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The findings, based on an analysis of more than 40,000 Danish patients, were published online Dec. 10 in the journal The Lancet.

Doctors often prescribe combinations of drugs — including aspirin, clopidogrel (Plavix) and vitamin K antagonists like warfarin (Coumadin) — after a patient experiences a heart attack. But it’s not clear whether the combinations are safe, the study authors noted.

The researchers looked at the effects of various regimens on patients who had their first heart attack between 2000 and 2005.

During an average of 16 months after their heart attack, 4.6 percent of the patients returned to the hospital because of bleeding or died with bleeding identified as the cause of death.

The annual incidence of bleeding was lowest among those who just took aspirin (2.6 percent) and highest among those who took clopidogrel plus a vitamin K antagonist (12.3 percent) or all three drugs (12 percent).

“In patients with first-time heart attack, all combinations of aspirin, clopidogrel and vitamin K antagonists are associated with increased risk of nonfatal and fatal bleeding, apart from monotherapy with a vitamin K antagonist, compared with aspirin alone,” the study authors wrote.

“Increased risk of bleeding was proportional to the number of drugs used. Nonfatal bleeding is an independent predictor associated with increased risk of recurrent heart attack or death. We propose that treatment with triple therapy or dual therapy with clopidogrel plus vitamin K antagonist should be prescribed only after thorough individual risk assessment and careful consideration of the risk-benefit ratio,” they concluded.

The center offers this list of possible warning signs of binge eating disorder:
Eating very quickly.
Eating beyond the point of satiety to the point of uncomfortable fullness.
Eating when not hungry.
Feeling embarrassed about eating, leading the person to eat alone.
Feeling guilt, disgust or depression after eating too much.

“After admission to a hospital, trauma patients can have worse outcomes based on insurance status,” the study authors wrote. “This concerning finding warrants more rigorous investigation to determine why such variation in mortality would exist in a system where equivalent care is not only expected but mandated by law.”

Dr. Heather Rosen, from Children’s Hospital Boston and Harvard Medical School, and colleagues analyzed statistics from the National Trauma Data Bank, which has tracked 2.7 million trauma patients admitted to over 900 U.S. trauma centers. The researchers looked at 687,091 adult patients admitted between 2002 and 2006.

Uninsured patients were more likely to die than insured patients even when researchers tried to adjust the statistics to eliminate the influence of factors such as gender, age and race that might throw off the results.

“Treatment often is initiated before payer status is recognized; thus, this provokes the question of whether differences exist in processes of care during the hospital stay,” the study authors wrote. “We can only speculate as to the mechanism of the disparities we have exposed; the true causes are still unclear. Although the lack of insurance may not be the only explanation for the disparity in trauma mortality, the accidental costs of being uninsured in the United States today may be too high to continue to overlook.”

Since clopidogrel can cause bleeding in the stomach, medications like omeprazole may be used in combination to reduce the production of stomach acid, and prevent stomach bleeding. Omeprazole is available by prescription and as an over-the-counter (OTC) medication to treat frequent heartburn

FDA wants to emphasize the following information for patients using clopidogrel:
Patients using clopidogrel should consult with their healthcare provider if they are currently taking or considering taking omeprazole, including Prilosec OTC.
Both clopidogrel and omeprazole can provide significant benefits to patients, and patients should always consult with their healthcare professional before starting or stopping any medication.
It is very important that patients talk with their healthcare professional about any over-the-counter (OTC) drugs they are taking before starting or while using clopidogrel

Patients who use clopidogrel and need a medication to reduce stomach acid can use antacids (such as Maalox or Mylanta) and most acid reducers, such as Zantac (ranitidine), Pepcid (famotidine), or Axid (nizatidine) because the FDA does not believe that these medicines will interfere with the anti-clotting activity of clopidogrel. However, Tagamet and Tagamet HB (cimetidine) should not be used. Ranitidine and famotidine are available by prescription and OTC and antacids are available OTC.

The manufacturers of clopidogrel have agreed to look at other possible drug interactions with clopidogrel. In the meantime, the clopidogrel label will be updated with new warnings on omeprazole and other drugs that could interact with clopidogrel in the same way. When more information becomes available, FDA will communicate any additional recommendations or conclusions on the use of clopidogrel.

Vermont and New Hampshire were the only states with a preterm birth rate under 10 percent, while in Louisiana, Alabama and Mississippi, the premature birth rate ranged from 16.5 to 18.3 percent.

Each year, the March of Dimes ranks each state according to its rate of premature births — babies born before 37 weeks of gestation. Preterm births contribute to infant mortality and can put children at risk for lifelong problems, including cerebral palsy and developmental disabilities.

The U.S. premature birth rate was 12.7 percent in 2007 (the year the birth data was collected), nearly twice the goal of 7.6 percent set by the federal government’s Healthy People 2010 campaign.

In the March of Dimes report, states were graded on how closely they came to meeting the preterm birth objective. No state earned an “‘A” and Vermont was the only state to earn a “B” grade. All the rest earned grades ranging from “C” to “F” and the nation overall earned a “D” grade.

Still, it wasn’t all bad news. Seven states — Arizona, Indiana, Missouri, Idaho, Massachusetts, Utah and Wisconsin — improved their grade year over year. However, Ohio’s and Oklahoma’s grades dropped.

“This year, we found a slight reduction in the rate of preterm birth,” said Jennifer Howse, March of Dimes president. “Overall, that’s encouraging. But as any good epidemiologist will tell you, one year does not a trend make.”

Howse said she was concerned that the recession, including job losses and loss of medical benefits, could reverse the trend when the birth statistics from 2008 and 2009 are analyzed. “I think we’re moving in the right direction, but I am worried we are going to see slippage,” Howse said.

The states that improved did so by targeting three key risk factors for premature birth: smoking during pregnancy, lack of health insurance for pregnant women, and elective inductions or cesarean sections done during the “late pre-term,” or between 34 to 36 weeks’ gestation. The March of Dimes recommends babies not be delivered by elective C-section or induction before 39 weeks.

Lack of health insurance keeps some women from getting prenatal care, which means health conditions that could affect the pregnancy, such as underlying infections, obesity, poor nutrition, diabetes, high blood pressure and periodontal disease, are less likely to be caught and treated.

About 33 states and the District of Columbia reduced the number of women of childbearing age who smoke; 21 states and Washington, D.C. insured more women year over year; while 27 states, Washington, D.C. and Puerto Rico lowered the late pre-term birth rate.

Though the target areas are important, Howse said physicians still don’t know all of the reasons why babies are born prematurely.

“We probably understand roughly half the risks that are associated with preterm birth, but the other half are very poorly understood from a biological standpoint,” Howse said

Dr. Harold Perl, a senior neonatologist at Hackensack University Medical Center in Hackensack, N.J., said that physicians in the United States are very skilled at taking care of premature babies after they are born, but more emphasis needs to be placed on preventing premature births in the first place.

“Overall, it’s a very important point that the March of Dimes is making,” Perl said. “We have to look not only at how well we take care of our premature babies, but what we can do to prevent mothers from having premature babies.”

The report didn’t explore some significant geographic variations in causes for preterm birth factors that need to be considered when designing education or intervention programs, Perl said. New Jersey and Missouri, for example, had roughly the same rate of premature births, 12.7 percent and 12.5 respectively.

But in Missouri, about 28.4 percent of expectant mothers smoked, ranking it among the states with the highest maternal smoking rates, compared to 12.8 percent in New Jersey, ranking it among the lowest.

In New Jersey, a key reason for premature births is the number of twins, triplets and higher-order multiples being born as a result of in vitro fertilization procedures, Perl said. Twins are delivered on average, at about 35 weeks, triplets at 33 weeks, and quadruplets at 29 weeks, according to the American College of Obstetricians and Gynecologists.

Perl recommends fertility doctors follow American Society for Reproductive Medicine guidelines that call for implanting no more than two embryos at a time for women under 35, and no more than three for women with poorer chances of becoming pregnant.

About 540,000 babies are born prematurely in the United States each year, costing more than $26 billion in additional health care costs.

It’s one of the reasons that the United States is ranked 30th in infant mortality, behind most other developed nations, according to a U.S. National Center for Health Statistics report issued earlier this month. Premature births have risen 36 percent since 1984, according to the report.

Warfarin is effective in preventing blood clots that can cause stroke in patients with atrial fibrillation (abnormal heart rhythm) and other diseases, but the drug has a narrow therapeutic range in which it prevents strokes but doesn’t cause bleeding, according to the researchers. This means that effective warfarin treatment requires regular laboratory monitoring to ensure warfarin levels remain in the range that lowers the risk of stroke without increasing the risk of bleeding.

This study included 18,113 atrial fibrillation patients in 44 countries who were randomly selected to receive either oral treatment with standard warfarin (6,022 patients) or dabigatran etexilate at either 110 milligrams (6,015 patients) or 150 milligrams (6,076 patients).

After one to three years of follow-up, 1.69 percent of patients in the warfarin group suffered a stroke or serious clot per year, compared with 1.53 percent and 1.11 percent of patients taking 110-milligram and 150-milligram doses of dabigatran etexilate, respectively, the study authors, from University Hospital in Uppsala, found.

Rates per year of major bleeding were 3.36 percent in the warfarin group and 2.71 percent and 3.11 percent for patients taking 110-milligram and 150-milligram doses of dabigatran etexilate, respectively.

The study was scheduled to be presented Sunday at the American Heart Association’s annual meeting in Orlando, Fla.

The patients in the study were an average age of 72 and included some who’d suffered a prior stroke (13 percent), patients with high blood pressure (79 percent), those who’d never taken an oral anti-clotting drug for more than two months (50.4 percent), and those who weren’t using an oral anti-clotting drug when they enrolled in the study (34 percent).

Dabigatran etexilate is approved for use in Canada and Europe but not in the United States.

“Few previous studies have measured the effectiveness of healthy behaviors in delaying mortality among adults with diagnosed diabetes,” lead researcher Dr. Sharon Saydah told Reuters Health. “We looked at the association of health behaviors with mortality in the general U.S. population among both adults with and without diabetes.”

The study included 1,177 people with diabetes and 15,217 without diabetes who took part in the Third National Health and Nutrition Examination Survey from 1988 to 1994 and were followed through 2001.

A greater number of healthy behaviors was linked to a 15 percent reduced risk of dying from any cause in diabetics and a 17 percent reduced risk in non-diabetics, after adjusting for various factors that might influence the results.

Subjects in the top 20 percent of healthy behavior “summary scores” had a 58 percent lower death rate than those in the bottom 40 percent.

Five self-reported healthy behaviors were assessed at the start of the study: physical activity, not smoking, higher healthy eating index, moderate alcohol intake (1-2 drinks per week), and maintaining weight or trying to lose weight in the past 12 months.

“Among the healthy behaviors studied, regular, moderate to vigorous physical activity was most protective for those with diabetes,” said Saydah, a senior scientist with the Centers for Disease Control and Prevention, Atlanta.

Moderate to vigorous physical activity significantly reduced the risk of dying in both adults with and without diabetes, whereas moderate alcohol use, was only protective only in people with diabetes.

In diabetes-free adults, current smoking and fewer healthy eating habits were both linked to increased risk of death, whereas the impact of diet on death in people with diabetes was inconclusive.

“These results provide information to health care providers and the general public on stressing the importance of … lifestyle factors such as physical activity in delaying mortality,” Saydah said.

The use of aldosterone antagonist therapy in patients with heart failure is designated as “useful and recommended” in chronic heart failure guidelines established by the American College of Cardiology/American Heart Association (ACC/AHA), but this study found that less than one-third of patients hospitalized for heart failure receive the treatment.

Researchers analyzed data on 43,625 patients admitted with heart failure and discharged home from 241 hospitals participating in a hospital recognition program called Get With The Guidelines — HF between 2005 and 2007.

The study found that 12,565 patients (28.8 percent) from 201 hospitals met ACC/AHA heart failure management guidelines criteria, and 4,087 eligible patients received an aldosterone antagonist when they were discharged from hospital. Overall, treatment increased from 28 percent to 34 percent during the study period, but there was wide variation in aldosterone antagonist use among hospitals — ranging from 0 percent to 90.6 percent.

“Aldosterone antagonist use in eligible patients was associated with younger age, African-American race/ethnicity, lower systolic blood pressure, history of implantable cardioverter-defibrillator use, depression, alcohol use and pacemaker implantation, and with having no history of renal insufficiency,” wrote Nancy M. Albert of the Cleveland Clinic and colleagues.

“These data confirm that in the context of a hospital-based performance improvement program, aldosterone antagonist therapy can be used according to guidelines with little inappropriate use. Given the substantial morbidity and mortality risk faced by patients hospitalized with HF and the established efficacy of aldosterone antagonist prescription in HF, a stronger uptake of aldosterone antagonist therapy indicated by evidence-based guidelines may be warranted,” the researchers concluded.

A study appearing in the October issue of the Archives of Surgery found that 85 percent of trauma patients with pulmonary emboli showed no sign of deep vein thrombosis, or blood clots in the lower extremities.

The lead author of the study, Dr. George Velmahos, chief of the division of trauma, emergency surgery and surgical critical care at Massachusetts General Hospital and professor of surgery at Harvard Medical School in Boston, said the findings also cast doubt on the use of filters to prevent the clots from traveling.

But an outside expert said the findings need to be received cautiously, at least for now.

“I think it’s an interesting report. I wouldn’t call it a bombshell”, said Dr. Jack Ansell, chairman of the department of medicine at Lenox Hill Hospital in New York City. “I think this study by no means answers this question or reverses the original concept that most pulmonary embolisms originate as venous thrombosis [blood clots] in the deep veins of leg or sometimes in pelvis or abdomen.”

According to Velmahos, the concept of clots in the lungs originating as clots in the legs has never been challenged, despite evidence in the literature that some patients suffering from pulmonary embolism did not show signs of having had a blood clot in the lower extremities.

For this study, Velmahos and co-authors looked back over medical records of 247 trauma patients who had undergone CT pulmonary angiography and CT venography.

Among 46 patients with PE, only 7 also had DVT, or 15 percent.

There are possible explanations, the team said. It’s possible that the entire original clot detached itself, leaving no traces. However, cadaver studies suggest that only a part of the leg clot breaks away, and a remnant is typically left behind. Or it could be that small clots exist and were not picked up by imaging techniques or even that the clots start in the upper extremities, which are not routinely examined.

Ansell also pointed to what he believes are several shortcomings in the study.

“There are still some issues that could account for why they didn’t see DVTs,” Ansell said. “The screening methods may not be ideal [and] small clots in calf veins are difficult to visualize by various techniques.”

“Having said that, there certainly is the possibility with certain types of injury that there could be clots formed just primarily in the lungs and not necessarily travel from other spots,” he added.

Velmahos felt that he had already excluded potential reasons for not seeing lower-extremity clots in pulmonary embolism patients, and said he is “very confident that a correlation cannot be established.” Yet he also acknowledged that “every retrospective study [which this is] should be viewed with a grain of salt.”

More studies need to be conducted, particularly to explore the hypothesis that pulmonary emboli actually form first in the lungs.

If it turns out that DVTs do not travel far from the legs, do tiny filters now used to trap them remain useful therapy? One expert said that issue may be a minor one.

“Pulmonary embolism and DVT are huge problems in trauma patients. The question is how to treat them,” said Dr. David Gillespie, a professor of surgery at the University of Rochester Medical Center. “Anticoagulants such as heparin have been the standard of care… The interpretation here should not be that all filters are bad [but] anticoagulants should be the main therapy.”

Finally, even if DVTs don’t detach and travel to the lungs, “this does not mean that DVT is unimportant,” Ansell said. “It is clearly established that most or many pulmonary emboli do originate in the legs in the lower extremities and one still needs to provide appropriate anticoagulant [blood-thinning] prophylaxis in patients who are at risk, whether they are trauma patients or just patients immobilized for other reasons in the hospital.”