The Language Of Medicine

Oct. 8, 2009 -- As the debate over health reform rages on, Vermonters can rejoice: Their state has the best-performing health system in the nation.

Meanwhile, states across the South and West are still struggling with high rates of uninsured residents, poor quality of health care, and wasteful spending.

That's according to the Commonwealth Fund, in a report tracking the best and worst health systems across the country. The group says wide variation between states highlights the need for broad health reform from Washington.

"Where you live matters" for access to medical care, costs, and quality in clinics and hospitals, says Kathy Schoen, senior vice president of the Commonwealth Fund. 

The report grades states on 38 indicators, including access to insurance, how many children receive regular "well care" and preventive visits, the degree to which states' residents live healthy lives, and how well hospitals do in preventing infections.

Vermont topped the list, ranking highly across the 38 measures. Other top states included Hawaii, Iowa, Minnesota, Maine, and New Hampshire.

Nevada, Arkansas, Louisiana, Oklahoma, and Mississippi were all at the bottom of the list. Those states suffer from poorly coordinated care, higher-than-average infant mortality rates, and high rates of smoking.

Texas is also near the bottom of the list, in part because of a 22% rate of adults without health insurance -- the highest in the nation.

"There is shockingly wide variation in the quality of health care across states," Karen Davis, the Commonwealth Fund's president, said in a conference call with reporters. "States cannot go it alone. Reform is needed on the national level."

The report details some positive news. The number of uninsured children is down across the country, due largely to a recent expansion in the State Children's Health Insurance Program (SCHIP) shared by Washington and the states. Hospitals and nursing homes are also doing a better job of tracking quality and reporting the results publicly, the report states.

At the same time, researchers warn that hospital quality -- based on readmission rates and other measures -- has not improved. Meanwhile, the number of adults without health coverage continues to march upward. Currently an estimated 47 million Americans have no health insurance.

"It looks like an epidemic," Schoen said.

"This is on the eve of the current recession," added Schoen, pointing out that the report's figures are based on 2008 data. "In other words, the worst is yet to come."

SOURCES:

Commonwealth Fund: "Aiming Higher: Results from a State Scorecard on Health System Performance, 2009."

Kathy Schoen, senior vice president, Commonwealth Fund.

Karen Davis, president, Commonwealth Fund.

Oct. 8, 2009 - Data from Australia and New Zealand's winter flu season suggest H1N1 swine flu will stress U.S. intensive care units in hard-hit areas.

Down Under hospitals are well equipped. Yet many had to struggle to keep up with severely ill swine flu patients, who have to be isolated from other patients to prevent spread of the pandemic flu.

From June through August -- winter in the Southern Hemisphere -- Australia and New Zealand ICUs admitted 15 times more patients with flu-like symptoms than in recent years.

"Our data indicate that the greatest effect on ICU resources in a given region occurs approximately four to six weeks after the first confirmed winter ICU admission, and that the extra workload lasts several weeks," report University of Western Australia researcher Steven A.R. Webb, PhD, MPH, and colleagues.

Among ICU patients with swine flu the death rate was 16%. That's the same death rate as Australian hospitals see in ICU patients with seasonal flu. But with seasonal flu, most patients with severe disease are elderly. Most patients with severe H1N1 swine flu were infants under age 12 months or adults 25 to 64.

In Australia and New Zealand, swine flu behaves very much as it does in the U.S. and elsewhere. About 30% of those with severe disease have no underlying condition.

But the majority of severe cases are among people with underlying conditions. In Australia and New Zealand, a disproportionate number of patients were pregnant, had chronic lung disease, or were morbidly obese. Indigenous populations were also disproportionately likely to be admitted to the ICU with swine flu.

Webb and colleagues report their findings in an early-release issue of The New England Journal of Medicine. Also appearing in this issue is a paper by CDC researcher Seema Jain, MD, and colleagues reporting on patients hospitalized with H1N1 swine flu from April through June 2009.

The U.S. data from last spring closely match the Down Under data from later in the year. Nearly 30% of patients hospitalized with H1N1 swine flu had no underlying condition. But most did. Those conditions have remained the same since last spring including: asthma, diabetes, heart disease, chronic obstructive pulmonary disease, neurologic disease, and pregnancy.

About one in four U.S. patients hospitalized with H1N1 swine flu were admitted to the ICU. Overall, 7% of hospitalized patients died.

SOURCES:

Webb, S.A.R. The New England Journal of Medicine, published online ahead of print, Oct. 8, 2009.

Jain, S. The New England Journal of Medicine, published online ahead of print, Oct. 8, 2009.

Oct. 8, 2009 - Some 10 million Americans may carry a recently discovered retrovirus now linked to chronic fatigue syndrome.

The virus, xenotropic murine leukemia virus-related virus or XMRV, was detected in 67% of 101 patients with chronic fatigue syndrome by Vincent C. Lombardi, PhD, of the Whittemore Peterson Institute in Reno, Nev., and colleagues.

The researchers also found the virus in nearly 4% of healthy comparison subjects -- suggesting that millions of Americans may carry the mysterious virus, which was first detected in prostate cancers.

"The discovery of XMRV in two major diseases, prostate cancer and now chronic fatigue syndrome, is very exciting. If cause and effect is established, there would be a new opportunity for prevention and treatment of these diseases," said Robert H. Silverman, PhD, of Cleveland Clinic's Lerner Research Institute, in a statement emailed to WebMD.

Silverman is on of the team of scientists that first discovered XMRV, and was among the researchers linking the virus to chronic fatigue syndrome and prostate cancer.

It's not yet proven that XMRV actually causes either chronic fatigue or prostate cancer.

In prostate cancer patients, the virus is seen in patients who carry a genetic mutation that disables a key virus-fighting immune response. But the virus is seen in chronic fatigue patients with and without this mutation.

Where did the virus come from? The virus is closely related to a retrovirus that's become part of the mouse genome. Oddly, XMRV cannot infect mouse cells -- but can easily infect human cells.

It's unlikely that so many humans have caught XMRV from mice. It's more likely that the virus is spread from human to human, but how that happens remains to be seen.

An editorial by John M. Coffin of Tufts University, Boston, and Jonathan P. Stoye of the Institute for Medical Research, London, accompanies the Lombardi report in the current issue of the online journal Sciencexpress.

Coffin and Stoye note that if 4% of healthy people truly do carry XMRV, it means that the virus is astonishingly widespread.

"If these figures are borne out in larger studies, it would mean that perhaps 10 million people in the United States and hundreds of millions worldwide are infected with a virus whose pathogenic potential for humans is still unknown," they write.

What is known is that viruses closely related to XMRV do cause many different diseases -- including cancer -- in other warm-blooded animals.

"Further study may reveal XMRV as a cause of more than one well-known 'old disease,' with potentially important implications for diagnosis, prevention, and therapy," Coffin and Stoye suggest.

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SOURCES:

Lombardi, V.C. Sciencexpress, Oct. 8, 2009.

Coffin, J.M. and Stoye, J.P. Sciencexpress, Oct. 8, 2009.

Urisman, A. PloS Pathogens, March 2006.

Schlaberg, R. Proceedings of the National Academy of Sciences, published online before print, Sept. 9, 2009.

Robert H. Silverman, PhD, professor of cancer biology, Cleveland Clinic Lerner Research Institute; email Oct. 8, 2009.

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