Pain characteristics suggest higher benefit from gallbladder surgery

According to a new study in Clinical Gastroenterology and Hepatology, better understanding of a patient's abdominal pain could help physicians know which patients will benefit most from surgical removal of the gallbladder. Nearly 800,000 gallbladder removal surgeries, or cholecystectomies, are performed annually in the U.S. at a cost exceeding $6 billion. Surgeries are often performed on patients whose gallstones are discovered via imaging tests after patient complaints of abdominal pain. Considering that abdominal pain persists in up to 50 percent of patients after cholecystectomy, physicians need a better way to determine who will benefit from surgery.
"Given the number of cholecystectomies that are performed, this study underscores the importance of taking a detailed history when selecting patients for surgery," said Johnson L. Thistle, MD, of Mayo Clinic and lead author of this study. "About 80 percent of gallstones never become symptomatic. Identifying the features of episodic gallbladder pain and differentiating them from symptoms of gastroesophageal reflux disease and irritable bowel syndrome should lead to improved symptom relief and value for patients with abdominal pain."
Researchers prospectively studied 1,008 patients with upper abdominal pain who had elective cholecystectomy for uncomplicated gallstone disease. The following pain characteristics, especially if multiple, were most predictive of pain relief after surgery: episodic pain (usually once a month or less), lasting 30 minutes to 24 hours, occurring during the evening or at night, and onset one year or less before presentation.
Gallstones form in the gallbladder and are composed predominately of cholesterol, which has separated out of solution in bile and formed crystals, much as sugar may form in the bottom of a syrup jar. Gallstones may be as small as a grain of sand or as large as a golf ball, and the gallbladder may contain anywhere from one stone to hundreds. It is not entirely known why some people develop gallstones and others do not.
Many people with gallstones have no symptoms, and often, the gallstones are found when tests are performed to evaluate other problems. In this case, no treatment is usually recommended. When symptoms do arise, gallbladder removal is the most widely used therapy.
Clinical Gastroenterology and Hepatology is the official journal of the American Gastroenterological Association.

*Source: American Gastroenterological Association

Folic acid in early pregnancy associated with reduced risk of severe language delay in children

Use of folic acid supplements by women in Norway in the period 4 weeks before to 8 weeks after conception was associated with a reduced risk of the child having severe language delay at age 3 years, according to a study in the October 12 issue of JAMA. "Randomized controlled trials and other studies have demonstrated that periconceptional [the period from before conception to early pregnancy] folic acid supplements reduce the risk of neural tube defects. To our knowledge, none of the trials have followed up their sample to investigate whether these supplements have effects on neurodevelopment that are only manifest after birth," the authors write.
Christine Roth, M.Sc., Clin.Psy.D., of the Norwegian Institute of Public Health, Oslo, and colleagues conducted a study to investigate whether maternal use of folic acid supplements was associated with a reduced risk of severe language delay among offspring at age 3 years. "Unlike the United States, Norway does not fortify foods with folic acid, increasing the contrast in relative folate status between women who do and do not take folic acid supplements," the researchers write. Pregnant women were recruited for the study beginning in 1999, and data were included on children born before 2008 whose mothers returned the 3-year follow-up questionnaire by June 16, 2010. Maternal use of folic acid supplements within the interval from 4 weeks before to 8 weeks after conception was the exposure. The primary outcome measured for the study was children's language competency at age 3 years as gauged by maternal report on a 6-point ordinal language grammar scale. Children with minimal expressive language (only 1-word or unintelligible utterances) were rated as having severe language delay.
The main analysis for the study included 38,954 children (19,956 boys and 18,998 girls). Of these children, 204 (0.5 percent) were rated as having severe language delay (159 [0.8 percent] boys and 45 [0.2 percent) girls). Children whose mothers took no dietary supplements in the specified exposure interval were the reference group (n = 9,052 [24.0 percent], with severe language delay in 81 children [0.9 percent]). Data for 3 patterns of exposure to maternal dietary supplements were: other supplements, but no folic acid (n = 2,480 [6.6 percent], with severe language delay in 22 children [0.9 percent]); folic acid only (n = 7,127 [18.9 percent], with severe language delay in 28 children [0.4 percent]); and folic acid in combination with other supplements (n = 19,005 [50.5 percent], with severe language delay in 73 children [0.4 percent]).
The researchers write that maternal use of supplements containing folic acid within the period from 4 weeks before to 8 weeks after conception was associated with a substantially reduced risk of severe language delay in children at age 3 years. "We found no association, however, between maternal use of folic acid supplements and significant delay in gross motor skills at age 3 years. The specificity provides some reassurance that there is not confounding by an unmeasured factor. Such a factor might be expected to relate to both language and motor delay."
The authors add that to their knowledge, no previous prospective observational study has examined the relation of prenatal folic acid supplements to severe language delay in children.
"If in future research this relationship were shown to be causal, it would have important implications for understanding the biological processes underlying disrupted neurodevelopment, for the prevention of neurodevelopmental disorders, and for policies of folic acid supplementation for women of reproductive age."

**Source: JAMA and Archives Journals

Survival disparities in African-American and white colo-rectal cancer patients

African-American patients with resected stage II and stage III colon cancer experienced worse overall and recurrence-free survival compared to whites, but similar recurrence-free intervals, according to a study published Oct. 12 in the Journal of the National Cancer Institute. Colorectal cancer is a leading cause of cancer-related deaths in the United States. In 2006, there were an estimated 146,970 new cases of colorectal cancer diagnosed in the U.S. Of those diagnosed, 15,000 were projected to occur in individuals of African ancestry, resulting in approximately 7,000 deaths. Despite overall improvements in colorectal cancer survival in the U.S., the survival difference between African-Americans and whites has not narrowed. The 5-year relative survival rates for black and white colorectal cancer patients between 1999 and 2005 were 57% and 68%. Although several causes of the disparities have been identified, the reasons are not well understood.
In order to determine the disparities of colorectal cancer survival outcomes between blacks and whites, Greg Yothers, Ph.D., of the National Surgical Adjuvant Breast and Bowel Project Biostatistical Center and colleagues, examined data from the Adjuvant Colon Cancer ENdpoinTs (ACCENT) collaborative group database to analyze 14,611 African-American and white patients with stage II or III colorectal cancer enrolled in 12 phase III randomized controlled clinical trials conducted in North America from 1977-2002. Within these trials, patients received the same adjuvant colon cancer therapy regardless of race, but care for other diseases or recurrent colon cancer was outside the scope of these trials. The researchers evaluated overall survival, recurrence-free survival (time to recurrence or death), and recurrence-free interval (time to recurrence).
The researchers found that the five-year overall survival rate was worse among the 1,218 African-American patients, compared to the whites, with a 4.6 percentage point decrement in 5-year survival, and a 3.7 percentage point decrement in recurrence-free survival. But there was no statistically significant difference in recurrence-free interval.
The authors write that the survival differences are most likely because of factors unrelated to a patient's response to adjuvant treatment. "Black patients with resected stage II and III colon cancer treated with identical adjuvant therapy experienced poorer overall and recurrence-free survival but similar recurrence-free interval compared with white patients," they write. "Biological differences, differences in general health, and disparities in health care outside the clinical trial are possible explanations for these findings…"
In an accompanying editorial, Olufunmilayo I. Olopade, M.D., Director of the Center for Clinical Cancer Genetics & Global Health at the University of Chicago, and colleagues write that the Yothers study is consistent with studies published in the last decade. "When treated equally, African-Americans have similar colon cancer-specific survival but continue to have poorer overall survival compared with white patients," they write. Going forward, trials must include basic information on patients' socio-demographic situation, as well as their tumor biology and co-morbid conditions, the editorialists write, adding that primary care of survivors should also be improved and monitored so that differences in survival after recurrence can be better understood. Lastly, trials examining genetic markers may require enrolment targets, so that a trial could close to accrual for whites but may remain open for African-Americans and other minorities. The editorialists write, "We have documented racial and ethnic differences in cancer survival by looking from 10,000 feet over the past decade, but it is past time for us to get out of the clouds and collect and integrate data that advance the field."

**Source: Journal of the National Cancer Institute

El ácido fólico también es útil para prevenir retrasos en el lenguaje

Desde hace años, los ginecólogos recomiendan tomar ácido fólico a las mujeres que estén pensando en quedarse embarazadas o ya se encuentren en las primeras semanas de gestación ya que se ha demostrado que este suplemento resulta beneficioso para el futuro bebé.
Hasta el momento, se sabía que el ácido fólico es muy útil para reducir el riesgo de problemas congénitos, como los defectos del tubo neural (anancefalia, espina bífida, hidrocefalia), aunque, a juzgar por los resultados de una reciente investigación, la lista de trastornos que podría prevenir podría ser más larga.
Según sus datos, que se publican en el último número de la revista 'Journal of the American Medical Association' ('JAMA'), el aporte de ácido fólico desde las cuatro semanas anteriores a la concepción hasta al menos las ocho semanas de gestación se asocia con un menor riesgo de retraso en el lenguaje en el bebé.
Los autores de esta investigación, dirigidos por Christine Roth, del Instituto de Salud Pública de Oslo (Noruega), realizaron un seguimiento a las madres de 38.954 niños nacidos entre 1999 y 2008. Entre otras pruebas, cada una de las participantes remitió a los investigadores las respuestas a un cuestionario sobre sus hábitos en el embarazo, las competencias motoras de sus pequeños y sus habilidades para comunicarse a los tres años.
Al cruzar los datos, los investigadores comprobaron que quienes menor riesgo de retraso en el lenguaje presentaban eran los hijos de aquellas participantes que habían tomado ácido fólico en el periodo de su embarazo incipiente.
En cambio, no había ninguna relación entre el consumo de ácido fólico y las destrezas motoras de los pequeños, lo que, según los investigadores, refuerza la hipótesis de que existe una relación independiente entre la ingesta del suplemento alimenticio y el desarrollo neurocognitivo de los pequeños.

-Confirmación
Pese a todo, en su trabajo reconocen que no han podido determinar las causas de esta asociación y que son necesarios nuevos trabajos que prueben que existe un vínculo causal entre ambos factores.
"Si en el futuro, la investigación muestra que existe una relación causal, estos tendrá importantes implicaciones para comprender los procesos biológicos que están detrás de los problemas del neurodesarrollo, para prevenir los trastornos en este campo y para llevar a cabo políticas de suplementos dietéticos en mujeres en edad reproductiva", concluyen.
Para José García Flores, ginecólogo del Hospital Universitario Quirón Madrid, la hipótesis que presentan los investigadores noruegos es muy plausible ya que el ácido fólico, presente en muchos alimentos de hoja verde, "puede considerarse un alimento para las células".
"Es un ayudante para la multiplicación celular, por lo que tiene sentido que su papel sea importante en distintas etapas del desarrollo", comenta este especialista.
Según explica, en España existe una recomendación universal de ingesta de ácido fólico, ya que se ha detectado cierto déficit en la ingesta de esta vitamina, que se relaciona con numerosos beneficios.
En el caso concreto de las embarazadas, se recomienda comenzar con el suplemento dos o tres meses antes de la gestación y continuar con él durante la lactancia, si bien, en la mayoría de los casos "las mujeres gestantes empiezan a tomar ácido fólico al inicio del embarazo".

**Publicado en "EL MUNDO"

New buzzwords 'reduce medicine to economics'

Physicians who once only grappled with learning the language of medicine must now also cope with a health care world that has turned hospitals into factories and reduced clinical encounters to economic transactions, two Beth Israel Deaconess Medical Center physicians lament. "Patients are no longer patients, but rather 'customers' or 'consumers'. Doctors and nurses have transmuted into 'providers,' Pamela Hartzband, MD and Jerome Groopman MD, write in the Oct. 13 edition of the New England Journal of Medicine.
"We are in the midst of an economic crisis and efforts to reform the health care system have centered on controlling spiraling costs. To that end, many economists and policy makers have proposed that patient care should be industrialized and standardized. Hospitals and clinics should be run like modern factories and archaic terms like doctor, nurse and patient must therefore be replaced with terminology that fits this new order."
The problem, Hartzband and Groopman, note, is that the special knowledge that doctors and nurses possess and use to help patients understand the reason for and remedies to their illness get lost in a system that values prepackaged, off-the-shelf solutions that substitute "evidence-based practice" for "clinical judgment."
"Reducing medicine to economics makes a mockery of the bond between the healer and the sick," they write. "For centuries doctors who were mercenary were publicly and appropriately castigated … Such doctors betrayed their calling. Should we now be celebrating the doctor whose practice, like a successful business, maximizes profits from 'customers'"?
Hartzband and Groopman say the new emphasis on "evidence-based practice" is not really a new phenomenon at all. "Evidence" was routinely presented on daily rounds or clinical conferences where doctors debated numerous research studies.
"But the exercise of clinical judgment, which permitted the assessment of those data and the application of study results to an individual patient, was seen as the acme of professional practice. Now some prominent health policy planners and even physicians contend that clinical care should essentially be a matter of following operating manuals containing preset guidelines, like factory blueprints, written by experts."
They note the subjective core of the concept is proven by the fact that working with the same data, different groups of experts often write different guidelines for conditions as common as hypertension and elevated cholesterol levels or for the use of screening tests for prostate and breast cancer.
"The specific cutoffs for treatment or no treatment … all necessarily reflect the values and preferences of the experts who write the recommendations. And these values and preferences are subjective, not scientific."
Even more troubling, the authors suggest, is the impact of the new vocabulary on future doctors, nurses, therapists and social workers who care for patients.
"Recasting their roles as providers who merely implement prefabricated practices diminishes their professionalism. Reconfiguring medicine in economic and industrial terms is unlikely to attract creative and independent thinkers with not only expertise in science and biology but also an authentic focus on humanism and caring.
"When we ourselves are ill, we want someone to care about us as people, not paying customers and to individualize our treatment according to our values. Despite the lip service paid to 'patient-centered care' by the forces promulgating the new language of medicine, their discourse shifts the focus from the good of the individual to the exigencies of the system and its costs.
"We believe doctors, nurses and others engaged in care should eschew the use of such terms that demean patients and professionals alike and dangerously neglect the essence of medicine."

*Source: Beth Israel Deaconess Medical Center

Expertos en nutrición alertan de los graves riesgos para la salud de los regímenes de moda

El otoño es tiempo de buenos propósitos. Uno de los más comunes consiste en mirarse al espejo y hacerse la firme promesa de bajar peso. Esta vez sí. Más del 40% de la población se ha puesto a régimen en los últimos seis meses, según revela un reciente estudio difundido y financiado por una empresa de alimentación dietética. Pero en ese camino, como en todo, no existen atajos. Al contrario: buscarlos puede generar serios problemas de salud, según advierte la jefa de la sección de Endocrinología y Nutrición del hospital de Getafe, Susana Monereo. «La dieta perfecta no existe», recuerda. «El secreto para perder peso es tan simple como adaptar la ingesta a nuestro ritmo de vida. Tendríamos que suprimir la palabra dieta de nuestro vocabulario -defiende- y pasar al concepto de alimentación saludable, que ése sí nos va a permitir bajar kilos de una manera sana».
«El secreto para perder peso es tan simple como adaptar la ingesta a nuestro ritmo de vida»Los expertos en nutrición llevan repitiendo ese criterio como una cantinela desde hace años. «El exceso de peso no puede combatirse con soluciones milagrosas, que por definición no existen, sino con una alimentación equilibrada, ajustada a las necesidades de cada uno, y acompañada de ejercicio diario», resume el presidente de la Sociedad Española de Nutrición, Javier Aranceta. El último tótem en caer ha sido la famosa dieta Dukan, que como todas las que le precedieron, también ha sido puesta en entredicho.
Después de haberse convertido su libro en un «best-seller» con más de 12 millones de lectores en una década, las consultas médicas han puesto de manifiesto que el régimen del nutricionista francés, basado en el consumo preferente de proteínas, también puede ser perjudicial para la salud.

**Lee la información completa en El Correo.

Secuencian el ADN de la llamada «peste negra»

Un grupo de científicos alemanes, canadienses y estadounidenses ha secuenciado por primera vez el ADN de una plaga medieval tras aplicar nuevas técnicas de recuperación genética en huesos de cuatro cadáveres de la «peste bubónica», que reposaban en un cementerio de Londres.
La llamada «peste negra» fue una pandemia devastadora que se desató hacia 1348, y que en cinco años terminó con entre un tercio y la mitad de la población europea de la época. El brote fue provocado por una variante de la bacteria Yersinia pestis, y el grupo de investigadores decidió lanzarse a la caza de su secuencia genética.
Los expertos consideran que descendientes directos de aquella plaga bubónica matan todavía a 2.000 personas cada año. Y casi todas las epidemias violentas en la actualidad, como el brote mortal de E.coli este año en Francia y Alemania, contienen restos del ADN de la bacteria responsable de la terrible plaga de hace más de 600 años.
«Los datos genéticos indican que esta variante bacteriológica es el ancestro de todas las plagas modernas que tenemos en el mundo. Todos los brotes de hoy día provienen de un descendiente de aquella plaga medieval», explica Hendrik Poinar, uno de los científicos responsables del proyecto, publicado ayer por la revista científica "Nature".