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Patients with early rheumatoid arthritis (RA) who respond poorly to standard treatment with methotrexate may benefit from additional treatment with tumor necrosis factor (TNF) blockers, a Swedish study suggests.

Previous research has shown that 20 percent to 40 percent of patients have a good response to methotrexate therapy and don’t need more intensive combination treatment.

This new study included 487 patients with early RA (less than one year’s duration) who were initially treated with methotrexate. After three to four months, the 258 patients with an inadequate response to methotrexate were randomly assigned to receive either the TNF blocker infliximib (Remicade) or the conventional disease-modifying antirheumatic drugs, sulfasalazine and hydroxychloroquine.

After 12 months, 39 percent of patients given infliximib achieved a good response, compared with 25 percent of patients given sulfasalazine and hydroxychloroquine.

“We believe that by treating all patients with methotrexate for 3 to 4 months, we screened out a sizeable proportion [30 percent in this trial] who would have been overtreated if aggressive combination therapy was used for all, an approach that could have increased the risk of side effects and potentially entailed high costs,” wrote the researchers from the Karolinska University Hospital and the Karolinska Institute.

A short period of treatment with methotrexate alone, followed by the addition of a TNF blocker only in patients who have an inadequate response to methotrexate, is the best treatment option for patients with early RA, they concluded.

The study appears in this week’s edition of The Lancet.

In related news, the U.S. Food and Drug Administration on Tuesday ordered that TNF blockers carry an updated “black box” label to warn doctors and patients that the drugs may increase the risk of cancer in children and adolescents.

Young athletes should be tested for heart abnormalities to prevent sudden cardiac death triggered by vigorous exercise, new Dutch research suggests.

Sudden cardiac death is the leading cause of death in young athletes, but no one knows how common it is, as figures vary and mandatory reporting does not exist, the study authors noted.

The idea of screening for potentially deadly heart abnormalities in athletes before they embark on a career in competitive sports has been debated for years.

Critics say that electrocardiograms (ECGs) pick up too many “normal irregularities” that result as the body adapts to the demands of competitive sports, leading to unnecessary alarm and needless investigations. Opponents also have questioned the cost effectiveness of testing.

But the findings, published online in September in the first of a series of quarterly partnership issues between the British Journal of Sports Medicine and the International Olympic Committee, may silence some of the critics.

The researchers screened 371 athletes between the ages of 12 and 35 over two years. They found that EKG produced false positive results for 47 athletes, or 11 percent of the group, which they declared an acceptable rate. EKG found heart problems in 10 athletes, four of whom were restricted from further participation in sports.

To detect one athlete with potentially deadly cardiovascular disease, 143 had to be screened, a number that is within acceptable limits, the researchers explained in a news release from the journal’s publisher.

In another review of the available evidence, researchers found that trying to pick up potentially fatal heart abnormalities through questionnaires and physical exams alone is ineffective.

And, because the survival rate is so low, relying on the use of defibrillators at an event is not considered a viable alternative, the research shows.

“Health-care governing bodies need to be convinced that now is the time for universal [EKG] screening of all young athletes and make the necessary provisions for nationwide screening programs to commence,” the study authors concluded.

Babies poised to enter the world feet first can pose serious complications for themselves and their moms.

Among single-baby pregnancies, just 3 percent to 5 percent are known as “breech presentations,” with the baby’s bottom, rather than head, positioned closest to the birth canal.

But though the numbers are small, experts say the risks can be big. Because of this, knowing about a breech presentation ahead of time can help the parents-to-be and their doctor decide what to do — whether to try to rotate the baby in the womb or prepare for a Cesarean delivery.

“The trend is not to deliver breech vaginally,” said Dr. Joshua Copel, a professor of obstetrics, gynecology and reproductive sciences at the Yale University School of Medicine. “Most breech [babies] get delivered by C-section.”

With breech presentation, vaginal birth can be far more difficult. According to the American College of Obstetricians and Gynecologists, it can be difficult to guide the baby’s head out of the mother’s body last because the baby’s body might not have stretched the cervix sufficiently. And a prolapsed cord — when the umbilical cord slips into the birth canal before the baby, stopping the flow of blood to the baby — is another increased risk in vaginal deliveries of breech babies.

The standard way to detect breech — by feeling a woman’s abdomen — isn’t foolproof. A BMJ study, in fact, reported that 30 percent of breech presentations were missed when this method was used. In some cases, that has prompted the addition of an ultrasound examination if a breech presentation is suspected.

“If I am uncertain about a baby’s position by 33 or 34 weeks, I recommend an ultrasound,” said Susan Moray, a certified professional midwife in Portland, Ore., and a spokeswoman for the Midwives Alliance of North America. “I think it’s used more than in the past.”

In fact, it can be overused, Moray said, citing a woman she knew who had 11 ultrasounds during her pregnancy.

But Copel and Moray agreed that ultrasound can be valuable in detecting breech babies.

Once the ultrasound confirms a breech presentation, they explained, a technique called external cephalic version can be done. This involves external manipulation to turn the baby in the womb to a head-first position.

It’s typically done at week 35 or 36. (A full-term pregnancy is about 40 weeks.) “Seventy percent of the time, it works,” Copel said.

The procedure typically is not done earlier, even if a baby’s breech presentation has been confirmed. “I don’t worry about breech presentation until the woman is getting close to 34 weeks,” Moray said. “Babies often flip around,” and the problem could correct itself, she explained.

Some evidence exists that breech presentations run in families or have a genetic link, according to another BMJ study, published last year. If one or both parents were born breech, it found, their children were twice as likely to be born that way, too.

And Moray said that she might pick up that information in her standard questioning of medical history. But Copel doesn’t believe that such information is of much practical use.

Even with a woman who had no family history of breech presentations, he said, he still has to keep in mind the possibility that the baby could be feet-down in the womb.

If a baby is still feet-first near the due date, a C-section will probably be recommended, Copel said. But some women may be committed to a vaginal birth and ask if that’s possible.

It could be, according to the American College of Obstetricians and Gynecologists, which issued a committee opinion on breech babies about three years ago. But the opinion stresses that great caution must be exercised if a breech baby is to be delivered vaginally and advises doctors to warn prospective parents of potential risks and have them sign a consent form saying that they’re aware of the risks.

In a breech baby, according to the American Academy of Family Physicians, the infant’s hip socket and thighbone are more likely to become separated during a vaginal delivery, and compression of the umbilical cord is also more likely, which can lead to brain damage from a lack of oxygen.

But Cesarean delivery is not risk-free either. Greater chances for bleeding and infection as well as longer hospital stays have been found for women who deliver by C-section.

But Copel said that the critical thing for a woman to do is to keep talking to her obstetrician/gynecologist. If the baby is found still to be breech late in pregnancy, she should discuss the options with her doctor at about 35 or 36 weeks, he said.

That way, he said, a decision can be made that’s best for both mother and child.

Preliminary findings suggest that responders to the attacks on the Twin Towers on 9/11 may be at higher risk for multiple myeloma, a cancer of the blood.

Notably, half of the cases identified among law enforcement officers were under the age of 45. Multiple myeloma is usually a disease of the elderly.

“This is very preliminary,” cautioned Dr. Mitchell Smith, director of the Lymphoma Service at Fox Chase Cancer Center in Philadelphia. “It could turn out to be a statistical fluke and means nothing or it could be the tip of the iceberg and we’ll see an increase in the next 10 years,” he said.

“The concerning thing,” he added, “is it makes biological sense. There is certain data that multiple myeloma is associated with an increased exposure to certain chemicals. It has never been shown with inhaled chemicals but this amount of exposure probably did get into the blood.” Smith was not involved in the study.

“Practitioners should be on the lookout for unusual disease patterns,” added Dr. Jacqueline Moline, lead author of the report, which appears in the August issue of the Journal of Occupational and Environmental Medicine. “Multiple myeloma is usually a disease that occurs in the seventh or eighth decade of life. A person is 10 times more likely to get myeloma when they’re 70 than when they’re 45 or 48. Clinicians should be sensitized to patients coming in with unusual symptoms. They should think broadly.”

And that includes being on the alert for other types of cancers as well, added Moline, who is director of the World Trade Center Medical Monitoring and Treatment Program at Mount Sinai School of Medicine in New York City. “Time is really going to give us the answer in terms of other exposures,” she said.

Rescue workers were heavily exposed to a toxic chemical soup released from the fires that raged at the World Trade Center site for three months after 9/11. The chemicals included several known carcinogens, some of which have been linked to a heightened risk of multiple myeloma.

Other health issues arising from the disaster that have already documented include a persistent “World Trade Center cough” in firefighters, along with increased levels of post-traumatic stress disorder (PTSD) and asthma.

According to a study released last week, new symptoms of PTSD have been reported as long as five and six years after the incident, although new cases of asthma have nearly returned to baseline levels.

However, there has been little information so far on cancer cases tied to the attack.

Of 28,252 responders being followed as part of the World Trade Center Medical Monitoring and Treatment Program, eight cases of multiple myeloma were diagnosed between Sept. 11, 2001 and Sept. 10, 2007.

Slightly more than six cases would be expected in the general population during a similar time frame, the researchers noted.

Even more intriguing, four of the cases were in men under the age of 45 when they were diagnosed. This compared to the 1.2 such cases that would be expected in the general population. There are actually slightly fewer cases than expected among responders 45 and over, the researchers noted.

All four cases were male law enforcement officers. None reported any other occupational exposure that might have raised their risk for this malignancy.

Three were present at the site on the day of the attack, when the dust cloud was heaviest. One of these spent 18 to 19 hours a day at Ground Zero, eating his meals there.

The other man worked near the site for almost two weeks following 9/11.

Their ages at time of diagnosis were 34, 37, 40 and 43 years, respectively.

“In all fairness, it is unusual for this patient population to have multiple myeloma but it’s not unheard of,” said Dr. Denise Pereira, assistant professor of clinical medicine at the University of Miami Miller School of Medicine. “But a lot of the things they were exposed to, such as benzene, have in the past possibly been implicated with an increased incidence in the cancer. It does make theoretical sense.”

According to the Leukemia & Lymphoma Society, more than 15,000 Americans are diagnosed each year with multiple myeloma. The disease affects blood cells called B-lymphocytes. While some myelomas are slow-moving and pose little immediate threat, others can be very aggressive.

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