Drainage, Chemo for Malignant Effusions
Neoplastic pericardial effusions should be treated aggressively with intracavitary infusions of thiotepa, a low-cost, low-risk procedure that extends life expectancy and improves quality of life, according to Alessandro Martinoni, M.D., and associates at the University of Milan's European Institute of Oncology.
Malignant pericardial effusions are common in cancer patients, and until now the resulting pericardial tamponade has been the immediate cause of death in 85% of affected patients. But developing the condition should no longer “be considered as a terminal event, but [rather] as a treatable condition requiring true therapeutic intervention instead of a mere palliative approach,” the investigators noted (Chest 2004;126:1412–6).
They performed percutaneous pericardiocentesis in 33 patients with metastatic breast, lung, skin, or endometrial cancers. All had pericardial effusions causing severe dyspnea, weakness, chest pain, and tachycardia, and 24 had cardiac tamponade. The malignant effusions were drained and thiotepa was administered in stages over a 5-day period. “All patients showed rapid and almost complete improvement of symptoms,” without any adverse effects, pain, or myelosuppression.
Pericardial effusions recurred in only three patients (9%) over several months of follow-up, and resolved with a repeat pericardiocentesis and thiotepa infusion. The treatment thus not only eliminated existing neoplastic effusion but also inhibited further effusion from developing. Median patient survival was 115 days (range 22–1,108 days), an “unexpected” result considering their extremely poor prognoses.
New Marker for HF Mortality in Elderly
The serum level of cystatin-C appears to be a stronger predictor of mortality in elderly people with heart failure than serum creatinine, reported Michael G. Shlipak, M.D., of San Francisco Veterans Affairs Medical Center, and his associates.
Cystatin-C, a serine protease inhibitor released by all functioning cells, can be used as a serum measure of renal function. Unlike creatinine, cystatin-C does not appear to be influenced by patient age, gender, or body mass, and so should be a particularly useful marker in elderly heart failure (HF) patients, the investigators said (J. Am. Coll. Cardiol. 2005;45:268–71).
They conducted a pilot study comparing cystatin-C with creatinine as a predictor of mortality, using data from a community-based longitudinal study of nearly 6,000 elderly subjects. During a median follow-up of 6.5 years, cystatin-C level was a better predictor of mortality in those who had HF. If larger studies confirm this finding, this new marker of renal function could replace traditional markers in risk assessment for HF patients, they said.
Injected Anti-VEGF for Macular Disease
Intravitreous injections of pegaptanib, an agent that blocks the activity of vascular endothelial growth factor, arrests the loss of visual acuity in patients with age-related macular degeneration due to choroidal neovascularization, according to Evangelos S. Gragoudas, M.D., of the Massachusetts Eye and Ear Infirmary, Boston, and associates.
They conducted two concurrent randomized trials involving 1,186 patients aged 50 years and older treated at 117 medical centers worldwide. The subjects, who had a broad spectrum of lesion sizes, angiographic types of lesions, and baseline levels of visual loss, were randomly assigned to receive either pegaptanib or sham eye injections every 6 weeks for 48 weeks.
Reductions in both moderate and severe losses of visual acuity were noted as early as at the time of the second injection, and benefit increased over time. The treatment also reduced the chance that patients would progress to legal blindness, and it actually improved vision in 33% of patients, the investigators said (N. Engl. J. Med. 2004;351:2805–16).
Racial Disparity Persists in ICD Use
The racial disparity in the use of implantable cardioverter defibrillators improved throughout the 1990s but still remained “substantial” by the year 2000, reported Peter W. Groeneveld of Veterans Affairs Medical Center, Philadelphia, and his associates.
The researchers analyzed Medicare data on more than 570,000 elderly patients hospitalized with ventricular arrhythmias during 1990–2000. At the beginning of that period, subjects of any race living in geographic areas where at least 10% of the population was African American had a 19%–23% lower chance of receiving an implantable cardioverter defibrillator (ICD) than did those living in areas with smaller black populations. But by 2000, ICD implantation rates had essentially equalized among geographic groups. For the study, geographic areas were defined using zip codes, and demographic data were obtained from the 1990 and 2000 U.S. Census.
It appears that early in the decade, ICD use “may have insufficiently 'penetrated' the health care systems where black patients were more likely to receive care.” Although this geographic situation has largely been ameliorated, a racial disparity still persists. “Even as late as 1999–2000, elderly black patients with ventricular arrhythmias continued to have approximately two-thirds the likelihood of receiving an ICD” as whites, the investigators said (J. Am. Coll. Cardiol. 2005;45:72–8).