News in brief - Jan. 17, 2005

Low adherence to asthma meds following hospitalization - Genetic variants in estrogen receptor pathways a risk for breast cancer - Second cesarean safer than VBAC - Few people know they have chronic kidney disease - Democracy -- healthier than dictatorship

Low adherence to asthma meds following hospitalization

About half of patients with severe asthma who were hospitalized because of the disease stopped using their prescribed inhaled and oral corticosteroids within one week of their discharge, according to a new study in the Dec. 15, 2004, issue of the American Journal of Respiratory and Critical Care Medicine.

"Our results provide strong evidence that even under optimal conditions with free medications and intensive inpatient education, discontinuation of both inhaled corticosteroids and oral corticosteroids is common within seven days of discharge home," said the study's lead author, Jerry A. Krishnan, MD, assistant professor of medicine at Johns Hopkins School of Medicine.

The researchers measured post-hospital adherence in 52 asthmatics. The participants were nearly all African-American, 65% were female and almost half had a history of near-fatal asthma.

Investigators advocate rigorous monitoring of adherence to therapy in clinical practice and home visits from nurses to patients with the worst asthma control who also, it turns out, are least likely to have used prescribed corticosteroids after discharge.

Genetic variants in estrogen receptor pathways a risk for breast cancer

A woman's risk of developing breast cancer is due in part to a group of very small variations in genes that code for a cell's estrogen receptors, according to a collaborative study that appeared in the Dec. 15, 2004, issue of Cancer Research.

Researchers led by Bert Gold, PhD, a scientist in the National Cancer Institute's Center for Cancer Research, studied the association between breast cancer risk and very small differences in the genes coding for estrogen and progesterone receptors, called single nucleotide polymorphisms.

Of 17 single nucleotide polymorphisms of the estrogen receptor gene called ESR1, there were two polymorphisms associated with breast cancer susceptibility.

One was associated with disease only in women older than 50; additionally, this polymorphism was very rare in the African-American population. The other polymorphism was associated only with disease in Ashkenazi Jewish women older than 50.

"We were pleasantly surprised to discover that some women have some genetic protections from breast cancer," Dr. Gold said.

"We know that half of familial breast cancer is due to genetic factors other than BRCA1 and BRCA2," said Kenneth Offit, MD, a cancer geneticist at Memorial Sloan-Kettering and a co-author of the study. "These finding suggest that genetic variants in estrogen receptor pathways may be one of many such risk factors."

Second cesarean safer than VBAC

Attempting a vaginal delivery after a cesarean puts the woman at increased risk of uterine rupture or endometritis but has no impact on the rate of maternal death or hysterectomy, according to a paper in the Dec. 16, 2004, New England Journal of Medicine.

Researchers at 19 academic health centers participating in a study funded by the National Institute of Child Health and Human Development Maternal Fetal Medicine Units Network prospectively observed more than 30,000 women over four years who had delivered initially by cesarean. More than 15,000 decided to have a cesarean for their subsequent births; more than 17,000 attempted to deliver vaginally. Of these, just under 1% had a uterine rupture. Nearly 3% developed endometritis, while just under 2% of those who had a second cesarean did.

The authors concluded that VBAC is riskier than a second cesarean, though the absolute risks are low.

"While the magnitude of these risks for serious complications is small, women who have had previous cesarean section and who are considering choices for childbirth should be aware of the level of risk involved," said Mark Landon, MD, lead author and vice chair of obstetrics and gynecology at the Ohio State University Medical Center in Columbus.

Few people know they have chronic kidney disease

The number of people with kidney failure doubled in the past 10 years, and the number starting dialysis or having a transplant went up by 50%. The number of people with early kidney disease, however, remained stable, with 7.4 million having less than half the kidney function of a healthy adult and another 11.3 million having protein in their urine, according to a study published in this month's Journal of the American Society of Nephrology.

Researchers who analyzed data from the National Health and Nutrition Examination Surveys conducted by the Centers for Disease Control and Prevention suggest that this means that 10 million to 20 million people have chronic kidney disease but are not aware of it.

"We need to increase awareness, diagnosis and treatment if we are going to reduce the rate of progression and complications," said Josef Coresh, MD, PhD, lead author and professor of epidemiology, medicine and biostatistics at the Johns Hopkins Bloomberg School of Public Health.

Democracy -- healthier than dictatorship

Those who live in democracies tend to have better health than those who live under more repressive regimes, according to a study published in the Dec. 18, 2004, issue of the British Medical Journal.

Researchers at Spain's University of Alicante created a database of the per capita gross national product, total government expenditure, a measure of inequality, freedom ratings, life expectancy and maternal and infant mortality for 98% of the world's population in 170 countries.

Countries that enjoyed the most freedom had the best health while those who had the least freedom had the worst health -- even when adjusted for the country's wealth.

"Democracy showed a stronger and more significant association with indicators of health ... than indicators of gross national product, total government expenditure or inequality in income," wrote the authors.