart disease deaths by 83%.

At the beginning of the study, heart disease deaths were most common in the Northeast through Appalachia and into the Midwest. Coastal North Carolina, South Carolina and Georgia also had high rates.

Most counties with the lowest death rates were located in the West, with some low-rate counties also scattered in Alabama, Florida and Mississippi.

By 2010, most high-rate counties were still in the eastern half of the country, but in the South, rather than in the North, with some parts of New England becoming pockets with lower death rates.

Declines were slowest in counties in Alabama, Mississippi, Louisiana, Arkansas, Oklahoma and parts of Texas, the authors reported in a paper scheduled for publication in Circulation.

Since the 1970s, national attention on the dangers of cigarette smoking and uncontrolled high blood pressure has led to a significant decline in deaths from coronary heart disease and myocardial infarction, but "heart disease" includes other conditions, such as heart failure, which have not decreased as much, said Dr. Donald A. Barr of Stanford University School of Medicine in California, who wrote an editorial accompanying the new study.

Comparable data for heart failure (associated with diabetes, obesity and underlying hypertension) has not been coming down as fast, Barr told Reuters Health by phone. He noted that heart failure is projected to increase over the next couple of decades, while coronary heart disease is expected to decline.

Heart failure disproportionately affects low-income Americans and African Americans, he said. "These at-risk populations are found in a somewhat higher proportion in those southeastern states."

"Combining heart failure and coronary heart disease under the global term 'heart disease' combines good news with not so good news," Barr said.

There were still meaningful declines in heart disease deaths in the South, Casper noted.

"Heart disease-related deaths are largely preventable, and with targeted public health efforts, it's possible to alleviate much of the heavy burden of this disease and close the geographic gap in declining heart disease death rates," Casper said.

"With collaboration, government agencies, medical care organizations, community groups, businesses and other organizations can provide more local opportunities for physical activity, as well as access to smoke-free spaces, affordable healthy foods, quality healthcare and social and economic well-being," Casper said.