Smoking bans may reduce hospitalizations for heart attack, asthma.

AMA Morning Rounds

Leading the News
Smoke-free workplace laws may be linked to lower heart attack rates.
The Washington Post (10/30, Huget) "The Checkup" blog reports, "A decline in the number of cases of myocardial infarction, or heart attack, in one Minnesota county appears linked to smoke-free workplace laws in that area, research published Monday in the Archives of Internal Medicine finds."
The New York Times (10/30, O'Connor) "Well" blog reports that "the study examined medical data in Olmsted County, which has a population of about 144,000, over two periods: the 18 months before the county banned smoking in restaurants in 2002, and the 18 months after it extended the ban to bars and all workplaces in 2007."
The Los Angeles Times (10/30, Healy) "Booster Shots" blog reports, "Banning indoor tobacco use from restaurants and workplaces drove down the rate of heart attacks by one-third in Olmsted County and reduced sudden cardiac death rates there by 17%." The researchers "found that outlawing tobacco smoke in restaurants alone was not enough to have any discernible effect: It was not until phase 2 of the Olmsted County ordnance was implemented--forbidding cigarette smoking inside of bars and workplaces as well--that the full influence of the measure became clear."
MedPage Today (10/30) reports, "Other studies of smoke-free workplace and public place laws have pointed to declines in acute MI rates and hospitalizations, fewer asthma admissions among children, and improved quality of life, Sara Kalkhoran, MD, and Pamela M. Ling, MD, MPH, both of the University of California San Francisco, pointed out in an invited commentary." Also covering the story are the NPR (10/30, Shute) "Shots" blog and Reuters (10/30, Pittman).
Smoking bans may reduce hospitalizations for heart attack, asthma. USA Today (10/30, Szabo) reports, "Smoking bans quickly and dramatically cut the number of people hospitalized for heart attacks, strokes and respiratory diseases such as asthma and emphysema, an analysis" of 45 studies, "the largest analysis of smoke-free legislation to date." Investigators found that "heart attack hospitalizations fell an average of 15% after communities passed laws banning smoking in areas such as restaurants, bars and workplaces." The researchers reported that "stroke hospitalizations fell 16%."
The Indianapolis Star (10/30, Berggoetz) reports, "The laws also were rapidly followed by a 24 percent decrease in hospitalizations for respiratory diseases, such asthma and chronic obstructive pulmonary disease."
HealthDay (10/30, Reinberg) reports, "The largest decreases in hospitalizations were seen in areas with the most restrictive policies - for instance, those that ban smoking in workplaces, restaurants and bars."
MedPage Today (10/30, Petrochko) reports, "The laws did not significantly reduce hospitalizations or death for transient ischemic attack, chronic obstructive pulmonary disease, or spontaneous pneumothorax." The research was published in Circulation.

From the AMA
Did you know? The AMA has been the leading advocate for improving health outcomes for 150 years. That’s right. In the early years, improving health outcomes meant protecting patients from patent medicines and “doctors” without medical training. Now it means developing clinical and patient-reported outcomes that ensure health equity and advance quality and safety. Learn more through the AMA’s weekly “Did You Know?” feature, which shares selected facts showing how the AMA has improved the nation’s health care system for America’s physicians and patients throughout its history.

Government and Medicine
States struggle to meet exchange deadline, citing "little guidance."
USA Today (10/29, Kennedy) reports that some states trying to meet the Nov. 16 deadline on healthcare exchanges are finding they have "so little guidance that they're afraid they'll have to make changes as more regulations come out after the presidential election." USA Today says most states "are starting from scratch," and the "limited guidance from the feds means that state officials need to answer some hard questions, such as...exactly what meets government regulations for mental health care." USA Today also runs an accompanying chart from the Kaiser Family Foundation that tallies the latest state decisions.
Idaho governor's task force recommends state build healthcare exchange. The Idaho Reporter (10/29, Hill) reports that Gov. Butch Otter's healthcare exchange task force voted 11 to 2 to recommend that the state create its own exchange, but Otter's office responded that he has made no decision yet on this "non-binding recommendation." His spokesman Jon Hanian said, "The governor appreciates the work of the group, and he can now act on it, or reject it or pursue a different course. He has made no decisions about this as yet."
Medical-Legal Landscape
California officials investigate allegations against HealthCare Partners.
The Los Angeles Times (10/30, Terhune) reports, "The California Department of Managed Health Care said Monday that it is 'reviewing the allegations that HealthCare Partners is operating as a health plan without a license.'" HealthCare Partners says it is "in full compliance with state and federal law." The Times adds, "HealthCare Partners is the largest operator of medical groups in the U.S., with a major presence in Southern California, Nevada and Florida." DaVita Inc. announced in May they would acquire HealthCare Partners for $4.42 billion and "state officials said they had no jurisdiction over the deal."
Health Coverage and Access
ACA high-risk pool "barely inched upward" during August.
CQ (10/29, Adams, Subscription Publication) reports that "the number of patients in the high risk pool program authorized by the 2010 health care overhaul barely inched upward in August to 86,072 from 82,000 in July, according to the most recent estimates released this month." That is "far below original enrollment expectations," pegged at 375,000 for the first year of the program out of the estimated 9 million people with pre-existing conditions. August's number "was lower than it had been in some previous months." CQ notes that CMS stopped an outreach program in May that was geared to getting referrals for patients from insurance agents and brokers.
Report: ACA's coverage subsidy cost 25% higher than first forecast.
CQ (10/30, Subscription Publication) reports, "The American Action Forum, an organization of right-leaning policy analysts headed by Douglas Holtz-Eakin, released a report Monday showing rising estimates of the costs of subsidies under the health care law to buy insurance." The report highlights a cost of $574 billion, some 25 percent more than the CBO projection of $462 billion that accompanied the ACA. The new number showed up in "a CBO reanalysis" done after the Supreme Court ruling on the ACA, and Holtz-Eakin, a former CBO director, wanted "to highlight this." He speculated that CBO originally "had a much more optimistic outlook for the recovery."
The Hill (10/29, Baker) reports in its "Healthwatch" blog that the report said of the new estimate, "Given the continued rise in health care costs in the United States, the stagnation of incomes during the post-2009 recovery, and the large upside risk due to employers no longer providing insurance, there is substantial reason to suspect that the price tag could rise much further yet."
Quality and Safety
Meningitis outbreak spreads to 19th state.
Reuters (10/30, McCune) reports that the meningitis outbreak has spread to 19 states, as the CDC announced Rhode Island's first case on Monday. 23 states nationwide received medication from the Massachusetts pharmacy linked to the outbreak, and now just four have not reported an instance of the disease. Per the CDC announcement, the total number of cases has now reached 347, up from 337 on Saturday.
CBS News (10/30, Jaslow) reports that Rhode Island joins Florida, Georgia, Idaho, Illinois, Indiana, Maryland, Michigan, Minnesota, New Hampshire, New Jersey, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, Texas and Virginia in reporting at least one case in the outbreak.
MedPage Today (10/30, Smith) reports, "The fallout from the fungal meningitis outbreak continues to spread with two more compounding pharmacies coming under fire, as the number of reported cases hits 354."
Ohio reports two more cases of meningitis. The AP (10/30) reports that Ohio has reported two more cases in the meningitis outbreak, bringing the total in that state to 13 cases. The AP notes that this comes as Ohio "cracks down on pharmacies that custom-mix prescriptions," like the Massachusetts facility linked with the outbreak. Jesse L. Wimberly, pharmacy inspector for the Ohio State Board of Pharmacy, said, "Now we're going to every one of these pharmacies that are designated for compounding."
The Columbus (OH) Dispatch (10/30, Crane) reports on the new Ohio cases, adding, "The Ohio Department of Health knows of 425 Ohioans who received the shots. Because of the long incubation period of this type of fungal meningitis, concerns remain for patients months after treatment with the steroids."
Report calls for more oversight over compounding pharmacies. The Hill (10/30, Viebeck) "Healthwatch" blog reports that Rep. Edward Markey (D-MA) released a report Monday "that chronicles the rise of compounders, which remix medicines for patients with special needs, and the patchwork of regulations that applies to them." Stemming from the ongoing meningitis outbreak which originated at one such pharmacy in Markey's state, his report "builds a case for stricter Food and Drug Administration (FDA) authority over compounders and charges the industry with evading attempts at oversight." The report reads in part, "Absent clear new statutory authority, FDA's efforts will ultimately be constrained by gaps in regulatory authority and thwarted by an industry that has historically resisted a federal role for the oversight of its activities."
Modern Healthcare (10/30, Lee, Subscription Publication) adds that prior to the meningitis outbreak, the FDA "had documented at least 23 deaths and 86 illnesses or injuries associated with problematic compounding pharmacy practices." The report spoke of "more than a decade of violations and problems at compounding pharmacies throughout the nation."
Reuters (10/30, Morgan) reports that in response to Markey's investigation, FDA Commissioner Margaret Hamburg said her agency will work with Congress to get "the authority we need to help prevent tragedies like this from happening again."
CQ (10/30, Norman, Subscription Publication) reports, that Markey's investigation showed that "for years the Food and Drug Administration has attempted to impose regulatory control over pharmacy compounders, but has been met with resistance from some industry members"
The Boston Globe (10/30, Calvan) reports on Markey's report, writing that "lawmakers' calls for tougher regulation of compounding pharmacies are nothing new. Over decades, there have been a series of attempts at the federal level to rein in a business that has largely evaded the kind of stringent oversight established drug makers face."
The Baltimore Sun (10/30, Walker) reports that in addition to finding the FDA had poor oversight of compounding pharmacies, the report also found that "the state board that regulate those pharmacies are doing an inadequate job." It read, "This analysis makes clear that state regulators are not, or cannot, perform the same sort of safety-related oversight of compounding pharmacy practices that FDA has historically undertaken." The Sun characterizes this as "argu[ing] for federal oversight of the facilities."
The Tennessean (10/30, Roche) reports further on the state pharmacy board angle, writing, "The report details congressional efforts to give the FDA clear control over the growing industry, but notes that court rulings have left unclear just when and how the FDA can step in. Provisions in a 1997 law governing compounding firms were struck down by one court ruling, then seemingly partially reaffirmed by another, the report states, adding that the FDA has subsequently tried to clarify its authority by issuing a compliance policy guide." Echoing this, the report reads, "FDA's efforts to assure the safety of compounding pharmacies have been challenged at every juncture by some members of the compounding pharmacy sector."
FDA investigating two more drugs from NECC. The AP (10/30) reports that health officials are now investigating two additional drugs from the New England Compounding Center, which "has been under scrutiny since last month, when a rare fungal form of meningitis was linked to its steroid shots used mostly for back pain." The announcement, which the FDA made Monday, "followed reports of three new infections. One is a report of a possible meningitis illness in a patient who got a spine injection of another type of steroid made by the company. The agency also learned of two heart transplant patients who got fungal infections after being given a third company product during surgery."
Florida cracking down on compounding pharmacies. The NBC News (10/30) "Vitals" blog reports that the Florida Department of Health has acted to suspend operations at a compounding pharmacy in Boca Raton, called Rejuvi Pharmaceuticals. This comes as states are cracking down nationwide against facilities similar to the New England Compounding Center, linked to the deadly meningitis outbreak.
Physicians report worries surrounding steroid shots, compounding pharmacies. American Medical News (10/30, O'Reilly) reports that following the deadly meningitis outbreak linked to drugs made at a compounding pharmacy in Massachusetts, "Across the country, doctors report facing questions from patients worried about the safety of their medications, especially those who receive steroid injections." The article continues, "Many pain clinics have seen a 25% rate of cancellations for steroid injections since the outbreak, said Robert Saenz, president of VIP Medical Consulting in San Antonio, which specializes in helping pain doctors avoid regulatory and medical liability problems."
Public Health
Experts foresee long-lasting vaccines for flu.
On the front of its Science Times section, the New York Times (10/30, D1, Zimmer, Subscription Publication) reports that Gary J. Nabel, the director of the Vaccine Research Center at the National Institute of Allergy and Infectious Diseases, "and other flu experts foresee a time when seasonal flu shots are a thing of the past, replaced by long-lasting vaccines." Recent research "on the virus has brought some hope for a change." Dr. Nabel said, "That's the goal: two shots when you're young, and then boosters later in life. That's where we'd like to go." Dr. Nabel "predicted that scientists would reach that goal before long - 'in our lifetime, for sure, unless you're 90 years old,' he said."
Researchers find potentially vulnerable spot on HIV's outer shell.
The New York Times (10/30, D5, McNeil, Subscription Publication) reports, "This month, South African researchers announced that they had found a vulnerable spot on the" human immunodeficiency "virus's outer shell that might present a good vaccine target, and that they had also learned, for the first time, at what stage of an infection it develops." The researchers "found only two women whose virus had the vulnerability - and it wasn't the same virus that first infected them, but a mutant that developed a few months later." The findings, "published by Nature Medicine on Oct. 21," were "praised as 'very interesting' by several AIDS experts."
Adult kidney disease associated with excess weight in teens.
The NBC News (10/30) "Vitals" blog reports, "Being obese or overweight during adolescence may raise the risk of having debilitating kidney disease later in life, according to a new study" published Oct. 29 in the Archives of Internal Medicine.
HealthDay (10/30, Reinberg) reports, "For the study, a team led by Dr. Asaf Vivante, of the Edmond and Lily Safra Children's Hospital, Sheba Medical Center in Tel Hashomer, collected data on almost 1.2 million 17-year-olds who were examined before service in the Israeli military between January 1967 and December 1997. The researchers then linked these teens to the Israeli end-stage kidney disease registry."
WebMD (10/30, Goodman) reports, "Some 25 years later, those who were overweight or obese as teens were roughly three to seven times more likely to be on dialysis for end-stage kidney disease compared to their normal-weight peers." Specifically, "among 100,000 people followed for a year, there were 2.32 cases of end-stage kidney disease diagnosed among those who had been at a healthy as teens; 6.08 cases diagnosed in adults who had been overweight; and 13.4 cases diagnosed in adults who had been obese when they entered the military." The Daily Mail (UK) (10/30, Bates) and Medscape (10/29, Fox) also cover the story.
Article explains how obesity affects the body.
The Wall Street Journal (10/29, Wang, Subscription Publication) reports that obesity does more than just increase the risk for diabetes and heart disease. It also makes people sleepy and fatigued during the daytime, even if they don't have obstructive sleep apnea. In teenage boys, it appears to decrease testosterone. Obese girls and women have an increased risk of developing polycystic ovarian syndrome which may affect their fertility. In mice, obesity seems to interfere with the sense of smell. Finally, obesity appears to be associated with increased rates of certain forms of cancer.
Interventional weight-loss programs successful even in younger kids.
Reuters (10/30, Joelving) reports that interventional programs for weight loss may help even younger children lose weight and that the earlier the intervention takes place, the more successful it will be, according to two studies published online Oct. 29 in the Archives of Pediatrics & Adolescent Medicine.
MedPage Today (10/30, Walsh) reports, "In one study, 44% of those ages 6 to 9 years who were moderately obese at baseline experienced a clinically meaningful 0.5-unit decrease in body mass index (BMI) z-score with behavioral treatment, compared with only 8% of those ages 14 to 16," researchers found. "And in a randomized trial comparing a multidisciplinary intervention and usual care for children ages 3 to 5 years, the intervention led to multiple significant benefits in body weight and composition, including a mean decrease in BMI z-score of ?0.5 units, and the changes persisted for a year." An accompanying editorial observed, "The early childhood years are periods of sensitivity to environmental influences, maximum societal care and protection, multiple settings for intervention, and changeability."
Birth season may influence development of celiac disease.
The New York Times (10/30, O'Connor) "Well" blog reports a hypothesis that "the season in which a person is born may influence the development" of celiac disease. "Some researchers suspect that babies born in spring and summer are more susceptible to the disease, which is triggered by the gluten in wheat, barley and rye." The most recent study to give credence to this theory "looked at nearly 2,000 people with confirmed celiac disease" and found that more patients with celiac disease "were born in the spring than in any other season." The study appeared in this month's Journal of Pediatrics.
Many patients with incurable lung cancer may misunderstand purpose of radiation.
The Los Angeles Times (10/30, Healy) "Booster Shots" blog reports, "Patients diagnosed with lung cancer that is considered incurable appear to misunderstand the purpose and likely effect of a treatment aimed at making them more comfortable," according to a study presented at the American Society for Radiation Oncology's annual meeting. Researchers "found that among 832 patients newly diagnosed with stage IIIB (wet) or stage IV lung cancer, 78% believed that radiation therapy would likely help them live longer and 43% believed that such treatment was 'very' or 'somewhat' likely to cure their cancer."
HealthDay (10/30, Preidt) reports that "64 percent did not understand that palliative radiation therapy was not at all likely to cure their cancer."
Analysis: Breast cancer screening saves lives, but many women overtreated.
The AP (10/30) reports, "Breast cancer screening for women over 50 saves lives, an independent panel in Britain has concluded, confirming findings in US and other studies." However, "that screening comes with a cost: The review," published online in The Lancet, "found that for every life saved, roughly three other women were overdiagnosed, meaning they were unnecessarily treated for a cancer that would never have threatened their lives." The AP adds, "The expert panel was commissioned by Cancer Research UK and Britain's department of health and analyzed evidence from 11 trials in Canada, Sweden, the UK and the US."
Use of LARCs becoming more common in US.
USA Today (10/30, Painter) reports that long-acting reversible contraceptives (LARCs) "are gaining new popularity in the" US. Only "a decade ago, such methods were used by just 2.4% of U.S. women who used any method, but by 2009, they had caught on with 8.5%, with IUDs leading the way by a large margin, according to a recent study from the non-profit Guttmacher Institute. New federal data show the same trend."
New tape may help prevent neonatal skin injuries.
In its "Booster Shots" blog, the Los Angeles Times (10/30, Brown) reports that "every year, Americans suffer more than 1.5 injuries from medical tape removal - and the ones who suffer most are babies in neonatal units, whose fragile skin is easily ripped when nurses and doctors remove medical devices affixed to the infants by super-sticky adhesive." The elderly also are commonly hurt by tape removal as well. In an attempt to "help out these fragile-skinned patients, a team of researchers at Brigham and Women's Hospital in Boston, along with collaborators at MIT, have invented a new type of quick-release medical tape that may reduce skin injuries." When pulled away from the body, "with its three-layer design that inserts a laser-etched release liner between the tape backing and the sticky adhesive, it doesn't tear apart from the skin;" instead, "the backing of the tape peels away from the sticky stuff, leaving a coating of adhesive on the skin that can then be gently removed 'using a rolling motion.'" A research (10/30) article describing the new tape appears on the Proceedings of the National Academy of Sciences' website.
The CNN (10/30, Landau) "The Chart" blog notes that the research on the new tape technology is "still preliminary, though; the tape has not yet been clinically tested."
Mental illness often overlooked in sports.
The New York Times (10/30, B8, Rhoden, Subscription Publication) reports, "For all of the current focus on traumatic brain injury as a result of concussions, mental illness, often overlooked, exists at every level of sports." In fact, "sports too often is a masking agent that hides deeply rooted mental health issues. The better the athlete, the more desperate to reach the next level, the less likely he or she will reach out for help. The gladiator mentality remains a primary barrier." Many athletes pride themselves on being mentally tough, making it very difficult for them to admit they need help.
More runners aged 50 and above participating in marathons.
The Wall Street Journal (10/29, Helliker, Subscription Publication) reports that increasingly, individuals aged 50 and older are participating in marathons. According to the research group Running USA, this age group represented approximately 18% of marathon finishers over the past two decades. The article discusses some of the potential risks for injury in this group, as well as the health benefits of running.
Some research suggests "perfectionism" may be genetic.
In "Health Journal" in the Wall Street Journal (10/29, Beck, Subscription Publication), columnist Melinda Beck discusses "perfectionism," and the possibility that it may be passed genetically from parents to children. Some research suggests this may be the case.
Tissue bank increases focus on different ethnic groups.
USA Today (10/30, Rudavsky) reports, "The Susan G. Komen for the Cure Tissue Bank at Indiana University Simon Cancer Center will collect samples in Kenya next summer to enhance research into the disease in African and African-American women." USA Today continues, "Buoyed by last year's Super Bowl initiative, the bank is now focusing on specific populations, said Dr. Anna Maria Storniolo, a professor of clinical medicine at IU School of Medicine and a co-founder of the bank." The bank possesses "tissue samples from 2,883 women" and blood samples from "about 8,200 women." The bank is currently working on acquiring more tissue samples from different ethnic groups because "breast cancer behaves differently in people of different ethnic backgrounds." Different ethnic groups are also at risk for different types of breast cancers.
Pharma & Device Update
Positive results seen in trial of cancer vaccine.
The Boston Herald (10/30, Kantor) reports that Celldex Therapeutics Inc. has "announced positive results from a Phase I study involving its solid tumor cancer vaccine, CDX-1401, in combination with two other drugs." This "is the first clinical study to demonstrate that an off-the-shelf vaccine that targets dendritic cells in vivo can safely lead to cellular immunity when combined with other drugs in cancer patients."
The Boston Business Journal (10/30, Donnelly, Subscription Publication) reports, "The study included 45 patients with advanced tumors, who had failed on other drugs. Melanoma patients represented the biggest cohort, with twenty one study participants." However, "the trial also included patients with non-small cell lung cancer, ovarian cancer, sarcoma and colorectal cancer."
Monday's Lead Stories
? CDC: 25 dead in meningitis outbreak, cases reach 337 in 18 states.
? Obama Administration to sponsor two Federal health insurance plans.
? Planned Parenthood gets TRO on Women's Health Program.
? Community healthcare clinics more "routine" for low-income Americans.
? J&J recalls surgical stapler devices, accessories.
? Smoking cessation may help women live longer.
? USDA recently lowered estimate of Americans' daily sugar consumption.