Standard radiation therapy dose provides pain relief for painful heel spurs (plantar fasciitis)

ScienceDaily (July 26, 2012) — Patients with plantar fasciitis (painful bone heel spur) experience significantly less pain and improved quality of life following a standard dose of external beam radiation therapy, a common cancer treatment similar to receiving an X-ray, according to a randomized, cooperative group study that was published online July 25, 2012, in the International Journal of Radiation Oncology • Biology • Physics (Red Journal), the official scientific journal of the American Society for Radiation Oncology (ASTRO).

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Approximately 8-10 percent of the population has severe bone heel spurs, with the most common treatments for alleviating the pain being ice, heat, and various anti-inflammatory agents. Steroids and local anesthetics can be injected, and oral analgesic medications may be prescribed, but most of these methods have only provided short-term pain relief. The results of this study demonstrated that up to 80 percent of standard dose patients experienced complete pain relief, and pain relief remained constant or even improved for up to 64 percent of the study participants during the follow-up period of 48 weeks post-treatment.

“Severe plantar fasciitis is a chronic health issue, and it can be extremely painful — many of these men and women cannot walk or stand for a long time,” said Marcus Niewald, MD, PhD, a radiation oncologist at Saarland University Medical Center in Homburg/Saar, Germany, and one of the study’s authors. “Radiation therapy has been used for its anti-inflammatory effect for more than 60 years. We are extremely encouraged by the results of our research because evidence of improved quality of life for patients is clearly evident with the standard dose regimen.”

This study was a prospective, randomized trial of a total of 66 patients, with evaluation every six weeks until 12-months post treatment. Four patients were secondarily excluded after the trial began; 29 patients received a standard dose regimen, and the remaining 33 patients received a low dose of radiation therapy. The standard dose patients were treated with a total dose of 6.0 Gy, applied in 6 single fractions of 1.0 Gy twice weekly on non-consecutive days. The low dose arm received 0.6 Gy, applied in 6 single fractions of 0.1 Gy twice weekly on non-consecutive days.

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The above story is reprinted from materials provided by American Society for Radiation Oncology.

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Journal Reference:

1. Marcus Niewald, M. Heinrich Seegenschmiedt, Oliver Micke, Stefan Graeber, Ralf Muecke, Vera Schaefer, Christine Scheid, Jochen Fleckenstein, Norbert Licht, Christian Ruebe. Randomized, Multicenter Trial on the Effect of Radiation Therapy on Plantar Fasciitis (Painful Heel Spur) Comparing a Standard Dose With a Very Low Dose: Mature Results After 12 Months’ Follow-Up. International Journal of Radiation Oncology*Biology*Physics, 2012; DOI: 10.1016/j.ijrobp.2012.06.022

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Efficacy of transcranial magnetic stimulation for depression confirmed in new study

ScienceDaily (July 26, 2012) — In one of the first studies to look at transcranial magnetic stimulation (TMS) in real-world clinical practice settings, researchers at Butler Hospital, along with colleagues across the U.S., confirmed that TMS is an effective treatment for patients with depression who are unable to find symptom relief through antidepressant medications. The study findings are published online in the June 11, 2012 edition of Depression and Anxiety in the Wiley Online Library.

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Previous analysis of the efficacy of TMS has been provided through more than 30 published trials, yielding generally consistent results supporting the use of TMS to treat depression when medications aren’t sufficient. “Those previous studies were key in laying the groundwork for the FDA to approve the first device for delivery of TMS as a treatment for depression in 2008,” said Linda Carpenter, MD, lead author of the report and chief of the Mood Disorders Program and the Neuromodulation Clinic at Butler Hospital. “Naturalistic studies like ours, which provide scrutiny of real-life patient outcomes when TMS therapy is given in actual clinical practice settings, are the next step in further understanding the effectiveness of TMS. They are also important for informing healthcare policy, particularly in an era when difficult decisions must be made about allocation of scarce resources.”

Carpenter explains that naturalistic studies differ from controlled clinical trials because they permit the inclusion of subjects with a wider range of symptomatology and comorbidity, whereas controlled clinical trials typically have more rigid criteria for inclusion. “As a multisite study collecting naturalistic outcomes from patients in clinics in various regions in the U.S., we were also able to capture effects that might arise from introducing a novel psychiatric treatment modality like TMS in non-research settings,” said Carpenter. In all, the study confirms how well TMS works in diverse settings where TMS is administered to a real-life population of patients with depression that have not found relief through many other available treatments.

The published report summarized data collected from 42 clinical TMS practice sites in the US, and included outcomes from 307 patients with Major Depressive Disorder (MDD) who had persistent symptoms despite the use of antidepressant medication. Change during TMS was assessed using both clinicians’ ratings of overall depression severity and scores on patient self-report depression scales, which require the patient to rate the severity of each symptom on the same standardized scale at the end of each 2-week period. Rates for “response” and “remission” to TMS were calculated based on the same cut-off scores and conventions used for other clinical trials of antidepressant treatments. Fifty-eight percent positive response rate to TMS and 37 percent remission rate were observed.

“The patient outcomes we found in this study demonstrated a response rate similar to controlled clinical trial populations,” said Dr. Carpenter, explaining that this new data validates TMS efficacy in treating depression for those who have failed to benefit from antidepressant medications. “Continued research and confirmation of the effectiveness of TMS is important for understanding its place in everyday psychiatric care and to support advocacy for insurance coverage of the treatment.” Thanks in part to the advocacy efforts of Dr. Carpenter, TMS was recently approved for coverage by Medicare in New England, and it is also now covered by BCBSRI. “Next steps for TMS research involve enhancing our understanding of how to maintain positive response to TMS over time after the course of therapy ends and learning how to customize the treatment for patients using newer technologies, so TMS can help even more patients.”

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The above story is reprinted from materials provided by Women & Infants Hospital, via EurekAlert!, a service of AAAS.

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MRSA cases in academic hospitals double in five years

ScienceDaily (July 26, 2012) — Infections caused by methicillin-resistant Staphylococcus aureus (MRSA) doubled at academic medical centers in the U.S. between 2003 and 2008, according to a report published in the August issue of Infection Control and Hospital Epidemiology, the journal of the Society for Healthcare Epidemiology of America.

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Researchers from the University of Chicago Medicine and the University HealthSystem Consortium (UHC) estimate hospitalizations increased from about 21 out of every 1,000 patients hospitalized in 2003 to about 42 out of every 1,000 in 2008, or almost 1 in 20 inpatients. “The rapid increase means that the number of people hospitalized with recorded MRSA infections exceeded the number hospitalized with AIDS and influenza combined in each of the last three years of the survey: 2006, 2007, and 2008,” said Michael David, MD, PhD, an assistant professor of medicine at the University of Chicago and one of the study’s authors.

The findings run counter to a recent CDC study that found MRSA cases in hospitals were declining. The CDC study looked only at cases of invasive MRSA — infections found in the blood, spinal fluid, or deep tissue. It excluded infections of the skin, which the UHC study includes.

MRSA infections, which cannot be treated with antibiotics related to penicillin, have become common since the late 1990s. These infections can affect any part of the body, including the skin, blood stream, joints, bones, and lungs.

The researchers attribute much of the overall increase they detected to community-associated infections — those that were contracted outside the healthcare setting. When MRSA first emerged it was primarily contracted in hospitals or nursing homes. “Community-associated MRSA infections, first described in 1998, have increased in prevalence greatly in the U.S. in the last decade,” David said. “Meanwhile, healthcare-associated strains have generally been declining.”

The study utilized the UHC database, which includes data from 90 percent of all not-for-profit academic medical centers in the U.S. However, like many such databases, the UHC data are based on billing codes hospitals submit to insurance companies, which often underestimate MRSA cases. For example, hospitals might not report MRSA cases that do not affect insurance reimbursement for that particular patient. In other cases, hospitals might be limited in the number of billing codes they can submit for each patient, which can result in a MRSA code being left off the billing report if it was not among the primary diagnoses.

David and his team corrected for these errors by using detailed patient observations from the University of Chicago Medical Center and three other hospitals. They looked at patient records to find the actual number of MRSA cases in each hospital over a three-year period. The team then checked the insurance billing data to see how many of those cases were actually recorded. They found that the billing data missed one-third to one-half of actual MRSA cases at the four hospitals. They used that rate of error as a proxy to correct the billing data from other 420 hospitals in the UHC database and arrive at the final estimates.

“I think this is still an underestimate of actual cases,” David said. “But we can say with some assurance that this correction gives us a more accurate lower bound for how many cases [of MRSA] there actually are. What’s clear from our data is that cases were on the rise in academic hospitals in 2003 to 2008.”

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The above story is reprinted from materials provided by University of Chicago Press Journals, via EurekAlert!, a service of AAAS.

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Journal Reference:

1. Michael Z. David, Sofia Medvedev, Samuel F. Hohmann, Bernard Ewigman, Robert S. Daum. Increasing Burden of Methicillin-Resistant Staphylococcus aureus Hospitalizations at US Academic Medical Centers, 2003? Infection Control and Hospital Epidemiology, August 2012 [link]

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CT angiography speeds emergency diagnosis of heart disease in low-risk patients

ScienceDaily (July 25, 2012) — Incorporating coronary CT angiography (CCTA) into the initial evaluation of low-risk patients coming to hospital emergency departments (EDs) with chest pain appears to reduce the time patients spend in the hospital without incurring additional costs or exposing patients to significant risks. The report of a study conducted at nine U.S. hospitals appears in the July 26 New England Journal of Medicine.

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“We found that the use of CCTA in emergency department evaluation of acute chest pain very effectively identified which patients did or did not have coronary artery obstruction, allowing clinicians to focus the use of resources on patients with heart disease,” says Udo Hoffmann, MD, MPH, director of the Cardiac MR PET CT program at Massachusetts General Hospital (MGH) and corresponding author of the NEJM article. “Although the use of CCTA added to the amount of diagnostic testing used in the evaluation process, compared with current standard protocols it significantly reduced length of stay without increasing costs.”

CCTA combines advanced CT scanning with the use of intravenous contrast material to produce detailed images of blood vessels supplying the heart without the need for cardiac catheterization. Several previous studies, including an immediate predecessor to the current one, have indicated that CCTA can effectively distinguish chest pain patients that do not have coronary artery disease, but those studies all had such limitations as lack of a control group or limited analysis of factors like costs and radiation exposure. The current study — ROMICAT (Rule Out Myocardial Infarction/Ischemia Using Computer Assisted Tomography)-II — was designed to determine whether a CCTA-based evaluation strategy could improve clinical decision making at different hospitals across the country.

From April 2010 to January 2012, patients arriving at the participating hospitals’ EDs for evaluation of chest pain who had no history of cardiovascular disease and whose initial tests — ECG and measurement of the biomarker troponin — did not clearly indicate a heart attack were invited to participate in the trial. Those who agreed to participate were randomly assigned to one of two groups. The control group proceeded with standard evaluation, with all diagnostic and treatment decisions being made by hospital physicians not part of the study group. The other group had CCTA as part of their ED evaluation, with the results being shared with attending physicians who, again, made all clinical decisions. Participants who were discharged from the hospital within 24 hours of arrival were called within 72 hours to assess their status, and all participants were called 28 days after hospital discharge and asked whether any return ED visits or rehospitalizations had taken place. Participant responses were verified by checking their medical records. About 1,000 patients completed the study, including the 28-day followup.

The investigators found that participants in the CCTA group had significant reductions in the amount of time from ED arrival until discharge either from the ED or after a hospital stay, with half of the CCTA group being discharged within 8.6 hours but only 10 percent of the control group being released so quickly. The amount of time until a diagnosis of heart disease was either ruled out or confirmed was also shorter for the CCTA group than for the controls, and more patients receiving CCTA were discharged directly from the ED rather than being admitted to an observation unit. The percentage of patients actually diagnosed with heart disease was similar in both groups at around 8 percent, and there were no missed diagnoses in either group.

Analysis of total clinical resources used from arrival to discharge indicated that CCTA participants had more diagnostic procedures than control group members, but the difference was not statistically significant. Neither were there any significant differences between groups in total costs through the 28-day followup in those participants for whom cost information was available. CCTA group participants were exposed to higher cumulative doses of radiation, but the authors note that recent studies have indicated that CCTA can often be successfully performed using lower doses and suggest that future studies test the utility of low-dose CCTA examination.

“It’s very important to strive for the greatest efficiency in diagnostic testing, and in this study, additional testing was primarily carried out in patients found to have coronary artery disease,” Hoffmann says. “There also were fewer adverse clinical events in those receiving CCTA, although the study group was too small to conclude that CCTA reduced those risks.

“Showing at a variety of clinical sites that CCTA is at least as good as standard ED evaluation without increasing costs elevates the procedure from one appropriate only for specialized settings to one that can be applied in many centers,” he adds. “I’d really like to commend the commitment and teamwork of all the participating sites and departments, which was essential to the successful completion of this study.” Hoffmann is an associate professor of Radiology at Harvard Medical School.

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The above story is reprinted from materials provided by Massachusetts General Hospital.

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Journal Reference:

1. Udo Hoffmann, Quynh A. Truong, David A. Schoenfeld, Eric T. Chou, Pamela K. Woodard, John T. Nagurney, J. Hector Pope, Thomas H. Hauser, Charles S. White, Scott G. Weiner, Shant Kalanjian, Michael E. Mullins, Issam Mikati, W. Frank Peacock, Pearl Zakroysky, Douglas Hayden, Alexander Goehler, Hang Lee, G. Scott Gazelle, Stephen D. Wiviott, Jerome L. Fleg, James E. Udelson. Coronary CT Angiography versus Standard Evaluation in Acute Chest Pain. New England Journal of Medicine, 2012; 367 (4): 299 DOI: 10.1056/NEJMoa1201161

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Disclaimer: This article is not intended to provide medical advice, diagnosis or treatment. Views expressed here do not necessarily reflect those of ScienceDaily or its staff.