Pharmacy points

The Iowa Senate on Monday voted 42-6 to approve a bill (HF 2539) that would expand Hawk-I coverage to tens of thousands more children, the Des Moines Register reports. Hawk-I is the state’s version of SCHIP. The legislation would increase the income eligibility threshold from about $41,000 for a family of four to about $62,000. The expansion would cost an estimated $5 million next year and about $25 million annually by 2011. The bill also would allow young adult children to remain on their parents’ health insurance, encourage the use of electronic health records and create a consumer advocate position in the Iowa Insurance Division. The measure does not include a mandate that all children have health coverage.

Details of the expansion would be determined by a commission, and the state Legislature would consider the recommendations next year. The bill now moves back to the House, which approved similar legislation in March (Leys, Des Moines Register, 4/8).

Reprinted with kind permission from http://www.kaisernetwork.org. You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery at http://www.kaisernetwork.org/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork.org, a free service of The Henry J. Kaiser Family Foundation© 2005 Advisory Board Company and Kaiser Family Foundation. All rights reserved.

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The current wage slowdown in the U.S. has a number of causes and has “been building for a long time,” and in recent years, the “cost of health care has aggravated the problem by taking a huge bite out of most workers’ paychecks,” columnist David Leonhardt writes in the New York Times. Leonhardt refers to a conversation with Ezekiel Emanuel of NIH, writing that, a “serious effort to curtail wasteful medical spending would directly help workers” and “spare them from paying the insurance premiums and taxes that cover that care.”

Leonhard suggests “job-creating investments in biomedical research” and other areas, and writes that presidential candidates Sens. Hillary Rodham Clinton (D-N.Y.), Barack Obama (D-Ill.) and John McCain (R-Ariz.) have discussed similar ideas. However, he adds that “there is still a lack of strategic seriousness to the discussion.” Leonhardt concludes that, because the economy “seems to be in recession, and recessions inevitably bring their own pay cuts, my guess is that the problem will look even bigger by the time the next president takes office” (Leonhardt, New York Times, 4/9).

Reprinted with kind permission from http://www.kaisernetwork.org. You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery at http://www.kaisernetwork.org/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork.org, a free service of The Henry J. Kaiser Family Foundation© 2005 Advisory Board Company and Kaiser Family Foundation. All rights reserved.

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Women who took conjugated equine estrogen, a commonly prescribed form of estrogen, had more than twice the risk of developing specific types of benign breast disease as women who took a placebo, according to a randomized controlled trial published online April 8 in the Journal of the National Cancer Institute.

The impact of conjugated equine estrogen on the risk of developing benign proliferative breast disease, a condition that is associated with increased risk of breast cancer, has been unclear. Some studies have reported an association while others have not. In the Women’s Health Initiative study, 10,739 postmenopausal women with hysterectomy were assigned to either conjugated equine estrogen or a placebo. Previous analyses did not show an increase in breast cancer incidence in the women who took estrogen alone after a median follow-up of seven years.

To determine whether the hormone increases the risk of benign proliferative breast disease, Tom Rohan, M.D., Ph.D., of the Albert Einstein College of Medicine in New York and colleagues identified and examined non-cancerous breast biopsies in each of the Women’s Health Initiative trial arms.

A total of 232 cases of benign proliferative breast disease were identified, with 155 cases among the women who took estrogen supplements and 77 in the placebo group. The risk of developing benign disease increased by more than two-fold for women taking conjugated equine estrogen, compared with those taking a placebo.

“The prevailing hypothesis concerning the natural history of breast cancer is that benign proliferative breast disease without atypia, proliferative disease with atypia, and in situ cancer represent successive steps preceding the development of invasive breast [cancer]. In keeping with this hypothesis, women with benign proliferative breast disease have an increased risk of subsequent breast cancer,” the authors write.

Although the women taking conjugated equine estrogen have not yet shown a significant increased risk of breast cancer in the Women’s Health Initiative study, if this hypothesis holds true, they might show increased risk later. Ongoing follow up of the study participants may help to resolve this issue.

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Article adapted by Medical News Today from original press release.
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The Journal of the National Cancer Institute is published by Oxford University Press and is not affiliated with the National Cancer Institute. Attribution to the Journal of the National Cancer Institute is requested in all news coverage. Visit the Journal online at http://jnci.oxfordjournals.org/.

Source:
Liz Savage
Journal of the National Cancer Institute

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One month of tough breathing may help asthma sufferers breathe easier in the long run, according to research from one University of Houston professor.

In a move that challenges one of the most basic tenets of the Hippocratic Oath - first do no harm - Richard Bond, associate professor of pharmacology at UH, is relying on a long-standing medical taboo to treat asthma. Although counterintuitive, Bond’s studies are reminiscent of hair-of-the-dog folk wisdom to treat like with like, in this case using beta blockers (or antagonists) instead of stimulants (or agonists) in asthmatics.

Coining the term “paradoxical pharmacology” - treating patients with medicine that initially worsens their symptoms before eventually improving their overall health - Bond first applied this hypothesis in studies with mice and then moved on to two clinical trials with humans. Currently in the second clinical trial, the part of this research analyzing mice was recently published in the American Journal of Respiratory Cell and Molecular Biology, which cited the relevance of Bond’s work as possibly leading to a paradigm shift in the treatment of asthma. The results of the first human trial were also recently published in Pulmonary Pharmacology and Therapeutics.

Acute asthma attacks have traditionally been treated with inhaler-type stimulant drugs that open constricted airways. Giving beta blockers to asthmatics has long been thought to be contraindicated, because their acute use may cause increased airway resistance. While the use of beta-stimulants is known to provide temporary relief, their effectiveness declines over time.

Bond’s tests initially done on asthmatic mice and later replicated in his first clinical trial with humans showed that while beta blockers initially made breathing problems worse, their continued use resulted in improved respiratory function after a 28-day period. These longer-term effects demonstrate that chronic use of beta blockers alleviates asthma by helping the smooth muscle lining the airways to relax and dilate, thereby allowing air to flow more freely.

“In order to move certain ideas forward, science often needs to be a collaborative effort,” Bond said. “You must find the right people willing to act as a team. I have been very lucky in that people have given my ideas a chance.”

Enlisting the help of some pulmonologists in the Texas Medical Center, Bond collaborated with Dr. Nick Hanania at The Baylor College of Medicine on both human trials. Also, Dr. Burton Dickey, chair of the department of pulmonary medicine at M.D. Anderson Cancer Center, and his colleagues decided to assist Bond’s research efforts when the mouse studies showed that chronic beta-blocker treatment has significant anti-inflammatory effects.

Using beta blockers when it seems a stimulant is called for defies medical dogma, but this is not a new concept. Bond’s work builds on an earlier breakthrough in treating congestive heart failure (CHF), in which case patients had been treated for decades with stimulant drugs to increase cardiac output. Beta blockers were prohibited because they initially further reduced the heart’s pumping power, but the stimulants ultimately caused the heart to wear out over time from the increased activity.

About a decade ago, the thinking on beta-blocker therapy was reversed when researchers discovered that although treatment with beta blockers reduced cardiac activity at first, the prognosis reversed itself after two to three months. This treatment shift reduced the mortality rate among CHF patients by up to 65 percent.

“Decades of conventional wisdom were overturned, and beta blockers replaced stimulants as the top drug for CHF patients,” Bond said. “For 30 years, intellect told us that beta blockers wouldn’t work to treat these patients, and unfortunately millions of heart patients died prematurely. It would be a tragedy to not have learned from that lesson.”

With his work based on this precedent, Bond points out that beta blockers are not the only example of paradoxical pharmacology. Hyperactive children are treated with the amphetamine-like Ritalin®, and the skin irritant retinoic acid is used to treat acne. Additionally, there has been research into using antipsychotic drugs traditionally used for schizophrenic patients to decrease the incidence of Alzheimer’s disease by suppressing the dopamine system, which is hypoactive in such neurodegenerative diseases. These examples further the case for investigating paradoxical approaches like Bond’s.

In Bond’s first clinical trial, he and his colleagues saw similar results in humans to what was seen in the mouse models. Mild asthmatics were treated for nine weeks with the beta blocker nadolol, with all subjects tolerating the drug and 80 percent experiencing a reduction in airway hyperresponsiveness. Laying the groundwork for continuing studies with beta blockers in the treatment of asthma, the results suggest there may be a way to counteract some of the negative aspects of traditional treatments.

“The principle that certain pharmacological compounds have different effects depending upon whether they are given for long or short periods has been demonstrated,” Bond said. “And even if I am correct about beta blockers ultimately being used in the treatment of asthma, there probably always will be a need for the inhaler-type agonist drugs to handle acute asthma attacks. I do believe, though, that beta blockers hold promise in a maintenance or preventative regimen that could reduce the number or severity of attacks and improve a patient’s quality of life.”

This research has received funding from the National Institutes of Health, as well as from two San Francisco-based organizations - a private biotechnology company called Inverseon and the philanthropic Sandler Program for Asthma Research. As the scientific founder of Inverseon, Bond leads a distinguished panel of scientists on the company’s advisory board, including Nobel Laureate in Medicine Sir James Black, who is considered the “father of beta blockers.”

“If we continue down this path, replicating these results, this paradoxical approach to asthma treatment may well become an important new approach to asthma therapy,” said Dr. William J. Garner, CEO of Inverseon. “We’ve already engaged in discussions with major pharmaceutical companies about taking this to the next level and are actively seeking additional funding for eventual product development.”

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Article adapted by Medical News Today from original press release.
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Source: Lisa Merkl
University of Houston

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Missouri Republican House leaders have introduced legislation that would expand health coverage to low-income state residents and require beneficiaries to contribute money to savings accounts to use toward deductibles and copayments, the St. Louis Post-Dispatch reports. The proposal, called “Insure Missouri,” is intended to replace a proposal of the same name by Gov. Matt Blunt (R). Blunt’s proposal failed to garner enough support among lawmakers.

Under the Republican proposal, individuals with annual incomes less than 85% of the federal poverty level would be eligible for coverage. Eventually, the income threshold could reach 225% of the poverty level. Beneficiaries would use a state Web site to purchase individual insurance policies with a set package of benefits. People who were denied coverage by insurers would be able to participate in a high-risk pool. The state would pay the premiums.

Beneficiaries also would be required to contribute 1% to 5% of their annual incomes, based on a sliding scale, to a savings account to pay deductibles and copays. Those who do not comply with the savings component would lose coverage. Deductibles could be as much as $2,500. The first $300 in preventive health care and two doctor visits would not be subject to deductibles or copays. The bill also would call for changes to the certification process for new medical facilities and enforce a price transparency mandate.

The proposal initially would cost the state an estimated $46 million and expand coverage to an additional 77,000 state residents (Young, St. Louis Post-Dispatch, 4/7).

Reprinted with kind permission from http://www.kaisernetwork.org. You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery at http://www.kaisernetwork.org/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork.org, a free service of The Henry J. Kaiser Family Foundation. © 2005 Advisory Board Company and Kaiser Family Foundation. All rights reserved.

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Not eating your apple a day? Perhaps you should be. Adults who eat apples, apple juice and applesauce have a significantly reduced risk of metabolic syndrome, a cluster of health problems that are linked to numerous chronic diseases such as diabetes and cardiovascular disease.

The study results, presented at the Experimental Biology 2008 meeting this week, were derived from an analysis of adult food consumption data collected in the 1999-2004 National Health and Nutrition Examination Survey (NHANES), the government’s largest food consumption and health database.

Dr. Victor Fulgoni analyzed the data, specifically looking at the association between consumption of apples and apple products, nutrient intake and various physiological parameters related to metabolic syndrome. When compared to non-consumers, adult apple product consumers had a 27% decreased likelihood of being diagnosed with metabolic syndrome.

Fulgoni notes, “We found that adults who eat apples and apple products have smaller waistlines that indicate less abdominal fat, lower blood pressure and a reduced risk for developing what is known as the metabolic syndrome.”

In addition to having a 30% decreased likelihood for elevated diastolic blood pressure and a 36% decreased likelihood for elevated systolic blood pressure, apple product consumers also had a 21% reduced risk of increased waist circumference - all predictors of cardiovascular disease and an increased likelihood of metabolic syndrome. Additionally, adult apple product consumers had significantly reduced C-reactive protein levels, another measurable marker related to cardiovascular risk.

Furthermore, apple product consumers’ diets were healthier than non-consumers - they had an overall greater intake of fruit and key nutrients, including dietary fiber, vitamins A and C, calcium and potassium. These consumers also ate less total fat, saturated fat, discretionary fat and added sugars.

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Article adapted by Medical News Today from original press release.
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Metabolic syndrome is believed to affect an estimated 36 million Americans. Metabolic syndrome, also known as Syndrome X and insulin resistance syndrome, is defined as having three or more of the associated symptoms, which include elevated blood pressure, increased waist size and abdominal fat, and elevated c-reactive protein levels.

Fulgoni, V., Fulgoni S., Haaga, S., Ebert, A. Apple consumption is associated with increased nutrient intakes and reduced risk of metabolic syndrome in adults from the National health and Nutrition Examination Survey (1999-2004). Experimental Biology 2008 Poster Presentation (unpublished).

Source:
Stacie Haaga
U.S. Apple Association

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The New York Daily News on Sunday examined a needle-exchange program in the New York City borough of Queens (Colangelo, New York Daily News, 4/6). The program, administered by the AIDS Center of Queens County, launched in November 2004.

The center began operating the needle-exchange program after garnering the support of New York City Mayor Michael Bloomberg, Department of Health Commissioner Thomas Frieden and Queens Borough President Helen Marshall (D) (Kaiser Daily HIV/AIDS Report, 12/14/04). Even with such “powerful support,” the center “treads carefully” as it works to expand needle exchanges in Long Island City, Jamaica, Far Rockaway and Corona, the Daily News reports. Although the center has encountered “initial resistance” in most locations, compromises and “continual meetings with local officials have smoothed the way,” according to the Daily News.

The center estimates that 70% of the syringes handed out are returned. “We know that when they bring syringes back to us, it means the syringes are not being disposed of improperly,” Steven Fox, the center’s harm reduction coordinator, said, adding, “It also means they’re not being shared.” According to the Daily News, part of the program’s success lies in its use of peer outreach workers — former or current injection drug users who go out into the communities and explain the importance of using clean needles, register new clients and distribute packs to help IDUs safely dispose of their needles.

Philip Glotzer, executive director of the center, said it is part of the center’s “no-pressure” approach. “Until you can get the person to the place where they’re ready to make healthier decisions, you at least keep them as healthy as can be,” Glotzer said (New York Daily News, 4/6).

Reprinted with kind permission from http://www.kaisernetwork.org. You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery at http://www.kaisernetwork.org/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork.org, a free service of The Henry J. Kaiser Family Foundation. © 2005 Advisory Board Company and Kaiser Family Foundation. All rights reserved.

A new study from Northwestern University’s Feinberg School of Medicine in Chicago reveals that use of minimally invasive endovascular stent grafts for the treatment of thoracic aortic disease is a viable alternative for patients who might not be able to survive open surgery.

“Traditional, open surgical management of thoracic aortic disease is a highly morbid, and often mortal process, especially when we treat the very elderly or patients with other pre existing illnesses,” said co-author Mark D. Morasch, MD, Associate Professor in the Division of Vascular Surgery. “New, minimally invasive endovascular techniques that use stent-grafts to treat these aortic problems have been developed as alternatives to these highly morbid open operations.”

In this study, the authors reviewed the early and mid-term results of these minimally invasive procedures in a high risk group of patients who were treated at one academic medical center.

One hundred fifteen patients were followed after treatment of a number of different types of aortic diseases including aneurysms, vessel tears from trauma, intramural hematomas and dissections. The patients were followed closely for an average of 15 months (range 1 to 78 months) after the endograft was placed. Thirty-five percent of the endografts were placed under emergent circumstances, including aneurysm rupture or acute aortic tear, where open surgery is known to be extremely risky. In 24 percent of the cases, one or more major aortic branch had to be moved or bypassed with an additional small operation prior to delivering the endograft to prevent compromise to important circulation.

Five percent of the patients treated in this study died following surgery, which compares very favorably with historic results from similar high-risk patients who undergo open an open operation. Despite the minimally invasive nature of the procedure, many patients still had some type of complication related to the treatment and in a few cases, repeat treatments were required to keep the patients safe.

“These advances in endovascular technology have allowed many patients to undergo much-needed life saving procedures who otherwise may not have survived treatment,” said Morasch. “On the other hand, some elderly and infirmed may not fare well even with a ‘minimally invasive’ therapy.”

Morasch added, “Unlike with open surgical repair, the long term durability of these minimally invasive therapies remains to be seen making long-term imaging surveillance necessary to monitor for a need for repeat intervention. Overall, the use of endografts for the treatment of thoracic aortic pathology is safe, effective and clearly a positive step forward but it does still carry risk in the complex patient population who come for endovascular repair.”

Full details of the researchers’ findings are available in the April issue of the Journal of Vascular Surgery.

About Journal of Vascular Surgery

Journal of Vascular Surgery provides vascular, cardiothoracic and general surgeons with the most recent information in vascular surgery. Original, peer-reviewed articles cover clinical and experimental studies, noninvasive diagnostic techniques, processes and vascular substitutes, microvascular surgical techniques, angiography and endovascular management. Special issues publish papers presented at the annual meeting of the Journal’s sponsoring society, the Society for Vascular Surgery. Visit the Journal web site at http://www.jvascsurg.org.

About the Society for Vascular Surgery

The Society for Vascular Surgery (SVS) is a not-for-profit society that seeks to advance excellence and innovation in vascular health through education, advocacy, research and public awareness. SVS is the national advocate for 2,400 vascular surgeons dedicated to the prevention and cure of vascular disease. Visit the website at http://www.VascularWeb.org.

Society for Vascular Surgery
633 N. St. Clair, 24th Fl.
Chicago, IL 60611
United States
http://www.vascularweb.org

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An article published in the open-access journal PLoS Medicine reports on the development and testing of two user-friendly methods that use changes in cross-sectional HIV prevalence (the fraction of the population infected with HIV) to estimate HIV incidence (the number of new infections occurring during a specific time period). Timothy Hallett (Imperial College London) and colleagues suggest that the incidence of HIV can be estimated from repeat surveys of prevalence with enough accuracy to monitor the epidemic.

Currently, 33 million people are infected with HIV (the virus that causes AIDS), and AIDS has already killed more than 25 million people. Working to thwart this epidemic, governments and international agencies have been assessing the impact of interventions by keeping track of how the virus spreads. Usually, agencies monitor generalized epidemics (ones that have spread to the whole population) by determining the prevalence of HIV infection among women who attend antenatal clinics. More accurate measures of HIV prevalence are being acquired by testing blood for antibodies related to the AIDS virus (serological testing).

Researchers, though still interested in prevalence, are also concerned with the incidence of the virus in order to gage how the epidemic changes over time and how the virus is transmitted. However, measures of incidence are generally more costly - researchers would have to identify individuals, test their blood and then repeatedly follow up the same individuals. Hallett and colleagues tackle this problem by developing mathematical methods that allow one to use prevalence data to estimate the incidence of HIV in generalized epidemics.

Realizing that changes in HIV incidence and mortality rates contribute to changes in HIV prevalence, the researchers developed models that include methods to disentangle these features. The first method combines information on mortality rates collected in cohort studies of HIV infection, while the second method uses data collected in long-running cohort studies that focuses on survival after HIV infection. Computer-simulated data and real data on HIV prevalence and incidence from cohort studies in Zimbabwe, Uganda, and Tanzania were used to assess the accuracy of the two methods. Both estimation methods resulted in accurate predictions of HIV incidence from the simulated data. When the data from Africa were used, the average difference between actual incidence measurements and estimates was 19% from the first method 14% from the second method.

“Neither method tends to systematically over- or underestimate incidence,” write the authors.

These findings indicate that repeat surveys of prevalence can help estimate HIV incidence rates with sufficient accuracy to monitor the epidemic. One potential weakness of the study is that it may be difficult to generalize to other parts of Africa where HIV epidemics are restricted to subsets of the populations. As the availability of prevalence measures from blood tests increases, the new methods presented for estimating HIV incidence from HIV prevalence could be very useful for tracking the progress of national epidemics and for informing HIV control programs.

Estimating incidence from prevalence in generalised HIV epidemics: Methods and validation
Hallett TB, Zaba B, Todd J, Lopman B, Wambura M, et al.
PLoS Medicine (2008). 5(4): e80.
doi:10.1371/journal.pmed.0050080
Click Here to View Article

About PLoS Medicine

PLoS Medicine is an open access, freely available international medical journal. It publishes original research that enhances our understanding of human health and disease, together with commentary and analysis of important global health issues. For more information, visit http://www.plosmedicine.org

About the Public Library of Science

The Public Library of Science (PLoS) is a non-profit organization of scientists and physicians committed to making the world’s scientific and medical literature a freely available public resource. For more information, visit http://www.plos.org

Written by: Peter M Crosta
Copyright: Medical News Today
Not to be reproduced without permission of Medical News Today

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African countries should increase health sector funding to mitigate worker shortages and prevent deaths from the continent’s five leading causes of death, including HIV/AIDS, the African Public Health Rights Alliance said Thursday, Reuters reports. Rotimi Sankore, coordinator of the group, urged African countries to allocate 15% of their annual budgets to the health sector to reduce the migration of health workers to wealthier nations (Nyambura-Mwaura, Reuters, 4/3).

More than 13,000 health workers trained in sub-Saharan African countries now practice in Australia, Britain, Canada and the U.S., according to an article recently published in the Lancet. Recruiting agencies use workshops, advertisements, e-mails and Web sites to attract health workers, according to the article. The agencies generally offer to pay higher salaries, cover moving expenses and provide assistance navigating the visa and citizenship process. The practice of recruiting trained health personnel from sub-Saharan Africa to work in developed nations is weakening health infrastructures and undermining efforts to fight HIV/AIDS in the region, the article said. In Africa, training the 1.5 million new health workers needed to resolve the shortage would cost about $3.3 billion annually during the next eight years (Kaiser Daily HIV/AIDS Report, 3/7).

Developing countries should “invest in health workers and professionals,” Sankore said, adding that if they do not, developed countries “will poach them and subsidize their own economies using our health workers.” Health spending should be an absolute priority because otherwise, investment in other sectors is “superfluous because everybody would have died out,” Sankore said. According to Sankore, Botswana has allocated 23% of its budget to health care, and Mauritius and Seychelles have allocated about 15% each. All other African countries have allocated only 3% to 9%, Sankore said. He added that compensation from countries that recruit health workers is not the solution. “Giving back [compensatory funds] to the developing world is not enough, because apart from the money lost in training those people, we are also losing lives,” Sankore said, adding that “those health professionals live there and contribute to that economy” (Reuters, 4/3).

Reprinted with kind permission from http://www.kaisernetwork.org. You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery at http://www.kaisernetwork.org/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork.org, a free service of The Henry J. Kaiser Family Foundation© 2005 Advisory Board Company and Kaiser Family Foundation. All rights reserved.

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