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.

Oct. 8, 2009 -- Adults with shingles are at increased risk for stroke, especially if they have shingles that affects the eyes, a study shows.

The study is not the first to show an elevated stroke risk associated with shingles, but it is the first to quantify the risk, researchers say.

Compared to adults without shingles, those with the painful skin rash were about 30% more likely to suffer a stroke within a year of the attack. Patients who had shingles in and around an eye had four times the risk for stroke in the year following the episode.

"If a person is already at risk for stroke, they should be aware that their risk may be higher if they have had shingles," study researcher Jiunn-Horng Kang, MD, MSc, tells WebMD.

Also known as herpes zoster, shingles is caused by the varicella-zoster virus (VZV) -- the same virus that causes chickenpox.

Anyone who has had chickenpox in childhood can develop shingles at some point in their lives.

In many people, the virus remains dormant in nerves. But in some, especially older people and those with compromised immune systems, it can reactivate as shingles.

The reawakened virus initially causes numbness, itching, severe pain, and even fever, headaches, and chills, followed by the blistering rash characteristic of shingles. The skin rash usually occurs within three to five days after symptoms begin.

Shingles can result in persistent pain lasting for months and even years after the rash has gone away.

The newly published study included nearly 8,000 adults treated for shingles between 1997 and 2001 and about 23,000 people matched for age and sex who had no history of shingles or stroke before 2001.

During the year following the shingles episode, 133 shingles patients (1.7%) and 306 people in the comparison group (1.3%) had strokes.

The shingles patients had a 31% increased risk for strokes of any kind and a nearly threefold increased risk for hemorrhagic strokes.

Hemorrhagic strokes, caused by bleeding in the brain, are much less common than ischemic strokes, which are caused by blocked arteries. Only about 10% to 15% of strokes involve brain bleeds.

Patients with shingles involving the skin around the eye and the eye itself were 4.28 times more likely to have a stroke than were people without shingles.

The study was published online today and will appear in the November issue of the American Heart Association journal Stroke.

Stress, Inflammation May Play Role

Varicella zoster virus-related blood vessel damage has been linked to stroke after shingles attacks, but this did not fully explain the high stroke risk seen in the study, Kang and colleagues wrote.

They added that the stress associated with shingles and the intense pain that can occur with outbreaks and following them could play a role, as could the inflammation that occurs with shingles outbreaks.

Stress, Inflammation May Play Role continued...

American Stroke Association spokesman Daniel Lackland, MD, says shingles patients and their doctors need to be aware of the new research.

Lackland is a professor of epidemiology and medicine at the Medical University of South Carolina in Charleston.

"This research needs to be confirmed, but it may be that shingles patients with risk factors for stroke need more aggressive monitoring and treatment than the average patient," he tells WebMD.

But he adds that the shingles-related stroke risk identified in the study is nowhere near as great as the risk associated with better-established stroke risk factors, like high blood pressure.

"The message doesn't change based on this study," he says. "Getting high blood pressure under control and treating other modifiable risk factors is what we have to focus on."

Early, aggressive treatment with antiviral drugs can lessen the length and severity of shingles attacks.

Kang says it remains to be seen if aggressive antiviral treatment can also lower stroke risk.

"This is a question we need to study," he says.

SOURCES:

Kang, J-H. Stroke: Journal of the American Heart Association, November 2009; online edition.

Jiunn-Horng Kang, MD, MSc, department of physical medicine and rehabilitation, Taipei Medical University Hospital, Taiwan.

Daniel Lackland, MD, professor of epidemiology and medicine, Medical University of South Carolina, Charleston; spokesman, American Stroke Association.

News release, American Stroke Association.

CDC: "Shingles Disease -- Questions and Answers."

Oct. 8, 2009 -- A single gene variant predicts breast cancer survival after tamoxifen treatment, a new study finds.

In the 46% of women with the "good" gene, tamoxifen works as well as newer drugs. For women with the gene variant linked to poor response to tamoxifen treatment, other treatment strategies would be a better choice.

In the past 25 years, tamoxifen has prevented more than half a million deaths from breast cancer. The drug helps prevent breast cancer recurrence after surgery. Tamoxifen is still a useful drug, although newer drugs called aromatase inhibitors seem to work better in clinical trials.

Now it appears that some women will do at least as well if they're treated with tamoxifen. Such women carry a version of a gene called CYP2D6 that makes tamoxifen work better.

The gene encodes an enzyme crucial to tamoxifen activity. About 46% of women have a version of the gene that contributes to high enzyme activity. Others have genes that contribute to low or intermediate activity of the enzyme.

Werner Schroth, PhD, of Germany's Fischer-Bosch Institute of Clinical Pharmacology, and colleagues analyzed CYP2D6 genes in 1,325 postmenopausal women treated with tamoxifen for early-stage breast cancer in Germany and in the U.S.

They found that women with the highly active version of the gene were significantly less likely to have their breast cancer come back after five years of tamoxifen treatment. These women had outcomes similar to those seen in women treated with aromatase inhibitors.

"[This] should provide new impetus to the medical and scientific community to revisit the issue of the relative efficacy of these two approaches in women with early breast cancer," Schroth and colleagues conclude.

The researchers suggest that genetic testing could identify women who should not be treated with tamoxifen.

Schroth and colleagues report the findings in the Oct. 7 issue of TheJournal of the American Medical Association.

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SOURCES:

Schroth, W. The Journal of the American Medical Association, Oct. 7, 2009; vol 302: pp 1429-1436.

National Cancer Institute web site: "Breast Cancer Treatment (PDQ)," and "Aromatase Inhibitors."