Plasma from patients who recovered from 2009 H1N1 influenza may be an option in the treatment of patients with a severe case of the disease, a case-control study showed.
The 20 patients in the study who received convalescent plasma therapy had a reduced viral load in the respiratory tract, a blunted cytokine response, and a lower mortality rate than those who refused the treatment, Kwok-Yung Yuen, MD, PhD, of the University of Hong Kong, and colleagues reported in the Feb. 15 issue of Clinical Infectious Diseases.
The study “very much supports the concept that plasma therapy can be of benefit,” according to John Treanor, MD, a vaccine researcher at the University of Rochester, who noted in an e-mail to MedPage Today that the treatment was used nearly a century ago during the 1918 influenza pandemic.

Yuen and his colleagues also noted that plasma therapy appeared to improve outcomes among patients infected with avian influenza (A/H5N1).

In the current study, the researchers recruited 93 adult patients (median age 53.5) who required intensive care for a laboratory-confirmed case of pandemic H1N1 influenza from Sept. 1, 2009, through June 30, 2010. All had deteriorated clinically in spite of optimal antiviral treatment.

Although 73 patients refused plasma therapy, 20 patients or their next-of-kin agreed to try it.

The plasma was obtained by apheresis from patients who had recovered from H1N1 influenza at least two weeks previously. Only plasma with a high neutralizing antibody titer (≥1:160) was used.

The treatment involved an infusion of 500 mL of plasma over a four-hour period on day two of the stay in the intensive care unit.

To the extent possible, the treatment and control groups were matched by age, sex, comorbidities, and disease severity at ICU admission.

Nonetheless, patients in the treatment group had more risk factors for severe disease, including a lower lymphocyte count, greater prevalence of obesity, and presentation with more severe symptoms.

Even so, the mortality rate was significantly lower among those who received convalescent plasma therapy (20% versus 54.8%, P=0.01), a benefit that remained after multivariate adjustment (OR 0.20, 95% CI 0.06 to 0.69).

At ICU admission, there was no significant between-group difference in viral load and cytokine level. A subgroup analysis, however, revealed that there were significant reductions in viral load on days three, five, and seven in the treatment group (P<0.05).

There were also reductions in cytokine levels in the treatment group — interleukin 6 and tumor necrosis factor-alpha on day five and interleukin 10 on days five, seven, and nine (P<0.05).

It is unknown exactly how the plasma therapy benefits patients, according to Yuen and his colleagues, who noted that they could not exclude the possibility that factors in the plasma might have reduced the harmful effect of undetected pathogens other than influenza.

Convalescent plasma therapy, which is safer now than in the early half of the 20th century because of donor screening, virological and microbiological testing, and apheresis, may have some advantages over antivirals, the researchers added in their paper.

Neutralizing antibodies, they explained, are not subject to drug resistance, and antigenic drift leading to loss of effectiveness is unlikely to affect treatment efficacy within the timescale of the H1N1 pandemic.

Yuen and his colleagues added, “The effect of convalescent plasma may be quite immediate in terminating the infective process and dampening down the cytokine response, whereas adamantanes and neuraminidase inhibitors or even newer antivirals active against the viral nucleoprotein cannot neutralize any virus that [has] already entered the host cells.”

According to Treanor, collecting convalescent plasma presents some feasibility issues during the course of an epidemic because the plasma will not be available at the beginning of the outbreak.

Some possible alternatives, he said, are collecting plasma from individuals who had a robust response to vaccination or using monoclonal antibody therapies, especially those that can neutralize multiple strains.

He added that, “if antibody is good, and it looks like it is, then the best strategy is an effective vaccine that induces high levels of antibody, obviously.”

The study was supported by the Ted Sun Foundation, the Research Fund for the Control of Infectious Diseases of the Food and Health Bureau, and the Hospital Authority of the Hong Kong Special Administrative Region.

The study authors reported that they had no conflicts of interest.

Treanor has made the following disclosure: “I am very significantly funded by industry to perform studies of experimental vaccines. This funding is in the form of contracts to my institution for my lab to conduct lab assays or for my clinical staff to enroll subjects and follow them in a variety of clinical studies. The sponsors of these studies currently include Protein Sciences Corporation, Bavarian Nordic, GlaxoSmithKline, Pfizer, Sanofi-Pasteur, Vaxinnate, Mercia Pharma, Paxvax, and Ligocyte. I am also considering attending a scientific advisory board for Novartis, for which I would receive an honorarium, and I am on the scientific advisory board for Immune Targeting Systems (ITS) and also received an honorarium in 2009 from Abbott for an advisory meeting. We also conduct clinical trials of experimental live vaccines through a contract with NIH, but the vaccines are supplied by MedImmune through a cooperative research and development agreement (CRADA) with NIAID.”

HELSINKI, Finland, April 10 – Deaths from coronary heart disease were significantly reduced among patients with dyslipidemia who were given early treatment with Lopid (gemfibrozil), according to an 18-year follow-up of patients in the Helsinki Heart Study.

The reduction in cardiac deaths was greatest among patients who started therapy between ages 40 to 47 and in a subgroup of patients who were overweight (BMI ?‰? 27.5) and whose lipid disorder was related to the metabolic syndrome, according to a report in the April 10 issue of Archives of Internal Medicine.

In an accompanying editorial, Hanna Bloomfield, M.D., of the Minneapolis VA Medical Center, discussed the role of fibrates in a world now dominated by statins. “The fibrates may be down,” she wrote, “but they are not yet out.”

The Helsinki Heart Study was a double-blind, controlled primary prevention study of 4,081 dyslipidemic middle-aged men given Lopid or placebo in 1982. After five years, the men were invited to continue Lopid therapy through 1995, and about two-thirds of the subjects in both groups chose to do so.

In the year 2000, the researchers compared coronary heart disease, cancer, and all-cause mortality among subjects in the original study. By 1995, subjects in the original Lopid group had a 32% lower relative risk of coronary heart disease mortality (P=.03) compared with the original placebo group, according to Leena Tenkanen, Ph.D., of the Helsinki Heart Study group here and Tampere University in Tampere, Finland, and colleagues.

Early treatment, the researchers found, was most significant. According to Kaplan Meier plots, the differences between the two groups decreased when follow-up was extended beyond 1995. Followed to the year 2000, the relative risk was only 23% lower (P= .05), Dr. Tenkanen said.

Moreover, in 1995 a significant age split appeared, she said. Among men ages 40 to 47 years at the beginning of the study, the relative risk of coronary heart disease mortality was 42% lower in the treated group compared with the controls (P=.07), but it was only 24% lower among those 48 to 57 years at the start. By the 18-year follow-up, the corresponding figures were 31% (P=.08) and 17%, Dr. Tenkanen said.

Overall, trends for all-cause and cancer mortality were not statistically significant, the researchers wrote.

However, prompt treatment was of most benefit for a subgroup of Lopid patients. Those patients in the highest tertiles for BMI (?‰?27.5) and triglycerides (?‰?184 mg/dL) had a 71% lower relative risk of coronary heart disease mortality (P

WASHINGTON — Many neurosurgeons plan to limit the number of Medicare patients they’ll treat if scheduled Medicare cuts take effect, a survey of American Association of Neurological Surgeons (AANS) members found.

The group is the latest to threaten to limit or stop treating Medicare patients if reimbursement rates are cut. Reimbursements for all physicians who treat Medicare patients are to be slashed 21% on March 1, unless Congress votes to override it.

Substantial cuts in reimbursement rates have been mandated every year under the Medicare system’s “sustainable growth rate” formula, but Congress has always voted to override them.

A spokesperson for the AANS admitted that “it is hard to imagine that Congress will allow a 21% cut go into effect in an election year (if ever).”

Said Katie Orrico, director of the Washington office of the AANS and Congress of Neurological Surgeons (CNS), “On the other hand, as the cost of these short-term ‘fixes’ continues to grow, coupled with an ever tighter federal budget, for Congress to fully address this problem is clearly a considerable challenge and one physicians and seniors are worrying about more and more.”

The AANS, along with the Council of State Neurosurgical Societies (CSNS), surveyed 678 neurological surgeons on their policies toward Medicare beneficiaries.

Some 97% of participants said they currently treat Medicare patients, making up about one-third of the patient mix at their practices. Three-quarters said they treat all new Medicare patients.

However, the survey indicated that many neurosurgeons limit the number of Medicare patients they see in more subtle ways. About 60% said they deliberately reduce the number of new Medicare patients in their practice because of low reimbursement.

Delays in seeing new patients were the most common way, according to the survey. The mean wait time for new Medicare patients to see a neurosurgeon was three to six days longer than for established Medicare patients. About a third of respondents who limit Medicare appointment slots used quotas.

Nearly 40% indicated they would decrease the number of new Medicare patients they treat if further Medicare cuts went into effect, and 18% said they’d stop accepting new Medicare patient altogether in that scenario.

“Neurosurgeons do not relish the prospect of eliminating Medicare patients from their practices,” Orrico said. “The problem, however, is that practice costs continue to rise and it is increasingly difficult to meet these expenses with ever dwindling reimbursement. Thus, to remain in practice, they have no choice but to consider insurance status when scheduling patients.”

The survey also found: 65% of respondents agreed that “more physicians are sending complex Medicare patients to other surgeons” while 52% said neurosurgeons are sending even routine cases to other doctors. 48% of respondents said they’ve observed Medicare patients putting off needed care because they couldn’t find a doctor who would treat them. 67% said it’s gotten harder to refer Medicare patients to other medical and surgical specialists.

About 3,400 neurosurgeons were asked to participate in the survey. The response rate was about 20%. The AANS indicated the response rates were accurate to ±5%.

The neurosurgeon groups, along with the American Medical Association (AMA), are urging a permanent repeal of the SGR formula. The groups are tired of pressing Congress every year for short-term fixes, which simply put off the payment cuts. The 21% reduction scheduled for this year reflects the accumulation of annual cuts not taken because of Congressional action.

Consequently, this year the physician community has been lobbying hard for a permanent change instead of another one-year postponement. But last week’s East Coast snowstorms and the floundering healthcare reform effort have jeopardized the effort.

Meditation diminishes activity in areas of the brain associated with mind-wandering, researchers found.
Compared with novice meditators, experienced study participants had significant deactivation in parts of the brain associated with the “default mode network” — areas linked with attentional lapses and anxiety, Judson Brewer, MD, of Yale University, and colleagues reported in the Proceedings of the National Academy of Sciences.
Practiced meditators also reported less mind-wandering during meditation than did their less experienced counterparts, the researchers found.
Aside from attention lapses and anxiety, the “default mode network,” or DMN, has also been associated with certain conditions, including ADHD and Alzheimer’s disease. Conversely, mindfulness training has been shown to benefit certain conditions, such as pain, substance use disorders, anxiety, and depression.

So to assess whether mindfulness-based meditation can reduce activity along this brain axis, the researchers analyzed both experienced meditators and controls who’d never practiced the technique. The researchers used functional MRI to assess brain activation during both a resting state and a meditation period in 12 experienced mindfulness meditation practitioners and 13 controls.

Groups attempted three different types of meditation: concentration, loving-kindness, and choiceless awareness. Concentration is intended to prevent practitioners from engaging with their preoccupations; loving-kindness focuses on fostering acceptance; and choiceless awareness allows for focusing on whatever arises in the conscious field of awareness at any moment.

Brewer and colleagues found that experienced meditators reported less mind-wandering during meditation than did controls, which was true across groups.

At the same time, they generally saw less activation in the main nodes of the DMN — the medial prefrontal cortex and the posterior cingulate corticies — in experienced meditators than in controls.

While there was significantly less activation in the posterior cingulate cortex/precuneus and in the superior, middle, and medial temporal gyri and uncus, the trend toward diminished activation in the medial prefrontal cortex was not significant, they noted.

With regard to the specific types of meditation, the researchers found less activation in experienced meditators than in controls in the following regions: Concentration: posterior cingulate cortex, left angular gyrus Loving-kindness: posterior cingulate cortex, inferior parietal lobule, and inferior temporal gyrus extending into hippocampal formations, amygdala, and uncus Choiceless awareness: superior and medial temporal gyrus

When using the posterior cingulate cortex as a seed region, the researchers saw significant differences in connectivity patterns with several other brain regions, notably the dorsal anterior cingulate cortex, for experienced meditators compared with controls. And when using the medial prefrontal cortex as the seed region, they found increased connectivity with the fusiform gyrus, the inferior temporal and parahippocampal gyri, and the left posterior insula.

These patterns held during the resting-state baseline period as well, the researchers said, suggesting that meditation practice “may transform the resting-state experience into one that resembles a meditative state, and, as such, is a more present-centered default mode.”

The researchers concluded that the overall results “support the hypothesis that alterations in the DMN are related to reduction in mind-wandering.”

Though the study was limited by a small sample size, the researchers concluded that the findings may have a host of clinical implications, including treatment of conditions linked with dysfunction of these areas, such as ADHD or Alzheimer’s disease.

The study was supported by grants from National Institute on Drug Abuse and the U.S. Veterans Affairs New England Illness Research Education and Clinical Center.

The researchers reported no conflicts of interest.

As increasing numbers of physicians work longer and harder to maintain income levels in the face of declining third-party reimbursements, some have opted out. Not out of medicine, but out of managed-care contracts.

They’re running cash-only practices.

And, instead of losing patients because they no longer take insurance, the recent job market has actually boosted the patient base for some cash-only doctors. Patients who have lost jobs — and the health insurance that went with those jobs — seek out cash-only practices, which typically charge less.

Even patients who are still employed have seen deductibles soar, so that some insured patients essentially pay out of pocket for routine care. They, too, have been seeking out cash-only practices.

Will the current economic climate continue to increase the number of physician who go cash-only?

Seven out of 10 respondents to a MedPage Today online spotcheck think so.

And so do a handful of new services — such as SimpleCare and PriceDoc — aimed at bringing cash-only patients together with cash-only doctors.

Benefits and risks

Statistics on the number of cash-only physicians are hard to come by, but, according to the CDC, in 2005-06, 11% of physicians had no managed care contracts.

These cash-only physicians are earning less than they used to, but that’s a trade-off that few regret.

Rick Baxley, M.D., a family physician in Orlando, Fla., retained only a third of his 4,900 patients when he decided to break ties with insurers in 2001. Now, however, Baxley has about 4,000 people on his patient roster and sees just 20 to 22 patients a day, down from 40 to 60 in his third-party-payer days.

His overhead has dropped significantly, however, so he still makes a decent living. “I’m not getting wealthy,” he said, “but my quality of life is off the charts.”

Cash-only physicians don’t operate like concierge practices, said Jeffrey J. Denning, a practice management consultant in La Jolla, Calif. “Concierge practices charge an annual membership fee of $1,000 or so for increased access to the physician in an upscale office environment, then bill insurance companies or Medicare for services. Nothing much changes in a cash-only practice except getting out of the insurance billing business.”

That means less paperwork and third-party interference, as well as reduced staffing needs and the ability to run the practice in smaller quarters.

Internist and emergency medicine physician Robert Berry, M.D., who launched his urgent care/internal medicine cash-only practice in Greenville, N.C., in 2001, estimated that his annual overhead is $200,000 less than that of physicians who collect from insurance companies.

As in most cash-only practices, Dr. Berry’s patients pay at time of service, so there’s no need to employ billing staff.

Dr. Baxley’s former practice had a staff of 22 for three physicians; he now has four employees, and has ditched a $12,000-per-year accounting software package in favor of QuickBooks, which costs him about $200 a month.

Because cash-only physicians have lighter workloads than their peers, noted Judy Capko, a consultant in Thousand Oaks, Calif., they’re better able to build strong healthcare partnerships with patients.

Patients, in turn, have easier access to care and are less likely to experience the rushed appointments that result when physicians see large numbers of patients to compensate for managed care’s low reimbursement rates.

The flip side of this, of course, is that cash-only patients must dig deeper into their pockets than patients who only need to fork over a copayment.

For physicians, the downside of the cash-only model includes the need to rebuild a practice. There’s also no telling how practices that aren’t set up to process insurance payments will be affected if healthcare reform results in a universal or single-payer medical system.

Among the other things a physician needs to consider before switching to cash-only:

Is there an increased risk of embezzlement? Not necessarily, say consultants, because “cash only” rarely means a drawer brimming with currency; most physicians with this practice model accept checks and credit cards. But it doesn’t hurt to have strict accounting policies and controls in place. And staffers who handle money should be bonded.

How are fees determined? Like most small-business operators, cash-only physicians look at what competitors are charging, calculate the cost of doing business, then tack on enough to make a profit. Dr. Berry said he strives to keep fees “between the cost of an oil change and a brake job.”

The fees, which are posted on his website, PATMOS EmergiClinic, include $10 for a rapid strep test, $60 for an intermediate office visit, and $80 for a complex visit.

What about Medicare patients? Consultant Judy Capko suggests that Medicare is one carrier physicians might want to stay connected with. A halfway tack — becoming a nonparticipating Medicare provider — is also a possibility. That’s what Dr. Baxley did.

That enabled him to keep his Medicare patients when he transitioned to a cash-only practice, and he can continue to treat existing patients as they age into Medicare.

Nonparticipating Medicare providers do not accept assignment and are reimbursed at slightly lower levels than participating providers. For cash-only physicians, this is an attractive option because the patient pays the doctor for services rendered; Medicare, in turn, reimburses the patient.

If you choose not to participate in Medicare, you must sign an “opt out” affidavit. In many states, that means you can’t re-up as a Medicare provider for two years.

What about promoting the practice? Physicians who drop third-party contracts typically have to advertise their practices until word-of-mouth kicks in.

At first, Dr. Berry ran the gamut from fliers to billboards to television. But, he said, “we currently have 8,700 patient charts and don’t need to advertise anymore.”

For those physicians without the resources to launch an advertising campaign, special services are cropping up to steer patients to cash-only physicians.

Renton, Wash., family physician Vern Cherewatenko, M.D., who launched his cash-only practice in 1997, also heads SimpleCare, which for a small fee — $125 for the first year and $50 annually after that — puts physicians’ names on its website and sends them information about how to create a cash-based practice.

Patients, who pay $29 a year for an individual and $39 for a family, can use the site to locate physicians in their area.

Another website, PriceDoc, will enable cash-paying patients to “comparison shop” online for medical, dental, vision, cosmetic, and other healthcare services and procedures. The site is a work in progress; it currently lists only clinicians in the state of Washington.

Transitioning to cash only

Consultants recommend establishing a cash-only practice in stages.

Physicians should cut ties with their worst-paying payers first, and offer to see patients with that coverage on a cash-only basis, said Jeff Denning. Let those patients know you’ll provide them with a superbill to submit claims on their own.

Then, one at a time, resign the remaining contracts, allowing time for the practice to stabilize after each cut. This strategy allows you to reverse course if sufficient patients don’t stay on board.

Send letters to patients at least 30 days before you stop accepting their health insurance, although in some instances you may need to provide contracted care for a longer period, said Steven Kern, a healthcare attorney in Bridgewater, N.J.

You’ll be on safer legal ground if you continue to see pregnant women until labor and delivery, and if you stick with a patient undergoing a specific course of treatment until the treatment is completed, especially if the patient can’t readily be transferred.

Bear in mind, too, that in some states you’re required to copy and transfer medical records of patients you “terminate” — a costly process if you don’t have an EMR.

Even cash-only doctors acknowledge the need for patients to have some medical insurance, though. Dr. Cherewatenko advises his patients to purchase catastrophic policies. “I have one myself that costs $150 a month with a $3,000 deductible,” he said.

Cherewatenko added, however, that because most medical problems can be handled at affordable prices, cash-only is a good bet for all concerned.

“It offers freedom of choice to patients and freedom from billing hassles for physicians,” he said. “I want to return medicine to patients and doctors. Patients come to see me because they know I’m working for them, not the insurance company.”

WASHINGTON — Medtronic has agreed to pay the U.S. Justice Department $23.5 million to settle allegations that the company paid doctors to implant its pacemakers and defibrillators.

The Justice Department contends that Medtronic paid doctors between $1,000 and $2,000 per patient implanted with a Medtronic pacemaker or defibrillator as part of four post-marking studies.

The payments were to entice doctors to use a Medtronic device over a competing device, and to persuade them to be loyal to Medtronic for future cardiac procedures, according to a press release from the Justice Department.

The settlement stems from allegations contained in two lawsuits that are pending in Minnesota and California.

“Patients who rely on their healthcare providers to implant vital medical devices expect that those decisions will be made with the patients’ best interests in mind,” Tony West, assistant attorney general for the department’s civil division, said in a press release. “Kickbacks, like those alleged here, distort sound medical judgments with financial incentives paid for by the taxpayers.”

Medtronic said the payment is not an admission that any of the company’s studies were “improper or unlawful.”

“Medtronic is happy to have this investigation behind us, so we can continue designing and executing clinical trials that generate evidence to improve patient care, outcomes, and cost effectiveness,” Marshall Stanton, MD, vice president of clinical research and reimbursement for the Medtronic’s Cardiac and Vascular Group, said in a statement.

Medtronic also is being investigated by the Justice Department over allegations that doctors paid by the company failed to report serious side effects associated with Medtronic’s spine surgery device, Infuse.

Many women wear high heels because they like the way they look, but these shoes can cause foot problems such as hammertoe, a condition in which the toes painfully bend in on each other, experts warn.

Dr. Tzvi Bar-David, a podiatrist at New York-Presbyterian Hospital/Columbia University Medical Center, has some advice for women on how to keep their feet comfortable without sacrificing fashion.

“To prevent hammertoe, it’s not necessary to give up on wearing heels entirely, but women should limit the amount of time they spend wearing them,” Bar-David said in a hospital news release. “I recommend wearing comfortable shoes for your commute or when you’re on your way to a party. Change into your heels when you get there.”

When shopping for shoes, look for styles with plenty of room for the toes, a uniform lift (rather than one that’s narrow and spiked) and strong arch support. “Don’t force yourself into a bad shoe,” Bar-David said. “When buying new shoes, try them on for 10 to 15 minutes. Even better, see if you can wear them home and return them later if they aren’t a good fit,” he added.

If hammertoe develops, there are pads and gel protectors to help treat the condition, but it is a good idea to see a doctor to make sure surgery isn’t necessary and to determine whether a condition such as arthritis or diabetes is involved. “In particular, people with diabetes have to be extra careful with hammertoe because the condition can cause infections and other problems,” Bar-David explained.

If surgery is needed to realign the bones, recovery may take a couple of weeks. But Bar-David said the modern procedure leads to fewer infections and a quicker recovery time.

More information

The University of Maryland Medical Center has more about hammertoe.

LOS ANGELES, Dec. 3 — Abnormal processing of visual details may lead individuals with body dysmorphic disorder to perceive themselves as ugly and disfigured, a case-control study found.

In an MRI study in which patients with the body-image disorder and controls looked at faces other than their own, the brain’s visual processing of these faces differed fundamentally among patients from processing in the controls, Jamie D. Feusner, M.D., of the University of California here, and colleagues, reported in the December issue of the Archives of General Psychiatry.

A predominance of left-sided visual activity for low spatial frequency imaging and normal faces suggested piecemeal encoding and detail analysis rather than holistic processing.

And the fact that these abnormalities occurred while patients viewed faces other than their own, suggests differences in visual processing beyond distorted perception of one’s own appearance, the researchers said.

Body dysmorphic disorder, which may affect 1.7% of the population, is a severe psychiatric condition that causes patients to believe they are ugly or disfigured, leading to severe emotional distress, functional impairment, and often severe depression and a risk for suicide.

A better understanding of the neurobiology of the disorder could assist in clarifying the pathophysiology of the symptoms and help improve clinical management, the researchers said.

To determine whether these patients have abnormal patterns of brain activity when visually processing others’ faces with high (sharp, detailed), low (blurry), or normal spatial frequency MRI information, the researchers studied 12 right-handed, medication-free patients with the disorder and 13 controls matched by age, sex, and educational achievement.

Functional magnetic resonance imaging, which showed changes in blood-oxygen-level resonance, was used while the participants performed matching tasks of three types of face stimuli.

Stimuli were neutral-emotional expressions of other individuals’ faces altered to include only high spatial frequency visual information, or altered to include only low spatial frequency visual information. In addition, the investigators used unaltered photographs of the same size.

Typical of people with the disorder, all 12 patients had a preoccupation with perceived facial defects. Eight had concerns solely about facial defects, and four also had non-face concerns.

The body dysmorphic patients showed greater left hemisphere activity relative to controls, particularly in the lateral prefrontal cortex and lateral temporal lobe regions for all MRI-measured face tasks, as well as dorsal anterior cingulate activity for the low spatial frequency task, the researchers reported.

Controls demonstrated mainly right predominance but recruited left-sided prefrontal and dorsal anterior cingulate activity for the high spatial frequency task.

This suggested, the investigators said, that those with the body- image disorder use a network for processing normal spatial frequency and low spatial frequency faces that controls used for only high spatial frequency faces.

The laterality patterns in these patients suggest a bias for local, or detail, processing over global processing of faces, the researchers said.

In addition, they said, the distorted body-image group showed abnormal activation of the amygdalae for high and low spatial frequency face tasks.

Clinically, individuals with this disorder may assume that everyone else is as detail-biased as they are in their perception of appearance, thereby contributing to extreme self-consciousness.

Future studies are important to test whether the abnormalities that may underlie the detail bias found in this study also exist for processing the individual’s own faces, the researchers said.

The study’s limitations included its small size, and the narrow range of severity of the body-image disorder, which probably did not provide enough variance to allow for a meaningful correlation of symptom severity with brain activation.

Future larger studies are needed that record emotional ratings for each task and that include individuals who have a range in severity from milder symptoms to severe body-image distortion, the researchers said.

The study was funded by a grant from the National Institute of Mental Health, a grant from the Saban Family Foundation, a donation from the Neysa Jane Body Dysmorphic Disorder Fund, Inc., and grants from the National Center for Research Resources, National Institutes of Health. The work was also supported by the Brain Mapping Medical Research Organization, Brain Mapping Support Foundation, Pierson-Lovelace Foundation, Ahmanson Foundation, William M. and Linda R. Dietel Philanthropic Fund at the Northern Piedmont Community Foundation, Tamkin Foundation, Jennifer Jones-Simon Foundation, Capital Group Companies Charitable Foundation, Robson Family, and Northstar Fund.

The researchers reported no financial conflicts.

Primary source: Archives of General Psychiatry

Source reference:

Feusner JD, et al “Visual information processing of faces in body dysmorphic disorder” Arch Gen Psychiatry 2007; 64: 1417-1426.

NEW ORLEANS — Patients who wake up with stroke symptoms that weren’t present when they fell asleep can safely receive thrombolytic treatment with tissue plasminogen activator (tPA), even though the stroke onset time is unknown, a British study suggested.

In a non-randomized study, patients with a so-called “wake-up” stroke who had clinical signs and CT scans indicating only early ischemic changes had outcomes following thrombolysis similar to patients with a known symptom onset time, according to Dulka Manawadu, MD, of King’s College London.

“I think the time is now right to prospectively randomize these patients with wake-up strokes into trials of thrombolysis,” she reported at the American Stroke Association’s International Stroke Conference here.

Steven Greenberg, MD, PhD, a neurologist at Harvard Medical School, said another approach, in addition to randomizing patients to tPA or no tPA, would be to use imaging to select patients who would most benefit from thrombolysis.

“It’s exciting to think that one or the other will widen the pool of people who can benefit from clot-busting treatments,” said Greenberg, who moderated a press briefing at which the results were presented.

Thrombolytic therapy has been shown to improve outcomes in patients with ischemic strokes when used within 4.5 hours of symptom onset, but use of tPA remains low. Partly explaining the low use is that for up to one-quarter of patients, the stroke onset time is not known, including for patients with wake-up strokes.

Clinicians are hesitant to use tPA outside the 4.5-hour window because of the possibility of increasing the risk of intracerebral hemorrhage without improving outcomes.

On the other hand, patients with wake-up strokes who are not treated have poor outcomes. Previous studies have shown that these patients have clinical and imaging characteristics similar to patients with a known stroke onset time and that about one-third would be eligible for tPA.

Manawadu and colleagues performed a retrospective study to examine whether tPA could be safely used in patients with wake-up stroke. They compared outcomes in 326 patients with a known symptom onset time who were treated within the recommended 4.5-hour window with 68 patients who woke up with stroke symptoms and were treated with tPA when CT scans revealed no or early ischemic changes.

At baseline, all of the patients had an NIH Stroke Scale (NIHSS) score of 5 or greater (mean 13.4 in the reference group and 12.6 in the wake-up group).

The average age was about 73 in both groups. There was a greater proportion of men in the reference group, but the vascular risk profile was similar.

Within the first 24 hours, the NIHSS score improved to a greater extent in the wake-up group, resulting in a significantly lower score (7.2 versus 11.5, P=0.001).

At 90 days, there were no between-group differences in rates of any intracerebral hemorrhage (20% in the reference group versus 22% in the wake-up group), symptomatic intracerebral hemorrhage (3.4% versus 2.9%), a modified Rankin Scale score of 0-1 (23.6% versus 16.2%), and a modified Rankin Scale score of 0-2 (38% versus 37%).

Mortality tended to be lower in the wake-up group (15% versus 26%, P=0.06), although Manawadu said that likely reflects inadvertent selection bias in the use of thrombolysis for those patients.

The findings were similar in an analysis restricted to patients 80 and younger.

Lee Schwamm, MD, a neurologist at Massachusetts General Hospital in Boston and an American Heart Association spokesperson, said only a fraction of patients who receive thrombolytic therapy are treated outside of the 4.5-hour window, but that it is appropriate in certain situations, including when clinical and imaging characteristics indicate that a patient with a wake-up stroke has minimal ischemic damage.

“Physicians are allowed to use drugs in an off-label manner once they’re FDA approved for a specific indication, and this seems like a very appropriate use,” he said.

The assumption, he said, is that the stroke occurred shortly before the patient woke up. “That’s why if all the other components are reassuring and its simply this question of an unobtainable time of onset then thrombolysis is reasonable.”

Still, Schwamm echoed Manawadu’s call for randomized studies.

Manawadu reported institutional grant support from King’s College Hospital Research and Development.

NEW ORLEANS, Nov. 13 — Retired National Football League players, though considerably heftier than the norm, had significantly better heart disease risk parameters than a matched set of community controls, according to researchers.

The former NFL players, who were significantly less likely to be sedentary than controls, had a lower prevalence of diabetes, hypertension, and metabolic syndrome, reported Alice Y. Chang, M.D., of the University of Texas Southwestern Medical Center in Dallas, at the American Heart Association meeting here.

Of 151 former athletes and 150 controls who had coronary calcium assessments, the ex-players were taller (187 versus 175 cm) and heavier (111.3 versus 96.3 kg), but the median body mass index was about 31.5 in both groups.

However, the retired athletes had a higher prevalence of hypercholesterolemia and impaired fasting glucose.

The findings, Dr. Chang said, deliver something of a mixed message about heart disease risk.

“First, being a professional athlete doesn’t protect you from developing heart disease later in life,” said Dr. Chang. “Secondly, remaining physically active may help protect against many of the health risks of large body size in former competitive football players.”

The investigators found that “age and hyperlipidemia, not body size, were the most significant predictors of subclinical coronary atherosclerosis among retired NFL players.”

The case-control study involved 201 former NFL players, who completed a health questionnaire and visited screening sites in Dallas, Atlanta, Miami, and San Francisco. The participants included recent retirees and older retirees.

The mean age of the group was 55, and 59% of the former players were African Americans. Linemen (typically the largest players on a team) accounted for about 30% of the group. These results were not significantly different when controlling for ethnicity or linemen status.

The retired players were compared with a control group drawn from two prospective cohort studies.

Screening evaluations for the former players and the control group included height, weight, waist and hip circumference, and blood pressure; fasting blood glucose, lipids, and C-reactive protein; and coronary artery calcification assessed by computed tomography.

The former players had a significantly smaller waist circumference (103.8 versus 107.4, P=0.007); larger waist-hip ratio (1.08 versus 0.98, P