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Endarterectomy versus Stenting in Patients with with Symptomatic Severe Carotid Stenosis (NEJM, October 19, 2006) November 2, 2006

Posted by rajkmd in Cardiology, Surgery.
3 comments

Background

  • Carotid enderarterectomy has been found to be beneficial for individuals with severe carotid stenosis
    • The North American Symptomatic Carotid Endarterectomy Trial (NASCET) showed that for patients with severe carotid stenosis defined as a stenosis greater than 70 percent, the number needed to treat in order to save one life over a period of 2 years was six.
  • Noninvasive methods of opening a carotid stenosis through stents have been previously studied, but have not been shown to benefit patients.
  • This randomized controlled trial was conducted to study whether stenting is not inferior to endarterectomy with regard to the risks of the procedure and its long term efficacy.
  • Enrollment began in 2000, but the safety committee recommended it be stopped in September 2005 

Methods

  • The study was completed in 20 academic and 10 nonacademic centers in France
    • Each center was required to have one neurologist, one vascular surgeon, and one interventionalist in order to join.
  • Inclusion criteria
    • at least 18 years of age or older
    • had a hemispheric or retinal transient ischemic attack or a nondisabling stroke (or retinal infarct) within 120 days of enrollment
    • Stenosis of 60 to 99 percent in the sympotmatic  carotid artery as determined by the NASCET method
      • This was changed in October 2003 because endarterectomy was shown to benefit symptomatic patients with moderate stenosis
      • Stenosis was determined by catheter aniography or by both duplex ultrasound and MRA of the carotid artery
  • Exclusion
    • Patinets were excluded if they moderate to severe diability from a stroke, nonathersclerotic carotid disease, severe tandem lesions, previous revascularization of a severe stenosis, h/o of bleeding d/o, uncontrlled HTN or DM, contraindications to heparin or clopidgrel, life expectancy  less than 2years, PCI or surgery within 30 days.
  • Patients were randomized by the degree of stenosis defined as >90 or <90 percent.
  • Primary endpt. was a composite of any stroke or death occuring within 30 days of treatment
  • Secondary endpts.  were myocardial infarction, TIA, cranial nerve injury, major local complications and systemic complications within 30 days after treatment, and composites of any of the following – stroke or death within 30 days after treatment + any stroke from day 31 after treatment to the end of the followup.
  • 872 patients needed to be enrolled to have a statistical power of 80 percent to assess whether stenting was not inferior to endarterectomy. 

Results

  • 527 pts were ulitmately enrolled.
  • There was no significant difference in the baseline characteristics of the two study arms.
  • The study found that stenting carried a greater risk than did endarterectomy
    • 30 day incidence  of any stroke or death was 3.9 % (95% CI, 2 to 7.2) after endarterectomy  and 9.6% (95% CI, 6.4 to 14) after stenting, with an absolute risk increase of 5.7.
    • This means that an add’l stroke or death resulted when 17 patients underwent stented rather than endarterectomy.
    • 30 day incidence of disabling stroke or death was 1.5% (95% CI, o.5 to 4.2) after endarterectomy vs 3.4% (96% CI, 1.7 to 6.7)
    • A greater percentage of strokes occured on the day of the procedure in the stenting grp.
  • The incidence of stroke or death did not vary based on whether the interventionalist was experienced or was being tutored during or after training
  • Patients had stents placed with cerebral protection devices had a lower incidence of stroke, but endarterectomy was safer even after taking this into account.
  • Hospital stay was shorter in the stenting group vs endarterectomy grp (3 days vs 4 days p 0.01)
  • 30 day incidence of stroke or death in the stent group did not depend on whether patients were on antiplatelet therapy or not. 

Discussion

  • The trial was stopped early for reasons of both safety and futility 
  • In this study, the 30-day risk of stroke or death was significantly higher in the group that underwent carotid artery stenting.
  • The differences are unlikely explained by the selection of sugeons with high level expertise and is most likely the a difference between the the therapeutic options.
  • The differences persisted at 6 months, but long term follow up data has yet to be compiled

THE BOTTOM LINE – In patients with symptomatic carotid artery stenosis of 60 percent or more,  carotid artery stenting carries a higher risk of developing a stroke or dying at 30 days and 6 months when compared to carotid endarterectomy. 

Dr. Micheal LoCurcio on the CARP trial. October 25, 2006

Posted by rajkmd in Cardiology, Surgery.
2 comments

In the comments section regarding this article…

Excellent review. I wanted to point out that the primary outcome for the study was long term mortality but that this data is actually buried within the text. The information you listed was from table 3 (which is presented as if it was the primary endpoint) but is actually the postoperative events at 30 days. The primary endpoint is actually 70 (22%) deaths in the revascularization group and 67 (23%) deaths in the no revascularization group at a median of 2.7 years (95% CI p=0.7-1.37). -Mike LoCurcio  

Thanks for the tip.  I’ll change the summary to reflect this.

Coronary-Artery Revascularization before Elective Vascular Surgery: The CARP trial (NEJM 2003:351;27) October 24, 2006

Posted by rajkmd in Cardiology, Surgery.
4 comments

to read the actual article click here

Background

  • Patients with peripheral vascular disease (PVD) have a high prevalence of concomitant coronary artery disease (CAD), which leads to a high incidence of perioperative cardiac complications during vascular surgery.
  • This is the first randomized trial to study the effect of coronary artery revascularization before elective vascular surgery
  • Previous investigations into the topic have yielded mixed results
    • The cohort study, The Coronary Artery Surgery Study with peripheral vascular disease. followed patients for 3.5 years and showed improved outcomes in the group receiving revascularization as compared to the group receiving conservative therapy.
    • On the other hand, studies using large registries of patients have shown no benefit and potential harm patients by causing complications and delays of the needed vascular surgeries.
  • The study was funded by the Cooperative Studies Program of the Department of Veteran Affairs Office of Research and Development.

Methods

  • Inclusion criteria- patients scheduled for an elective vascular operation for either an expanded abdominal aortic aneurysm or severe symptoms associated with PVD in the legs.
  • Exclusion criteria
    • Need for urgent or emergency surgery
    • Severe coexisting illness
    • Prior revascularization without evidence of recurrent ischemia
    • Left main stenosis 50 percent or greater
    • Left ventricle ejection fraction less than 20 percent
    • Severe aortic stenosis
  • Coronary angiography was recommended if the consulting cardiologist deemed the patient at increased risk of perioperative cardiac complications.
    • Risk was determined by a combination of factors including the presence or absence of ischemia in noninvasive stress testing as well as independent risk factors of CAD, such as prior stroke, insulin-dependent diabetes, and renal failure.
  • Based on the angiogram, patients received revascularization if the patients had a stenosis of at least 70 percent and could tolerate a revascularization procedure
    • The decision to undergo percutaneos coronary intervention (PCI) versus coronary artery bypass (CABG) was left up to the local investigators
  • After randomization, either the cardiac or vascular procedure was expected to be performed within three weeks
    • Patients undergoing a CABG waited three months beore recieving their vascular procedure
    • Patients undergoing PCI waited two weeks for their vascular procedure to be completed due to increase risk of instent thrombosis
  • Three days after vascular surgery was performed cardiac enzymes were monitored and ekgs were obtained.  Three months after vascular surgery, LVEF was determined using radionuclide angiography.
  • Primary end point: long term mortality
  • Secondary end point: myocardial infarction, stroke, limb loss, and dialysis.
  • Patients were followed for approximately five years and the study was powered to detect difference in the 3.5 year survival rate of at least 75 percent of the two arms of the study.
  • This was an intention to treat analysis

Results

  • 5859 patients were initally screened and of these, 510 patients were eventually enrolled
    • Of the 510 patients who underwent randomization, 258 were assigned to a strategy of preoperative coronary artery revascularization and 252 underwent no preoperative revascularization.
  • No significant differences in the baseline characteristics.
  • Of the 258 in the coronary artery revascularization arm, 240 (93 percent) actually underwent revascularization
    • 41 percent underwent CABG
    • 59 percent underwent PCI
    • Patients undergoing had a higher number of vessels revascularized (3 vs 1.3), higher death rates (2 vs 1.4), and longer stays in the hospital (7 vs 1 day)
    • 87 percent of the patients eventually underwent vascular surgery
      • Vascular surgery occured  a median 48 days after CABG and median 41 days after PCI
  • Before vascular surgery, there were more deaths in the coronary-artery revascularization group  than the conservatively managed patients ( 10 deaths vs 1 death)
  • There was no mention in the stude regarding the number of perioperative myocardial infarctions during vascular surgery.
  • Primary endpt –> at a median of 2.7 years after randomization, mortality was 22 percent in the revascularization grp and 23 percent in the no revascularization grp (relative risk, 0.98; 95 percent CI, 0.70 to 1.37)
  • At thirty days, there was not a significant difference in death rates in the two groups (3.1 vs 3.4 percent, p=0.87)
  • Secondary endpt –> there was also not a significant difference between the coronary artery revascularization arm versus the conservative management arm in terms of the 
    • the rate of myocardial infarction, either using cardiac enzymes (11.6 vs 14.3 p=0.37) or cardiac enzymes with ECG (8.4 vs 8.4, p=0.99)
    • the rate of stroke (0.4 vs 0.8, p=0.59)
    • the percentage of patients losing of a leg (0.4 vs 0.8, p=0.11)
    • the percentage of patients requirine renal dialysis (0.4 vs 0.4, p=0.97)

Discussion

  • The authors of this study conclude that, “Among patients with stable coronary artery disease, coronary artery revascularization before elective major vascular surgery does not improve long term survival”.
  • There was no reduction in death, myocardial infarction, or length of stay after vascular surgery in either group.
  • This is in line with the current recommendations of the American College of Cardiology, American Heart Association, and American College of Physicians, which only recommend coronary artery revascularization of patients with unstable cardiac symptoms or advances coronary disease that have been proven to have benefit irrespective of future surgery.

THE BOTTOM LINE:  In patients with stable coronary artery disease, preoperative coronary-artery revascularization before non-emergent vascular surgery does not improve the rate of death, decrease the number of postoperative myocardial infarctions or stroke,  decrease the percentage of patients losing a leg, or decrease the need for renal dialysis.

Dr. Nate Link on the STAR-2 trial October 24, 2006

Posted by rajkmd in Primary Care, Women's Health.
1 comment so far
This comment is in relation to the following trial:
The STAR P-2 trial is the most recent of several studies assessing the impact of SERMS on breast cancer. In the NSABP P-1 trial (NCI 1998;90:1371), tamoxifen prevented about 4 cases of breast cancer per 1000 high risk women treated per year (a 50% relative risk reduction!) but caused modest increases in thromboembolism, stroke, and endometrial cancer. In the MORE trial (JAMA 1999;282:637) raloxifene prevented 4 breast cancers and 6 vertebral fractures per 1000 women per year but also caused increases in thromboembolism and stroke. The STAR P-2 trial was the first to compare these two drugs head to head.Based on all three trials we would expect either raloxifene or tamoxifen to reduce the incidence of invasive breast cancer by 50%, but all the prevented cancers will be estrogen receptor positive, the tumors that are the easiest to treat and cure anyway. The studies were not large enough or long enough to determine whether breast cancer mortality will be affected by the SERMS. The scorecard: for every 1000 women at high risk for breast cancer who take raloxifene for one year, one can expect treatment to prevent 4 cases of invasive breast cancer and 6 cases of vertebral fracture, and to cause 1 stroke and 2 cases of thromboembolism. Mortality is unlikely to be affected in the short-term. Tamoxifen appears to be somewhat more likely to cause thromboembolism and uterine cancer – probably about 1 case per 1000 of each – and less likely to prevent fractures. Overall, raloxifene appears to have an edge in benefits versus risks.
Despite the favorable publicity surrounding these results, the nuances of the data and modest increases in serious outcomes such as stroke and thromboembolism preclude a simple recommendation for use of SERMS. The higher the baseline risk of breast cancer, the more favorable will be the benefit/risk ratio, but patient preference clearly needs to be a part of this decision.

Effect of rosiglitazone on the frequency of diabetes in patients with impaired glucose tolerance or impaired fasting glucose: The DREAM trial. October 20, 2006

Posted by rajkmd in Endocrine.
3 comments

 To see the Lancet summary of this article click here

 The Big Picture

  • GlaxoSmithKline recieved a patent on rosiglitazone in 1991 and released the drug under the trade name Avandia  in 1999
  • According to IMS health, in 2002, Avandia had annual sales of $1.1 billion
  • The patent for Avandia will expire in 2015
  • It is estimated that approximately 10 to 15 percent of Americans have either impaired glucose tolerance or impaired fasting glucose.
    • A drug that would prevent these Americans from developing diabetes would be very profitable.
  • The risk of developing diabetes in patients with impaired glucose tolerance has been found to be from 3.6 to 8.7 percent per patient year
  • This study was funded by the Canadian Institute of Health, Sanofi-Aventis, GlaxoSmithKline, and King Pharmaceuticals

Background

  • Type 2 diabetes affects 5 percent of adult worldwide
  • Acarbose and metformin reduce the incidence of diabetes by 25-30 percent
  • More importantly, lifestyle intervention reduce the incidence of diabetes by 50 percent.
  • Rosiglitazone is a approved in patients with established type 2 diabetes
    • activates peroxisome proliferator-activated gamma receptors which play a role in insulin resistance
    • increase hepatic and peripheral insulin sensitivity
    • promote pancreatic beta cell health

Methods

  • 24,592 people aged 30 yo or older were assessed for elgibility with a 75 g oral glucose tolerance test between July, 2001 and August, 2003
  • Inclusion criteria
    • impaired fasting glucose defined as fasting glucose between than 110.9 mg/dl and 127.27 mg/dl and a 2 hour plasma glucose concentration less than 202 mg/dl or
    • impaired glucose tolerance defined as a fasting glucose between fasting glucose as less than 110.9 mg/dl and a 2 hr plasma glucose concentration between 127.27 and 202 mg/dl
  • Exclusion criteria
    • People with a history of diabetes (except gestational diabetes), cardiovascular disease (including heart failure and known decreased ejection fraction), or intolerance to either ACE inhibitors or thiazolidinediones.
  • If patients were deemed eligibile, they entered a 17 day run in period and if patients took at least 80 percent of run in meds they were enrolled for randomization.
  • All patients were provided with advice about healthy diets and lifestyle habits to reduce diabetes
  • Patients randomized to recieve initially 4 mg and then titrated up to 8 mg of rosiglitazone.  Patients were also concurrently randomly assigned to either  ramipril (titrated to 15 mg) or placebo with a 2×2 factorial design
  • Composite primary endpt –> incident diabetes or death from any cause during active treatment period
  • Secondary endpt–>regression to normal fasting and 2h glucose tolerance, renal events, glucose concentrations, and a composite of cardiovascular events (myocardial infarction, stroke, a CV death, revascular procedure, heart failure, new angina with evidence of ischemia, or ventricular arrhythmia)

Results

  • 5269 people with a mean age of 54.7 (SD 10.9) years were randomly assigned to recieve either placebo or rosigiltazone
    • 57 percent had isolated had isolated impaired glucose tolerance and 14 percent had isolated impaired glucose tolerance and 29 percent had both
    • Patients were followed for a median of 3 years
  • 72 percent of the patients were compliant in the experimental group while  75 percent of patients were compliant in the placebo group.  Compliance was defined as 80 percent adherent to the drug regimen
  • Reasons for stopping the drug (% of experimental grp vs % placebo grp)
    • patient refusal 18.9 vs 16.7
    • edema 4.8 vs 1.6
    • physician advise 1.9 vs 1.5
    • weight gain 1.9 vs 0.6
  • Primary outcome of diabetes or death was seen in 11.6 percent in the rosiglitzone grp as opposed to 26 percent in the placebo group – an absolute risk reduction of 14 percent
    • This reduction was entirely due to a reduction in the incidence of diabetes as death rates in the two groups were similar
  • There was slight increase cardiovascular complications in the rosiglitazone group 2.9 percent compared to placebo at 2.1 percent that was not statistically significant (p=0.08)
    • This was almost entirely due to an increase in confirmed heart failure  0.5 percent in the rosiglitazone vs 0.1 percent in the placebo group (p=0.01), which occured equally irrespective of whether they were taking ramipril.
  • Patients with a BMI <28, decreased waist-to-hip ratio, decreased waist circumference, and decreased hip circumference did better in the placebo group

Discussion

  • This study shows that 8mg of rosiglitazone along with lifestyle recommendation decreases the risk of diabetes in patients with impaired fasting glucose or impaired glucose tolerance.
  • There was an increase in patients developing confirmed CHF who were taking rosiglitazone.
  • The reduction is similar to reductions which have seen in patients who make lifestyle changes
    • It is greater, though, than changes seen with metformin or acarbose.
  • Patients with increased BMI and increased waist to hip ratios developed diabetes at the same rate as patients with lower BMIs and decreased waist to hip ratios.

THE BOTTOM LINE: Rosiglitazone in combination with lifestyle conselling decreased the incidence of the developing diabetes in patients without diabetes who have impaired fasting glucose levels or glucose tolerance.  There is, however, a small, but statistically significant, increase in the development of documented congestive heart failure in patients taking rosiglitazone. 

Dr. Mashall Fordyce on Causes of Death Among Persons with AIDS in the Era of Highly Active Antiretroviral Therapy: New York City October 19, 2006

Posted by rajkmd in Infectious Disease.
1 comment so far

Marshall Fordyce – October 19, 2006[Edit]

Our very own Dr. Judy Aberg (head of the NYU/Bellevue AIDS Clinical Trials Group) wrote the accompanying editorial to this study published in AIM. In it, she highlights several points: in the post HAART era, HOPS (HIV Outpatient Study) demonstrated a reduction in mortality attributed to both opportunistic prophylaxis and the introduction of HAART; that in contrast to the original clinical guidelines for HIV+ patients, vaccinations (pneumococcus and hepatitis) are currently recommended; and that this study of New Yorkers underscores the fact that mortality is higher in the population of HIV+ patients that we care for: poor people, people of color, and those with a history of IVDU. It is important for us to note that, despite the trend highlighted in this study of New Yorkers, 75% of deaths were HIV-related. Our efforts to screen everybody at Bellevue is critical to case finding and further treatment and prevention. Does anyone know what our current seropositvity rate is?

If you know the answer post it in the comments.  Thanks for your thoughts Marshall.

Banning Transfatty Acids – A Case Study October 17, 2006

Posted by rajkmd in Cardiology.
2 comments

The debate on whether to ban tranfats in New York City is heating up.  Here what happened in Denmark after a two year ban…

Denmark an Example After Transfat Ban

COPENHAGEN, Denmark — Two years ago Denmark declared war on killer fat, making it illegal for any food to have more than 2 percent transfats. Offenders now face hefty fines _ or even prison terms. The result? Today hardly anyone notices the difference.

The french fries are still crispy. The pastries are still scrumptious. And the fried chicken is still tasty. (…)

Producers also argue that removing transfat from processed food will change certain tastes and textures beloved by consumers.

But they have been called the tobacco of the nutrition world. They lower good cholesterol while raising bad cholesterol.

Even consuming less than five grams of transfat _ the amount found in one piece of fried chicken and a side of french fries _ a day has been linked with a 25 percent increased risk of heart disease.

“No other fat at these low levels of intake, has such harmful effects,” said Dr. Dariush Mozaffarian, a cardiologist at Harvard’s School of Public Health.

Although the Danish health ministry reports that cardiovascular disease has dropped by 20 percent in the last five years, similar reductions have been reported in other countries that are making an effort to combat heart disease by measures such as regulating the food and tobacco industries, and by educating the public about the need to exercise. In countries that are making no effort to regulate the amount of transfat in food, such as Hungary and Bulgaria, heart disease rates have continued to climb.

Banning the transfats, though, might be bad for cardiologist.  Maybe, we should reconsider…

Test characteristics of alpha-fetoprotein for detecting hepatocellular carcinoma in patients with Hepatitis C: a systematic review and critical analysis (Annals of Internal Medicine, July 2003) October 15, 2006

Posted by rajkmd in GI.
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by Drs. Saul Blecker and Raj Khandwalla To read the actual article, click here  Background

Methods

  • Medline search from 1996 to 2002
  • Inclusion criteria – randomized control studies and case control studies that determine the sensivity and specificity
  • Gold Standard was defined CT, MRI, disease-free greater than 2 years, and/or histopathology. 
  • Each study that was included in this review was graded by the three authors

Results

  • A total five studies were included.
  • A cutoff value of ABP was considered to be 20 mcg/L
  • Sensitivity at this level ranged from 41 to 65 percent
  • Specificity ranged from 80 to 94 percent
  • Positive likelihood ratio was 3.1 to 6.8
  • Negative likelihood ratio was 0.4 to 0.6
  • Using alternative cutoff ratios
    • Greater than 200 mcg/L –> Sensitivity decreases to 20 to 45 percent and Specificity increases to 99 to 100 percent

Discussion

  • Evidence of using AFP is limited and the studies used in this review had questionable methodology
  • Given the significant concerns regarding the studies used the authors of the studies could not pool the data to calculate sensitivity and specificity
  • The prevalence of HCC in HCV positive patients is 5 percent.
    • Thus, using a cutoff of 20 mcg/L a positive test means that the patients has a 14 to 25 percent probability of having HCC.  A negative test means that the patient has a 2 to 3 percent chance of having HCC.
  • If the patient is higher risk (ie known hepatic nodule or liver failure) using a cutoff >200 mcg/L would be very specific for HCC, but at a low level would not rule out HCC.

THE BOTTOM LINE:  Using a cutoff of 20 mcg/L, the sensitivity of measuring alpha-fetoprotein levels in the screening of hepatocellular carcinoma in patients with hepatitis C infection ranges from 41 to 65 percent and the specificity is 80 to 94 percent.  Given the range of these value, widespread screening is debatable.

Causes of Death Among Persons with AIDS in the Era of Highly Active Antiretroviral Therapy: New York City (Annals of Internal Medicine, Sept. 19th, 2006) October 12, 2006

Posted by rajkmd in Infectious Disease.
1 comment so far

by Raj Khandwalla

Background

  • With the introduction of HAART therapy and prophylaxis  against common opportunistic disease, the morbidity and mortality associated with HIV/AIDS has decreased dramatically
    • Between 1996 and 1998, HIV-related morbidity and mortality  decreased by 60 percent in the United States
  • Over time, the portion of deaths among patients with HIV from non-HIV causes has increased
  • This is a population based analysis of the causes of death among HIV positive patients from 1999 through 2004
    •  the study is made up of two registries – the New York City HIV/AIDS Reporting System and Vital Statistics Registry

Methods

  • Inclusion criteria: age of 13 years old or older who recieved a diagnosis of AIDS and were alive between 1999 and 2004. 
    • Patients had to be reported to the New York City HIV/AIDS Reporting System as of Sept 30, 2005
    • Patients had to be residents of New York City at the time of diagnosis
    • Among those who died, patients needed a known underlying cause of death
  • The registry – The New York City HIV/AIDS Reporting System is a population based registry who recieved a diagnosis of AIDS as defined by the CBC
    • The reporting system recieves reports of possible AIDS diagnosis through an electronic  laboratory reporting system or through physician report and chart review 
  • Defining AIDS
    • CD4 < 0.200 x 10^9 cells/L or less than 14 percent of total lymphocytes or
    • 1 of more 26 opportunistic illnesses
  • Patients were classified by zip code and by ethnicity including Hispanic, non Hispanic people of European origin, non Hispanic African American, or other
  • HIV transmission categories
    • Injection drug use
    • Men who have sex with men
    • High-risk heterosexual sex
    • Sex with an HIV positive partner, IV drug user, or with a bisexual man
  • Outcome – underlying cause of death.  Persons with an unknown cause of death (1.8% of the total) were excluded from the anaylsis.

Baseline Demographics

  • Median age 46 yo
  • Gender, Male – 69.9 %
  • Ethnicity
    • African American 46.9 %
    • Hispanic 33.4 %
    • Non Hispanic people of European origin 18.2%
    • Other 1.5%
  • HIV transmission category
    • Men who have sex with men 23.6 %
    • IV drug users 33.2 %
    • High-risk heterosexual 14.4 %
    • Other transmission risk 1.7 %
    • Unknown 27.2 %
    • Among men with a known transmission category, 44.8% had sex with other men and 44.5% used injection drugs.
    • Among women with a known transmission category, 48.3% used injection drugs and 47.4% had high risk heterosexual sex.
  • Socioeconomic status by zip code
    • Poverty 60.3 %
    • Nonpoverty 35.7%
    • Unknown 4 %
  • Time of AIDS diagnosis
    • Before 1996 32.4%
    • 1996-1998 24.6%
    • 1999-2004 43%

Results

  • Deaths
    •  74.2 percent of patients with known AIDS and known causes of death in NYC between 1999 and 2004, died of HIV related causes
    • 24 percent of patients with known AIDS died of non-HIV related causes
      • 7.4 percent died of substance abuse related deaths
      • 5.7 percent died of cardiovascular disease
      • 5 percent died of cancer
      • Accidents, chronic lower respiratory airway disease, cancer, diabetes, suicide, kidney disease each made up less 0.8 percent of deaths
  • Trends in Deaths
    • Both the rate of HIV related deaths and the rate of non HIV related death decreased each year of the study
      • 54.9 percent decrease in HIV related deaths from 1999 to 2004
      • 34.3 percent decrease in non HIV related deaths from 1999 to 2004
    • Mortality rate for HIV related causes of death increased with age
    • Rates of HIV related deaths were higher for
      • women compared to men
      • African American men followed by Hispanic, and non Hispanic people of European heritage or other in both the HIV related and non HIV related groups.
    • Mortality rates were lowest for men who have sex with men and highest for injection drug users for both HIV related and non HIV related causes of death
    • The strongest predictor of death was a CD4 count <50 x 10^6
    • IV drug use was the strongest nonclinical predictor of death for both HIV related or non HIV related causes of death

 Discussion

  • Between 1999 and 2004 in New York City, the rate of HIV related and non HIV related deaths has declined in people with AIDS
  • HIV related deaths continue to account for the vast majority (74%) of deaths, but the proportion of non HIV related causes of death increased by 33% during this five year time period.
  • The paper recommends that physicians taking care of HIV/AIDS patients should treat patients with “standard practices appropriate  for their age and sex” in addition to their HIV status.

THE BOTTOM LINE: People with AIDS are living longer.  While HIV related causes of deaths, still make up a majority mortalities in this population, non HIV related causes of death are quickly increasing among AIDS patients.  The advent of HAART is clearly helping people live longer.  As such, physicians should treat their patients for common causes of death among the general population.

Outsourcing healthcare to India October 12, 2006

Posted by rajkmd in Medical Economics, Uncategorized.
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The surgeons aren’t going to be happy.  They can outsource elective procedures, but you can’t outsource primary care.

Union Disrupts Plan to Send Ailing Workers to India for Cheaper Medical Care 

A few weeks ago, Carl Garrett, a 60-year-old North Carolina resident, was packing his bags to fly to New Delhi and check into the plush Indraprastha Apollo Hospital to have his gall bladder removed and the painful muscles in his left shoulder repaired. Mr. Garrett was to be a test case, the first company-sponsored worker in the United States to receive medical treatment in low-cost India.

But instead of making the 20-hour flight, Mr. Garrett was grounded by a stormy debate between his employer, which saw the benefits of using the less expensive hospitals in India, and his union, which raised questions about the quality of overseas health care and the issue of medical liability should anything go wrong. 

“No U.S. citizen should be exposed to the risks involved in traveling internationally for health care services,” Leo W. Gerard, the president of the union, said in a recent letter to the Senate and House committees that oversee health care. He expressed his concern about the willingness of employers to offer incentives to employees to go overseas.

With medical costs in India routinely 80 percent lower than in the United States, experts predict that globally standardized health care delivered in countries like India and Thailand will eventually change the face of the health care business.

Providing health care to foreigners could generate $20 billion for India by 2012, according to a study by McKinsey & Company, the consulting firm, although McKinsey did not say how many patients that figure represents. With 150,000 overseas patients last year — though only a small fraction of them Americans — India is already the global leader in importing foreign patients for low-cost treatment. Its best hospitals have Western-trained doctors and are equipped with modern equipment.