Betsy Bates

SAN DIEGO — So-called benign hallucinations associated with dopaminergic treatment for Parkinson's disease rarely remain “benign,” calling into question the accuracy of the term.

Researchers at Rush University in Chicago studied the clinical progression of 48 patients with Parkinson's disease who were diagnosed with hallucinations characterized by the patient's retention of the insight that the hallucinations are unreal.

These hallucinations have been called benign, and traditionally have been associated with a score on the Unified Parkinson Disease Rating Scale (UPDRS) of 2.

In 2 years, just 2 of the 48 patients at Rush continued to have benign hallucinations without requiring either a decrease in their dose of dopaminergic medications or an addition of neuroleptic agents to counteract the hallucinations or progressing to more serious hallucinations with loss of insight (UPDRS Thought Disorder score of 3) or to delusions (UPDRS Thought Disorder score of 4).

Most patients, 39 of 48, progressed to scores of 3 or 4.

Among nine patients who remained at a score of 2, seven required reduced dopaminergic medication doses in response to worsening hallucinations, and three required neuroleptics to control the hallucinations.

Although the median time to progression of hallucinations to the point where patients were frankly delusional was less than 2 years after the onset of the study, the total length of time that patients were suffering from hallucinations prior to enrollment in the study was not certain, reported Dr. Christopher G. Goetz, director of the Rush movement disorders center, in a poster presentation at the annual meeting of the American Neurological Association.

However, the study made clear that even if hallucinations seem “benign … at the moment,” they “portend serious consequences” and should not be given a label that suggests they are unimportant clinical developments, he said.

“Because hallucinations progress, the concept of benign hallucinations is prognostically misleading,” Dr. Goetz and his associates said.

“The term benign hallucinations should be considered generally unsound and dropped from the operative vocabulary,” Dr. Goetz and associates concluded.

SAN DIEGO — So-called benign hallucinations associated with dopaminergic treatment for Parkinson's disease rarely remain “benign,” calling into question the accuracy of the term.

Researchers at Rush University in Chicago studied the clinical progression of 48 patients with Parkinson's disease who were diagnosed with hallucinations characterized by the patient's retention of the insight that the hallucinations are unreal.

These hallucinations have been called benign, and traditionally have been associated with a score on the Unified Parkinson Disease Rating Scale (UPDRS) of 2.

In 2 years, just 2 of the 48 patients at Rush continued to have benign hallucinations without requiring either a decrease in their dose of dopaminergic medications or an addition of neuroleptic agents to counteract the hallucinations or progressing to more serious hallucinations with loss of insight (UPDRS Thought Disorder score of 3) or to delusions (UPDRS Thought Disorder score of 4).

Most patients, 39 of 48, progressed to scores of 3 or 4.

Among nine patients who remained at a score of 2, seven required reduced dopaminergic medication doses in response to worsening hallucinations, and three required neuroleptics to control the hallucinations.

Although the median time to progression of hallucinations to the point where patients were frankly delusional was less than 2 years after the onset of the study, the total length of time that patients were suffering from hallucinations prior to enrollment in the study was not certain, reported Dr. Christopher G. Goetz, director of the Rush movement disorders center, in a poster presentation at the annual meeting of the American Neurological Association.

However, the study made clear that even if hallucinations seem “benign … at the moment,” they “portend serious consequences” and should not be given a label that suggests they are unimportant clinical developments, he said.

“Because hallucinations progress, the concept of benign hallucinations is prognostically misleading,” Dr. Goetz and his associates said.

“The term benign hallucinations should be considered generally unsound and dropped from the operative vocabulary,” Dr. Goetz and associates concluded.

SAN DIEGO — So-called benign hallucinations associated with dopaminergic treatment for Parkinson's disease rarely remain “benign,” calling into question the accuracy of the term.

Researchers at Rush University in Chicago studied the clinical progression of 48 patients with Parkinson's disease who were diagnosed with hallucinations characterized by the patient's retention of the insight that the hallucinations are unreal.

These hallucinations have been called benign, and traditionally have been associated with a score on the Unified Parkinson Disease Rating Scale (UPDRS) of 2.

In 2 years, just 2 of the 48 patients at Rush continued to have benign hallucinations without requiring either a decrease in their dose of dopaminergic medications or an addition of neuroleptic agents to counteract the hallucinations or progressing to more serious hallucinations with loss of insight (UPDRS Thought Disorder score of 3) or to delusions (UPDRS Thought Disorder score of 4).

Most patients, 39 of 48, progressed to scores of 3 or 4.

Among nine patients who remained at a score of 2, seven required reduced dopaminergic medication doses in response to worsening hallucinations, and three required neuroleptics to control the hallucinations.

Although the median time to progression of hallucinations to the point where patients were frankly delusional was less than 2 years after the onset of the study, the total length of time that patients were suffering from hallucinations prior to enrollment in the study was not certain, reported Dr. Christopher G. Goetz, director of the Rush movement disorders center, in a poster presentation at the annual meeting of the American Neurological Association.

However, the study made clear that even if hallucinations seem “benign … at the moment,” they “portend serious consequences” and should not be given a label that suggests they are unimportant clinical developments, he said.

“Because hallucinations progress, the concept of benign hallucinations is prognostically misleading,” Dr. Goetz and his associates said.

“The term benign hallucinations should be considered generally unsound and dropped from the operative vocabulary,” Dr. Goetz and associates concluded.

SAN FRANCISCO — Morbidity and mortality conferences at Massachusetts General Hospital missed three out of every four complications and one of every two deaths in surgical patients over the course of a year, Dr. Matthew M. Hutter reported at the annual clinical congress of the American College of Surgeons.

Dr. Hutter and associates compared statistics compiled by a nurse reviewer in conjunction with the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) with cases discussed at weekly morbidity and mortality (M&M) conferences.

In 1,439 sampled cases representing 24% of operations, the NSQIP reviewer found a 29% morbidity rate and 28 deaths. Weekly M&M conferences during the same year addressed morbidity in just 6% of cases and made note of just 14 of the deaths.

An analysis of the cases determined that the ACS-NSQIP program identified significantly more complications of every subtype, including wound infections, cardiac complications, urinary tract and renal issues, and others.

Deaths not mentioned in any M&M conference included six due to patient disease and seven that occurred after patients had been transferred to a medical service or when they were being treated as outpatients within 30 days of surgery. One death unaccounted for in M&M conferences had incomplete data.

“At Massachusetts General, we pride ourselves … in a supposedly rigorous academic environment. We decided things had to change,” said Dr. Hutter, director of the hospital's Center for Clinical Effectiveness in Surgery and a member of the surgery department faculty at Harvard Medical School, Boston.

As a result of the study, the hospital has significantly bolstered the content and revised the structure of its M&M conferences, by including, for example, an ongoing review of its own NSQIP results and comparative data from other hospitals. It also has introduced a Web-based reporting tool that standardizes definitions for complications and allows residents and others to quickly input information about any case.

Although the confidential system can be accessed only for peer review, it contains data about everything from a postsurgical infection to an unanticipated return to the operating room or intensive care unit.

The Web-based system serves as an objective, watchful eye on individual patients and the care they receive. It also captures trends that can be identified and used to improve systems, feedback, and approaches to care.

The changes cost $100,000, but if they reduce complications at the same rate seen in the landmark Veteran's Administration NSQIP study, it will end up saving millions, Dr. Hutter asserted.

The NSQIP system was implemented in 1991. By 2001, the NSQIP system in Veterans Affairs hospitals had documented a 27% decrease in complications and a 45% improvement in morbidity, including a 50% drop in major complications, resulting in $11,000 in savings for each case in which a complication did not occur.

“With this report, we are starting to hear the death knell of the traditional M&M conference,” said Dr. David R. Flum, a surgery department faculty member at the University of Washington in Seattle who served as a formal discussant of Dr. Hutter's paper.

Dr. Flum noted that although M&M conferences were “never really intended to be a surveillance system” and served a historic function of revisiting errors, they have often been grounded in opinion, marred by recall bias, and sometimes even driven by “personal and political vendettas.”

Not every complication or death offers a lesson to be learned, he added, noting some of the Massachusetts General deaths resulted from carcinomatosis or total gut necrosis discovered during surgery. But an accurate and consistent real-time surveillance system will provide invaluable information and lead to improved care, he said.

“They took the best elements in this system—standardized definitions, standardized reporting criteria—and they empowered their residents to become the surveillance system,” he noted.

M&M conferences were established in the early 1900s by Dr. Ernest Amory Codman, the “father of surgical outcomes,” who called the review of cases an “end results system.”

Weekly M&M conferences have been required by the American College of Graduate Medical Education for surgical residency programs since 1983 and have been an integral tradition of surgical departments in academic and community hospitals for decades.

SAN FRANCISCO — Morbidity and mortality conferences at Massachusetts General Hospital missed three out of every four complications and one of every two deaths in surgical patients over the course of a year, Dr. Matthew M. Hutter reported at the annual clinical congress of the American College of Surgeons.

Dr. Hutter and associates compared statistics compiled by a nurse reviewer in conjunction with the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) with cases discussed at weekly morbidity and mortality (M&M) conferences.

In 1,439 sampled cases representing 24% of operations, the NSQIP reviewer found a 29% morbidity rate and 28 deaths. Weekly M&M conferences during the same year addressed morbidity in just 6% of cases and made note of just 14 of the deaths.

An analysis of the cases determined that the ACS-NSQIP program identified significantly more complications of every subtype, including wound infections, cardiac complications, urinary tract and renal issues, and others.

Deaths not mentioned in any M&M conference included six due to patient disease and seven that occurred after patients had been transferred to a medical service or when they were being treated as outpatients within 30 days of surgery. One death unaccounted for in M&M conferences had incomplete data.

“At Massachusetts General, we pride ourselves … in a supposedly rigorous academic environment. We decided things had to change,” said Dr. Hutter, director of the hospital's Center for Clinical Effectiveness in Surgery and a member of the surgery department faculty at Harvard Medical School, Boston.

As a result of the study, the hospital has significantly bolstered the content and revised the structure of its M&M conferences, by including, for example, an ongoing review of its own NSQIP results and comparative data from other hospitals. It also has introduced a Web-based reporting tool that standardizes definitions for complications and allows residents and others to quickly input information about any case.

Although the confidential system can be accessed only for peer review, it contains data about everything from a postsurgical infection to an unanticipated return to the operating room or intensive care unit.

The Web-based system serves as an objective, watchful eye on individual patients and the care they receive. It also captures trends that can be identified and used to improve systems, feedback, and approaches to care.

The changes cost $100,000, but if they reduce complications at the same rate seen in the landmark Veteran's Administration NSQIP study, it will end up saving millions, Dr. Hutter asserted.

The NSQIP system was implemented in 1991. By 2001, the NSQIP system in Veterans Affairs hospitals had documented a 27% decrease in complications and a 45% improvement in morbidity, including a 50% drop in major complications, resulting in $11,000 in savings for each case in which a complication did not occur.

“With this report, we are starting to hear the death knell of the traditional M&M conference,” said Dr. David R. Flum, a surgery department faculty member at the University of Washington in Seattle who served as a formal discussant of Dr. Hutter's paper.

Dr. Flum noted that although M&M conferences were “never really intended to be a surveillance system” and served a historic function of revisiting errors, they have often been grounded in opinion, marred by recall bias, and sometimes even driven by “personal and political vendettas.”

Not every complication or death offers a lesson to be learned, he added, noting some of the Massachusetts General deaths resulted from carcinomatosis or total gut necrosis discovered during surgery. But an accurate and consistent real-time surveillance system will provide invaluable information and lead to improved care, he said.

“They took the best elements in this system—standardized definitions, standardized reporting criteria—and they empowered their residents to become the surveillance system,” he noted.

M&M conferences were established in the early 1900s by Dr. Ernest Amory Codman, the “father of surgical outcomes,” who called the review of cases an “end results system.”

Weekly M&M conferences have been required by the American College of Graduate Medical Education for surgical residency programs since 1983 and have been an integral tradition of surgical departments in academic and community hospitals for decades.

SAN FRANCISCO — Morbidity and mortality conferences at Massachusetts General Hospital missed three out of every four complications and one of every two deaths in surgical patients over the course of a year, Dr. Matthew M. Hutter reported at the annual clinical congress of the American College of Surgeons.

Dr. Hutter and associates compared statistics compiled by a nurse reviewer in conjunction with the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) with cases discussed at weekly morbidity and mortality (M&M) conferences.

In 1,439 sampled cases representing 24% of operations, the NSQIP reviewer found a 29% morbidity rate and 28 deaths. Weekly M&M conferences during the same year addressed morbidity in just 6% of cases and made note of just 14 of the deaths.

An analysis of the cases determined that the ACS-NSQIP program identified significantly more complications of every subtype, including wound infections, cardiac complications, urinary tract and renal issues, and others.

Deaths not mentioned in any M&M conference included six due to patient disease and seven that occurred after patients had been transferred to a medical service or when they were being treated as outpatients within 30 days of surgery. One death unaccounted for in M&M conferences had incomplete data.

“At Massachusetts General, we pride ourselves … in a supposedly rigorous academic environment. We decided things had to change,” said Dr. Hutter, director of the hospital's Center for Clinical Effectiveness in Surgery and a member of the surgery department faculty at Harvard Medical School, Boston.

As a result of the study, the hospital has significantly bolstered the content and revised the structure of its M&M conferences, by including, for example, an ongoing review of its own NSQIP results and comparative data from other hospitals. It also has introduced a Web-based reporting tool that standardizes definitions for complications and allows residents and others to quickly input information about any case.

Although the confidential system can be accessed only for peer review, it contains data about everything from a postsurgical infection to an unanticipated return to the operating room or intensive care unit.

The Web-based system serves as an objective, watchful eye on individual patients and the care they receive. It also captures trends that can be identified and used to improve systems, feedback, and approaches to care.

The changes cost $100,000, but if they reduce complications at the same rate seen in the landmark Veteran's Administration NSQIP study, it will end up saving millions, Dr. Hutter asserted.

The NSQIP system was implemented in 1991. By 2001, the NSQIP system in Veterans Affairs hospitals had documented a 27% decrease in complications and a 45% improvement in morbidity, including a 50% drop in major complications, resulting in $11,000 in savings for each case in which a complication did not occur.

“With this report, we are starting to hear the death knell of the traditional M&M conference,” said Dr. David R. Flum, a surgery department faculty member at the University of Washington in Seattle who served as a formal discussant of Dr. Hutter's paper.

Dr. Flum noted that although M&M conferences were “never really intended to be a surveillance system” and served a historic function of revisiting errors, they have often been grounded in opinion, marred by recall bias, and sometimes even driven by “personal and political vendettas.”

Not every complication or death offers a lesson to be learned, he added, noting some of the Massachusetts General deaths resulted from carcinomatosis or total gut necrosis discovered during surgery. But an accurate and consistent real-time surveillance system will provide invaluable information and lead to improved care, he said.

“They took the best elements in this system—standardized definitions, standardized reporting criteria—and they empowered their residents to become the surveillance system,” he noted.

M&M conferences were established in the early 1900s by Dr. Ernest Amory Codman, the “father of surgical outcomes,” who called the review of cases an “end results system.”

Weekly M&M conferences have been required by the American College of Graduate Medical Education for surgical residency programs since 1983 and have been an integral tradition of surgical departments in academic and community hospitals for decades.

SAN DIEGO – Characteristic patterns of gene expression in blood samples can now identify patients with migraine, Tourette's syndrome, neurofibromatosis type 1, tuberous sclerosis type 2, Down syndrome, and early ischemic stroke, among other diseases, Dr. Frank Sharp said at the annual meeting of the American Neurological Association.

The notion that genomic expression can provide a fingerprint of a disease is increasingly proving to be true, although the patterns in blood are not as robust as those found in tissue and are sometimes seen in complex combinations, said Dr. Sharp, who is professor of neurology at the M.I.N.D. Institute, University of California, Davis.

The findings in stroke are particularly intriguing, however, with profound implications for better understanding the timing and nature of inflammatory responses to acute stroke, which in turn could aid in early diagnosis, prognosis, and treatment. Dr. Sharp and his associates have identified shifting alterations in the gene expression in blood cells in response to stroke, reflecting the release of proteins, changes in neurotransmitters, and immunologic responses.

Early results of a University of Cincinnati trial found that a set of 18 genes involved in leukocyte activation and inflammation correctly identified ischemic stroke in 10 of 15 patients at 3 hours, 13 of 15 patients at 5 hours, and all 15 patients at 24 hours post stroke.

Patients who had been taking aspirin prior to their strokes had a significantly different genomic expression of 143 genes when their blood samples were compared with samples from patients who were not taking aspirin prior to enrollment in the Combined Approach to Lysis Utilizing Eptifibatide and rt-PA in Acute Ischemic Stroke (CLEAR) trial.

“This is, in fact, a biologic response to dying tissue … white [blood] cells sensing dead brain or unhappy brain. It's [valuable for] much more than just diagnosis. In my mind, every single one of these genes … is a potential therapeutic target for stroke.”

Polymorphonuclear leukocytes and monocytes drive the distinguishing genetic profile of ischemic stroke. But genetic expression of CD8 and natural killer cells are more pronounced in the fingerprint for Tourette's syndrome. For migraine, monocyte platelet genes are the ones to watch. “It turns out that for autism, lupus, and rheumatoid arthritis … we can map these genes onto these cell types and they're all different.

“You can see a profile in every muscular disease. What we don't know is how specific these profiles are,” he said. Not every disease will be equally amenable to categorization. Five genes in the blood differentiate neurofibromatosis type 1 and tuberous sclerosis type 2, for example.

The profile of Down syndrome involves 200 genes, and the genetic fingerprint looks different still in Down syndrome patients with congenital heart disease.

Dr. Sharp acknowledged the contributions of many colleagues in his pursuit of an understanding of blood genomics, including Dr. Yang Tang, who is also at the University of California, Davis.

SAN DIEGO – Characteristic patterns of gene expression in blood samples can now identify patients with migraine, Tourette's syndrome, neurofibromatosis type 1, tuberous sclerosis type 2, Down syndrome, and early ischemic stroke, among other diseases, Dr. Frank Sharp said at the annual meeting of the American Neurological Association.

The notion that genomic expression can provide a fingerprint of a disease is increasingly proving to be true, although the patterns in blood are not as robust as those found in tissue and are sometimes seen in complex combinations, said Dr. Sharp, who is professor of neurology at the M.I.N.D. Institute, University of California, Davis.

The findings in stroke are particularly intriguing, however, with profound implications for better understanding the timing and nature of inflammatory responses to acute stroke, which in turn could aid in early diagnosis, prognosis, and treatment. Dr. Sharp and his associates have identified shifting alterations in the gene expression in blood cells in response to stroke, reflecting the release of proteins, changes in neurotransmitters, and immunologic responses.

Early results of a University of Cincinnati trial found that a set of 18 genes involved in leukocyte activation and inflammation correctly identified ischemic stroke in 10 of 15 patients at 3 hours, 13 of 15 patients at 5 hours, and all 15 patients at 24 hours post stroke.

Patients who had been taking aspirin prior to their strokes had a significantly different genomic expression of 143 genes when their blood samples were compared with samples from patients who were not taking aspirin prior to enrollment in the Combined Approach to Lysis Utilizing Eptifibatide and rt-PA in Acute Ischemic Stroke (CLEAR) trial.

“This is, in fact, a biologic response to dying tissue … white [blood] cells sensing dead brain or unhappy brain. It's [valuable for] much more than just diagnosis. In my mind, every single one of these genes … is a potential therapeutic target for stroke.”

Polymorphonuclear leukocytes and monocytes drive the distinguishing genetic profile of ischemic stroke. But genetic expression of CD8 and natural killer cells are more pronounced in the fingerprint for Tourette's syndrome. For migraine, monocyte platelet genes are the ones to watch. “It turns out that for autism, lupus, and rheumatoid arthritis … we can map these genes onto these cell types and they're all different.

“You can see a profile in every muscular disease. What we don't know is how specific these profiles are,” he said. Not every disease will be equally amenable to categorization. Five genes in the blood differentiate neurofibromatosis type 1 and tuberous sclerosis type 2, for example.

The profile of Down syndrome involves 200 genes, and the genetic fingerprint looks different still in Down syndrome patients with congenital heart disease.

Dr. Sharp acknowledged the contributions of many colleagues in his pursuit of an understanding of blood genomics, including Dr. Yang Tang, who is also at the University of California, Davis.

SAN DIEGO – Characteristic patterns of gene expression in blood samples can now identify patients with migraine, Tourette's syndrome, neurofibromatosis type 1, tuberous sclerosis type 2, Down syndrome, and early ischemic stroke, among other diseases, Dr. Frank Sharp said at the annual meeting of the American Neurological Association.

The notion that genomic expression can provide a fingerprint of a disease is increasingly proving to be true, although the patterns in blood are not as robust as those found in tissue and are sometimes seen in complex combinations, said Dr. Sharp, who is professor of neurology at the M.I.N.D. Institute, University of California, Davis.

The findings in stroke are particularly intriguing, however, with profound implications for better understanding the timing and nature of inflammatory responses to acute stroke, which in turn could aid in early diagnosis, prognosis, and treatment. Dr. Sharp and his associates have identified shifting alterations in the gene expression in blood cells in response to stroke, reflecting the release of proteins, changes in neurotransmitters, and immunologic responses.

Early results of a University of Cincinnati trial found that a set of 18 genes involved in leukocyte activation and inflammation correctly identified ischemic stroke in 10 of 15 patients at 3 hours, 13 of 15 patients at 5 hours, and all 15 patients at 24 hours post stroke.

Patients who had been taking aspirin prior to their strokes had a significantly different genomic expression of 143 genes when their blood samples were compared with samples from patients who were not taking aspirin prior to enrollment in the Combined Approach to Lysis Utilizing Eptifibatide and rt-PA in Acute Ischemic Stroke (CLEAR) trial.

“This is, in fact, a biologic response to dying tissue … white [blood] cells sensing dead brain or unhappy brain. It's [valuable for] much more than just diagnosis. In my mind, every single one of these genes … is a potential therapeutic target for stroke.”

Polymorphonuclear leukocytes and monocytes drive the distinguishing genetic profile of ischemic stroke. But genetic expression of CD8 and natural killer cells are more pronounced in the fingerprint for Tourette's syndrome. For migraine, monocyte platelet genes are the ones to watch. “It turns out that for autism, lupus, and rheumatoid arthritis … we can map these genes onto these cell types and they're all different.

“You can see a profile in every muscular disease. What we don't know is how specific these profiles are,” he said. Not every disease will be equally amenable to categorization. Five genes in the blood differentiate neurofibromatosis type 1 and tuberous sclerosis type 2, for example.

The profile of Down syndrome involves 200 genes, and the genetic fingerprint looks different still in Down syndrome patients with congenital heart disease.

Dr. Sharp acknowledged the contributions of many colleagues in his pursuit of an understanding of blood genomics, including Dr. Yang Tang, who is also at the University of California, Davis.

SAN DIEGO – So-called benign hallucinations associated with dopaminergic treatment for Parkinson's disease rarely remain “benign,” calling into question the accuracy of the term.

Researchers at Rush University in Chicago studied the clinical progression of 48 patients with Parkinson's disease who were diagnosed with hallucinations characterized by the patient's retention of the insight that the hallucinations are unreal. These hallucinations have been called benign, and traditionally have been associated with a Unified Parkinson Disease Rating Scale (UPDRS) Thought Disorder score of 2.

In 2 years, just 2 of the 48 patients at Rush continued to have benign hallucinations without requiring either a decrease in their dose of dopaminergic medications or an addition of neuroleptic agents to counteract the hallucinations or progressing to more serious hallucinations with loss of insight (UPDRS Thought Disorder score of 3) or delusions (UPDRS Thought Disorder score of 4).

Most, 39 of 48, progressed to scores of 3 or 4. Among nine patients who remained at a score of 2, seven required reduced dosages of dopaminergic medications in response to worsening of hallucinations and three also required neuroleptics to control the hallucinations.

Although the median time to progression of hallucinations to the point where patients were frankly delusional was less than 2 years after the onset of the study, the total length of time patients had hallucinations prior to enrollment was uncertain, noted Dr. Christopher G. Goetz, director of the Rush movement disorders center, in a poster presentation at the annual meeting of the American Neurological Association.

However, the study made clear the fact that even if hallucinations seem “benign … at the moment,” they “portend serious consequences” and should not be given a label that suggests they are unimportant clinical developments, he said.

“Because hallucinations progress, the concept of benign hallucinations is prognostically misleading,” Dr. Goetz and associates concluded. “The term benign hallucinations should be considered generally unsound and dropped from the operative vocabulary.”

SAN DIEGO – So-called benign hallucinations associated with dopaminergic treatment for Parkinson's disease rarely remain “benign,” calling into question the accuracy of the term.

Researchers at Rush University in Chicago studied the clinical progression of 48 patients with Parkinson's disease who were diagnosed with hallucinations characterized by the patient's retention of the insight that the hallucinations are unreal. These hallucinations have been called benign, and traditionally have been associated with a Unified Parkinson Disease Rating Scale (UPDRS) Thought Disorder score of 2.

In 2 years, just 2 of the 48 patients at Rush continued to have benign hallucinations without requiring either a decrease in their dose of dopaminergic medications or an addition of neuroleptic agents to counteract the hallucinations or progressing to more serious hallucinations with loss of insight (UPDRS Thought Disorder score of 3) or delusions (UPDRS Thought Disorder score of 4).

Most, 39 of 48, progressed to scores of 3 or 4. Among nine patients who remained at a score of 2, seven required reduced dosages of dopaminergic medications in response to worsening of hallucinations and three also required neuroleptics to control the hallucinations.

Although the median time to progression of hallucinations to the point where patients were frankly delusional was less than 2 years after the onset of the study, the total length of time patients had hallucinations prior to enrollment was uncertain, noted Dr. Christopher G. Goetz, director of the Rush movement disorders center, in a poster presentation at the annual meeting of the American Neurological Association.

However, the study made clear the fact that even if hallucinations seem “benign … at the moment,” they “portend serious consequences” and should not be given a label that suggests they are unimportant clinical developments, he said.

“Because hallucinations progress, the concept of benign hallucinations is prognostically misleading,” Dr. Goetz and associates concluded. “The term benign hallucinations should be considered generally unsound and dropped from the operative vocabulary.”

SAN DIEGO – So-called benign hallucinations associated with dopaminergic treatment for Parkinson's disease rarely remain “benign,” calling into question the accuracy of the term.

Researchers at Rush University in Chicago studied the clinical progression of 48 patients with Parkinson's disease who were diagnosed with hallucinations characterized by the patient's retention of the insight that the hallucinations are unreal. These hallucinations have been called benign, and traditionally have been associated with a Unified Parkinson Disease Rating Scale (UPDRS) Thought Disorder score of 2.

In 2 years, just 2 of the 48 patients at Rush continued to have benign hallucinations without requiring either a decrease in their dose of dopaminergic medications or an addition of neuroleptic agents to counteract the hallucinations or progressing to more serious hallucinations with loss of insight (UPDRS Thought Disorder score of 3) or delusions (UPDRS Thought Disorder score of 4).

Most, 39 of 48, progressed to scores of 3 or 4. Among nine patients who remained at a score of 2, seven required reduced dosages of dopaminergic medications in response to worsening of hallucinations and three also required neuroleptics to control the hallucinations.

Although the median time to progression of hallucinations to the point where patients were frankly delusional was less than 2 years after the onset of the study, the total length of time patients had hallucinations prior to enrollment was uncertain, noted Dr. Christopher G. Goetz, director of the Rush movement disorders center, in a poster presentation at the annual meeting of the American Neurological Association.

However, the study made clear the fact that even if hallucinations seem “benign … at the moment,” they “portend serious consequences” and should not be given a label that suggests they are unimportant clinical developments, he said.

“Because hallucinations progress, the concept of benign hallucinations is prognostically misleading,” Dr. Goetz and associates concluded. “The term benign hallucinations should be considered generally unsound and dropped from the operative vocabulary.”

SANTA BARBARA, CALIF. – Men and women are similarly devoted to long-term participation in Alcoholics Anonymous, progressing at about equal rates through the 12 steps that define the voluntary, nonprofit program for problem drinkers.

But a study presented at the annual meeting of the Research Society on Alcoholism found intriguing gender differences in two areas of Alcoholics Anonymous (AA) participation.

Women just starting out in AA tended to place more emphasis on deferring to a higher power for their recovery than women who had spent more than a year in the program.

For men, the pattern was reversed. Men just starting out were much less likely than women to place a high degree of importance on a higher power's role in their recovery. But those who had spent more than a year in the program attributed a great deal of importance to a higher power's role, surpassing women's ratings on this measure.

Men, regardless of how long they had participated in AA, were significantly more likely than women to participate in sister AA 12-step programs such as Narcotics Anonymous.

J. Scott Tonigan, Ph.D., of the center on alcoholism, substance abuse, and addictions at the University of New Mexico, Albuquerque, studied the responses of 99 AA members from five AA groups to a series of questionnaires about the program.

The cohort included 73 men and 26 women. Their average age was 44, and they reported an average of 69 months of abstinence.

Most had attended AA for more than 1 year, but 35 were newcomers, allowing Dr. Tonigan to capture differences in participants' outlooks based on their longevity in AA.

Regardless of gender, participants who had spent more time in the program were significantly more likely to say they were following the central constructs of AA: making amends to others, believing in a higher power, practicing AA behaviors, and completing steps in the program.

“Perhaps … they had more time to do so relative to the short-term AA members,” Dr. Tonigan wrote in his poster.

In this study, just 3 of 26 women but 28 of 73 men said they had attended sister AA programs. Women who had been involved with AA longer placed less emphasis on a higher power than did women who had just started AA, while for men the reverse was true.

Dr. Tonigan said it is possible that these unexpected findings could be attributable to the cross-sectional nature of the study, to gender differences in substance abuse (with regard to attendance at sister AA program meetings), or to type 1 error, because the number of subjects in the study was small.

He stressed that men and women tend to similarly complete AA steps, read AA literature, and find sponsors–all key elements in the program's proven ability to foster abstinence.

However, he said, a better understanding of what keeps men and women attending AA may help clinicians to assist their patients in benefitting from the mutual-help group.

SANTA BARBARA, CALIF. – Men and women are similarly devoted to long-term participation in Alcoholics Anonymous, progressing at about equal rates through the 12 steps that define the voluntary, nonprofit program for problem drinkers.

But a study presented at the annual meeting of the Research Society on Alcoholism found intriguing gender differences in two areas of Alcoholics Anonymous (AA) participation.

Women just starting out in AA tended to place more emphasis on deferring to a higher power for their recovery than women who had spent more than a year in the program.

For men, the pattern was reversed. Men just starting out were much less likely than women to place a high degree of importance on a higher power's role in their recovery. But those who had spent more than a year in the program attributed a great deal of importance to a higher power's role, surpassing women's ratings on this measure.

Men, regardless of how long they had participated in AA, were significantly more likely than women to participate in sister AA 12-step programs such as Narcotics Anonymous.

J. Scott Tonigan, Ph.D., of the center on alcoholism, substance abuse, and addictions at the University of New Mexico, Albuquerque, studied the responses of 99 AA members from five AA groups to a series of questionnaires about the program.

The cohort included 73 men and 26 women. Their average age was 44, and they reported an average of 69 months of abstinence.

Most had attended AA for more than 1 year, but 35 were newcomers, allowing Dr. Tonigan to capture differences in participants' outlooks based on their longevity in AA.

Regardless of gender, participants who had spent more time in the program were significantly more likely to say they were following the central constructs of AA: making amends to others, believing in a higher power, practicing AA behaviors, and completing steps in the program.

“Perhaps … they had more time to do so relative to the short-term AA members,” Dr. Tonigan wrote in his poster.

In this study, just 3 of 26 women but 28 of 73 men said they had attended sister AA programs. Women who had been involved with AA longer placed less emphasis on a higher power than did women who had just started AA, while for men the reverse was true.

Dr. Tonigan said it is possible that these unexpected findings could be attributable to the cross-sectional nature of the study, to gender differences in substance abuse (with regard to attendance at sister AA program meetings), or to type 1 error, because the number of subjects in the study was small.

He stressed that men and women tend to similarly complete AA steps, read AA literature, and find sponsors–all key elements in the program's proven ability to foster abstinence.

However, he said, a better understanding of what keeps men and women attending AA may help clinicians to assist their patients in benefitting from the mutual-help group.

SANTA BARBARA, CALIF. – Men and women are similarly devoted to long-term participation in Alcoholics Anonymous, progressing at about equal rates through the 12 steps that define the voluntary, nonprofit program for problem drinkers.

But a study presented at the annual meeting of the Research Society on Alcoholism found intriguing gender differences in two areas of Alcoholics Anonymous (AA) participation.

Women just starting out in AA tended to place more emphasis on deferring to a higher power for their recovery than women who had spent more than a year in the program.

For men, the pattern was reversed. Men just starting out were much less likely than women to place a high degree of importance on a higher power's role in their recovery. But those who had spent more than a year in the program attributed a great deal of importance to a higher power's role, surpassing women's ratings on this measure.

Men, regardless of how long they had participated in AA, were significantly more likely than women to participate in sister AA 12-step programs such as Narcotics Anonymous.

J. Scott Tonigan, Ph.D., of the center on alcoholism, substance abuse, and addictions at the University of New Mexico, Albuquerque, studied the responses of 99 AA members from five AA groups to a series of questionnaires about the program.

The cohort included 73 men and 26 women. Their average age was 44, and they reported an average of 69 months of abstinence.

Most had attended AA for more than 1 year, but 35 were newcomers, allowing Dr. Tonigan to capture differences in participants' outlooks based on their longevity in AA.

Regardless of gender, participants who had spent more time in the program were significantly more likely to say they were following the central constructs of AA: making amends to others, believing in a higher power, practicing AA behaviors, and completing steps in the program.

“Perhaps … they had more time to do so relative to the short-term AA members,” Dr. Tonigan wrote in his poster.

In this study, just 3 of 26 women but 28 of 73 men said they had attended sister AA programs. Women who had been involved with AA longer placed less emphasis on a higher power than did women who had just started AA, while for men the reverse was true.

Dr. Tonigan said it is possible that these unexpected findings could be attributable to the cross-sectional nature of the study, to gender differences in substance abuse (with regard to attendance at sister AA program meetings), or to type 1 error, because the number of subjects in the study was small.

He stressed that men and women tend to similarly complete AA steps, read AA literature, and find sponsors–all key elements in the program's proven ability to foster abstinence.

However, he said, a better understanding of what keeps men and women attending AA may help clinicians to assist their patients in benefitting from the mutual-help group.

SAN FRANCISCO — Patients with esophageal adenocarcinoma may benefit from reduced postsurgical morbidity after undergoing vagal-sparing esophagectomy, Dr. Daniel S. Oh reported at the annual clinical congress of the American College of Surgeons.

Compared with other surgical options, “vagal-sparing esophagectomy is associated with reduced morbidity and shorter length of stay, with similar early outcomes,” said Dr. Oh, speaking on behalf of a team of surgeons at the University of Southern California led by Dr. Thomas R. DeMeester.

Pioneered at USC, the vagal-sparing procedure preserves the vagal nerves and gastric reservoir. The diseased esophagus is removed from the mediastinum with a vein-stripping tool and is replaced by a section of the patient's colon or a gastric tool formed from the greater curvature of the stomach. The procedure is aimed at reducing postsurgical gastrointestinal side effects of traditional esophagectomy, such as dumping syndrome, diarrhea, and reduced stomach capacity.

The incidence of esophageal adenocarcinoma is rising faster than for any other cancer, noted Dr. Oh, who presented an 18-year retrospective study of the USC experience with surgical options for treating this increasingly important malignancy.

He reviewed 78 cases of esophageal adenocarcinoma with invasion through the basement membrane into the lamina propria, but not through the muscularis mucosa. Median follow-up was 38 months.

The cases included 65 related to Barrett's esophagus and 13 cases associated with intestinal metaplasia of the cardia (CIM). Gastroesophageal reflux disease symptoms were present in 63 of 65 of the Barrett's cases, and 10 of 13 of those associated with CIM. The symptoms were present for 20 years, on average, in Barrett's patients vs. 8 years for CIM patients. Infection with Helicobacter pylori was rare in both groups; just three of the Barrett's patients, and none of the CIM patients had infection.

A subgroup of patients underwent lymphadenectomy; just 1 lymph node in 1,020 sampled (1 patient in 23) showed evidence of metastasis with hematoxylin and eosin staining. Immunohistochemistry showed evidence of micrometastasis in 3 of the 848 lymph nodes examined (2 of 19 patients).

“Based on the low prevalence of metastasis in our patients, we began looking at the extent of resection [being performed], in order to lessen the morbidity of esophagectomy,” Dr. Oh said.

Only 2 complications were seen in the 20 patients treated with vagal-sparing esophagectomy, compared with 11 complications in the 23 patients treated with en bloc esophagectomy and 13 complications in the 31 patients who had a transhiatal esophagectomy (THE), a procedure developed at the University of Michigan, Ann Arbor. Four patients underwent simple transthoracic esophagectomy due to complicating factors such as prior radiation that precluded a typical transhiatal esophagectomy with an anastomosis in the neck. No patient in any group had residual signs of Barrett's esophagus.

The hospital stay was also shorter: 12 days after vagal-sparing esophagectomy, compared with 22 days after en bloc resection and 17 days after THE.

The overall operative mortality was nearly 3% (2 patients). Two patients died of systemic disease, one at 2 years and one at 7 years following resection.

“There was no difference in survival based on the type of surgical resection performed,” said Dr. Oh, but he noted that the 5-year follow-up was longer for the en bloc resection patients than for the others.

In upper endoscopies performed by the surgeon prior to surgery, 53 of 78 patients had a visible lesion, and the lesion was cancerous in 48. In five patients, high-grade dysplasia was diagnosed within a visible lesion. Among 25 patients with no visible lesion, 16 had cancer and 9 had high-grade dysplasia.

The tumor origin in almost half of the patients in the series was within 1 cm of the gastroesophageal junction. There was a “progressive decrease in the frequency [of tumors] further up the esophagus,” Dr. Oh said.

An esophageal adenocarcinoma lesion is visible on endoscopy. Courtesy Dr. Daniel S. Oh

SAN FRANCISCO — Patients with esophageal adenocarcinoma may benefit from reduced postsurgical morbidity after undergoing vagal-sparing esophagectomy, Dr. Daniel S. Oh reported at the annual clinical congress of the American College of Surgeons.

Compared with other surgical options, “vagal-sparing esophagectomy is associated with reduced morbidity and shorter length of stay, with similar early outcomes,” said Dr. Oh, speaking on behalf of a team of surgeons at the University of Southern California led by Dr. Thomas R. DeMeester.

Pioneered at USC, the vagal-sparing procedure preserves the vagal nerves and gastric reservoir. The diseased esophagus is removed from the mediastinum with a vein-stripping tool and is replaced by a section of the patient's colon or a gastric tool formed from the greater curvature of the stomach. The procedure is aimed at reducing postsurgical gastrointestinal side effects of traditional esophagectomy, such as dumping syndrome, diarrhea, and reduced stomach capacity.

The incidence of esophageal adenocarcinoma is rising faster than for any other cancer, noted Dr. Oh, who presented an 18-year retrospective study of the USC experience with surgical options for treating this increasingly important malignancy.

He reviewed 78 cases of esophageal adenocarcinoma with invasion through the basement membrane into the lamina propria, but not through the muscularis mucosa. Median follow-up was 38 months.

The cases included 65 related to Barrett's esophagus and 13 cases associated with intestinal metaplasia of the cardia (CIM). Gastroesophageal reflux disease symptoms were present in 63 of 65 of the Barrett's cases, and 10 of 13 of those associated with CIM. The symptoms were present for 20 years, on average, in Barrett's patients vs. 8 years for CIM patients. Infection with Helicobacter pylori was rare in both groups; just three of the Barrett's patients, and none of the CIM patients had infection.

A subgroup of patients underwent lymphadenectomy; just 1 lymph node in 1,020 sampled (1 patient in 23) showed evidence of metastasis with hematoxylin and eosin staining. Immunohistochemistry showed evidence of micrometastasis in 3 of the 848 lymph nodes examined (2 of 19 patients).

“Based on the low prevalence of metastasis in our patients, we began looking at the extent of resection [being performed], in order to lessen the morbidity of esophagectomy,” Dr. Oh said.

Only 2 complications were seen in the 20 patients treated with vagal-sparing esophagectomy, compared with 11 complications in the 23 patients treated with en bloc esophagectomy and 13 complications in the 31 patients who had a transhiatal esophagectomy (THE), a procedure developed at the University of Michigan, Ann Arbor. Four patients underwent simple transthoracic esophagectomy due to complicating factors such as prior radiation that precluded a typical transhiatal esophagectomy with an anastomosis in the neck. No patient in any group had residual signs of Barrett's esophagus.

The hospital stay was also shorter: 12 days after vagal-sparing esophagectomy, compared with 22 days after en bloc resection and 17 days after THE.

The overall operative mortality was nearly 3% (2 patients). Two patients died of systemic disease, one at 2 years and one at 7 years following resection.

“There was no difference in survival based on the type of surgical resection performed,” said Dr. Oh, but he noted that the 5-year follow-up was longer for the en bloc resection patients than for the others.

In upper endoscopies performed by the surgeon prior to surgery, 53 of 78 patients had a visible lesion, and the lesion was cancerous in 48. In five patients, high-grade dysplasia was diagnosed within a visible lesion. Among 25 patients with no visible lesion, 16 had cancer and 9 had high-grade dysplasia.

The tumor origin in almost half of the patients in the series was within 1 cm of the gastroesophageal junction. There was a “progressive decrease in the frequency [of tumors] further up the esophagus,” Dr. Oh said.

An esophageal adenocarcinoma lesion is visible on endoscopy. Courtesy Dr. Daniel S. Oh

SAN FRANCISCO — Patients with esophageal adenocarcinoma may benefit from reduced postsurgical morbidity after undergoing vagal-sparing esophagectomy, Dr. Daniel S. Oh reported at the annual clinical congress of the American College of Surgeons.

Compared with other surgical options, “vagal-sparing esophagectomy is associated with reduced morbidity and shorter length of stay, with similar early outcomes,” said Dr. Oh, speaking on behalf of a team of surgeons at the University of Southern California led by Dr. Thomas R. DeMeester.

Pioneered at USC, the vagal-sparing procedure preserves the vagal nerves and gastric reservoir. The diseased esophagus is removed from the mediastinum with a vein-stripping tool and is replaced by a section of the patient's colon or a gastric tool formed from the greater curvature of the stomach. The procedure is aimed at reducing postsurgical gastrointestinal side effects of traditional esophagectomy, such as dumping syndrome, diarrhea, and reduced stomach capacity.

The incidence of esophageal adenocarcinoma is rising faster than for any other cancer, noted Dr. Oh, who presented an 18-year retrospective study of the USC experience with surgical options for treating this increasingly important malignancy.

He reviewed 78 cases of esophageal adenocarcinoma with invasion through the basement membrane into the lamina propria, but not through the muscularis mucosa. Median follow-up was 38 months.

The cases included 65 related to Barrett's esophagus and 13 cases associated with intestinal metaplasia of the cardia (CIM). Gastroesophageal reflux disease symptoms were present in 63 of 65 of the Barrett's cases, and 10 of 13 of those associated with CIM. The symptoms were present for 20 years, on average, in Barrett's patients vs. 8 years for CIM patients. Infection with Helicobacter pylori was rare in both groups; just three of the Barrett's patients, and none of the CIM patients had infection.

A subgroup of patients underwent lymphadenectomy; just 1 lymph node in 1,020 sampled (1 patient in 23) showed evidence of metastasis with hematoxylin and eosin staining. Immunohistochemistry showed evidence of micrometastasis in 3 of the 848 lymph nodes examined (2 of 19 patients).

“Based on the low prevalence of metastasis in our patients, we began looking at the extent of resection [being performed], in order to lessen the morbidity of esophagectomy,” Dr. Oh said.

Only 2 complications were seen in the 20 patients treated with vagal-sparing esophagectomy, compared with 11 complications in the 23 patients treated with en bloc esophagectomy and 13 complications in the 31 patients who had a transhiatal esophagectomy (THE), a procedure developed at the University of Michigan, Ann Arbor. Four patients underwent simple transthoracic esophagectomy due to complicating factors such as prior radiation that precluded a typical transhiatal esophagectomy with an anastomosis in the neck. No patient in any group had residual signs of Barrett's esophagus.

The hospital stay was also shorter: 12 days after vagal-sparing esophagectomy, compared with 22 days after en bloc resection and 17 days after THE.

The overall operative mortality was nearly 3% (2 patients). Two patients died of systemic disease, one at 2 years and one at 7 years following resection.

“There was no difference in survival based on the type of surgical resection performed,” said Dr. Oh, but he noted that the 5-year follow-up was longer for the en bloc resection patients than for the others.

In upper endoscopies performed by the surgeon prior to surgery, 53 of 78 patients had a visible lesion, and the lesion was cancerous in 48. In five patients, high-grade dysplasia was diagnosed within a visible lesion. Among 25 patients with no visible lesion, 16 had cancer and 9 had high-grade dysplasia.

The tumor origin in almost half of the patients in the series was within 1 cm of the gastroesophageal junction. There was a “progressive decrease in the frequency [of tumors] further up the esophagus,” Dr. Oh said.

An esophageal adenocarcinoma lesion is visible on endoscopy. Courtesy Dr. Daniel S. Oh

SAN FRANCISCO — A sharp uptick in the prevalence and severity of Clostridium difficile colitis among hospital patients nationwide suggests that the trend extends beyond documented cases in focused regions of the United States and Canada, Dr. Rocco Ricciardi said at the annual clinical congress of the American College of Surgeons.

Analysis of national hospital data indicates “a significant change in the epidemiology of C. difficile colitis, which is likely secondary to a more virulent pathogen or less effective therapies,” Dr. Ricciardi said.

C. difficile, a gram-positive, spore-forming bacterium, was first described in 1935. Its emergence as an important cause of severe colitis can be traced to the increased use of antibiotics, which disrupt the normal flora of the colon and permit it to flourish.

Dr. Ricciardi, a colorectal surgeon on the faculty of the University of Minnesota, examined inpatient data from the Nationwide Inpatient Sample, a discharge database of approximately 7 million hospital stays per year in 1,000 hospitals in more than 30 states.

He found nearly 300,000 cases of C. difficile colitis documented in inpatient charts during the study period (1993–2003). Of those, C. difficile colitis was the primary diagnosis in 69,373 cases. The average age of the patients was 67, and 59% were females. Most patients (64%) were white.

The prevalence rose dramatically not only for primary cases of C. difficile colitis—when the condition was the major reason for hospitalization—but also for patients with a secondary diagnosis of the disease.

The findings were both statistically and clinically significant. They reflect trends seen in smaller studies from Pittsburgh and Portland, Ore., and the province of Quebec.

The case fatality rate in patients with any diagnosis of C. difficile on their charts was 7.8% in 1993, rising to 9.3% in 2003, with the sharpest increase seen from 2001 to 2003, Dr. Ricciardi said.

The C. difficile-associated mortality rate per 100,000 discharges rose from 20 to greater than 50 during the 11-year period.

The colectomy rate per 1,000 patients with a primary or secondary diagnosis of C. difficile increased from just over 1 in 1993 to 3.4 in 2003. The curve made a sharp upward turn between 2000 and 2003.

Logistic regression analysis showed that the prevalence, case/fatality rate, and colectomy rate rose even after adjustment for age, gender, race, payer type, and comorbidity.

Discussant Dr. Karen E. Deveney, professor of surgery at Oregon Health Sciences University in Portland, hailed the investigation as an important confirmation in a population study of trends seen in her city and other regions.

“I am struck by the similarity between this study and previous publications. All seem to agree that C. difficile is increasing in prevalence and severity,” she said.

SAN FRANCISCO — A sharp uptick in the prevalence and severity of Clostridium difficile colitis among hospital patients nationwide suggests that the trend extends beyond documented cases in focused regions of the United States and Canada, Dr. Rocco Ricciardi said at the annual clinical congress of the American College of Surgeons.

Analysis of national hospital data indicates “a significant change in the epidemiology of C. difficile colitis, which is likely secondary to a more virulent pathogen or less effective therapies,” Dr. Ricciardi said.

C. difficile, a gram-positive, spore-forming bacterium, was first described in 1935. Its emergence as an important cause of severe colitis can be traced to the increased use of antibiotics, which disrupt the normal flora of the colon and permit it to flourish.

Dr. Ricciardi, a colorectal surgeon on the faculty of the University of Minnesota, examined inpatient data from the Nationwide Inpatient Sample, a discharge database of approximately 7 million hospital stays per year in 1,000 hospitals in more than 30 states.

He found nearly 300,000 cases of C. difficile colitis documented in inpatient charts during the study period (1993–2003). Of those, C. difficile colitis was the primary diagnosis in 69,373 cases. The average age of the patients was 67, and 59% were females. Most patients (64%) were white.

The prevalence rose dramatically not only for primary cases of C. difficile colitis—when the condition was the major reason for hospitalization—but also for patients with a secondary diagnosis of the disease.

The findings were both statistically and clinically significant. They reflect trends seen in smaller studies from Pittsburgh and Portland, Ore., and the province of Quebec.

The case fatality rate in patients with any diagnosis of C. difficile on their charts was 7.8% in 1993, rising to 9.3% in 2003, with the sharpest increase seen from 2001 to 2003, Dr. Ricciardi said.

The C. difficile-associated mortality rate per 100,000 discharges rose from 20 to greater than 50 during the 11-year period.

The colectomy rate per 1,000 patients with a primary or secondary diagnosis of C. difficile increased from just over 1 in 1993 to 3.4 in 2003. The curve made a sharp upward turn between 2000 and 2003.

Logistic regression analysis showed that the prevalence, case/fatality rate, and colectomy rate rose even after adjustment for age, gender, race, payer type, and comorbidity.

Discussant Dr. Karen E. Deveney, professor of surgery at Oregon Health Sciences University in Portland, hailed the investigation as an important confirmation in a population study of trends seen in her city and other regions.

“I am struck by the similarity between this study and previous publications. All seem to agree that C. difficile is increasing in prevalence and severity,” she said.

SAN FRANCISCO — A sharp uptick in the prevalence and severity of Clostridium difficile colitis among hospital patients nationwide suggests that the trend extends beyond documented cases in focused regions of the United States and Canada, Dr. Rocco Ricciardi said at the annual clinical congress of the American College of Surgeons.

Analysis of national hospital data indicates “a significant change in the epidemiology of C. difficile colitis, which is likely secondary to a more virulent pathogen or less effective therapies,” Dr. Ricciardi said.

C. difficile, a gram-positive, spore-forming bacterium, was first described in 1935. Its emergence as an important cause of severe colitis can be traced to the increased use of antibiotics, which disrupt the normal flora of the colon and permit it to flourish.

Dr. Ricciardi, a colorectal surgeon on the faculty of the University of Minnesota, examined inpatient data from the Nationwide Inpatient Sample, a discharge database of approximately 7 million hospital stays per year in 1,000 hospitals in more than 30 states.

He found nearly 300,000 cases of C. difficile colitis documented in inpatient charts during the study period (1993–2003). Of those, C. difficile colitis was the primary diagnosis in 69,373 cases. The average age of the patients was 67, and 59% were females. Most patients (64%) were white.

The prevalence rose dramatically not only for primary cases of C. difficile colitis—when the condition was the major reason for hospitalization—but also for patients with a secondary diagnosis of the disease.

The findings were both statistically and clinically significant. They reflect trends seen in smaller studies from Pittsburgh and Portland, Ore., and the province of Quebec.

The case fatality rate in patients with any diagnosis of C. difficile on their charts was 7.8% in 1993, rising to 9.3% in 2003, with the sharpest increase seen from 2001 to 2003, Dr. Ricciardi said.

The C. difficile-associated mortality rate per 100,000 discharges rose from 20 to greater than 50 during the 11-year period.

The colectomy rate per 1,000 patients with a primary or secondary diagnosis of C. difficile increased from just over 1 in 1993 to 3.4 in 2003. The curve made a sharp upward turn between 2000 and 2003.

Logistic regression analysis showed that the prevalence, case/fatality rate, and colectomy rate rose even after adjustment for age, gender, race, payer type, and comorbidity.

Discussant Dr. Karen E. Deveney, professor of surgery at Oregon Health Sciences University in Portland, hailed the investigation as an important confirmation in a population study of trends seen in her city and other regions.

“I am struck by the similarity between this study and previous publications. All seem to agree that C. difficile is increasing in prevalence and severity,” she said.

SAN DIEGO — Short children grew taller when their growth hormone doses were adjusted to their insulinlike growth factor 1 levels rather than to their weight, according to randomized study results.

“IGF-1 levels do matter,” said Dr. Pinchas Cohen, professor and director of research and training in the division of endocrinology at the University of California, Los Angeles.

In all, 172 children diagnosed with growth hormone deficiency or idiopathic short stature were enrolled in the 2-year trial sponsored by Novo Nordisk Inc., and the Lucile Packard Foundation for Children's Health.

The children were aged 3–15 years and significantly below normal height for their age, with a mean standard deviation score of −2.63. They also had low levels of IGF-1, the core mediator of growth hormone action on linear growth, Dr. Cohen reported at the annual meeting of the Endocrine Society.

The complex study design featured a control group of 34 children who received a conventional 40 mcg/kg per day dose of growth hormone. The other two groups received targeted, adjustable doses of growth hormone based on their IGF-1 levels at 3-month checkups.

One group (70 children) received growth hormone in amounts necessary to achieve normal IGF-1 levels. The other group (68 children) received enough growth hormone to drive their IGF-1 levels two standard deviations above the norm.

The three groups achieved mean IGF-1 levels of +0.4, +0.4, and +2.0 standard deviation scores in the first 9 months of the study, and doses of 41 mcg/kg per day, 33 mcg/kg per day, and 110 mcg/kg per day were required to sustain these levels.

The big difference in height was seen in children whose growth hormone dose was aimed at raising their IGF-1 levels to two standard deviations above the norm. In this group, children with growth hormone deficiency grew 45% more, and children with idiopathic short stature grew 58% more than children in the other groups.

Dr. Cohen serves as a consultant or receives research support from several companies that manufacture human growth hormone, including Novo Nordisk.

SAN DIEGO — Short children grew taller when their growth hormone doses were adjusted to their insulinlike growth factor 1 levels rather than to their weight, according to randomized study results.

“IGF-1 levels do matter,” said Dr. Pinchas Cohen, professor and director of research and training in the division of endocrinology at the University of California, Los Angeles.

In all, 172 children diagnosed with growth hormone deficiency or idiopathic short stature were enrolled in the 2-year trial sponsored by Novo Nordisk Inc., and the Lucile Packard Foundation for Children's Health.

The children were aged 3–15 years and significantly below normal height for their age, with a mean standard deviation score of −2.63. They also had low levels of IGF-1, the core mediator of growth hormone action on linear growth, Dr. Cohen reported at the annual meeting of the Endocrine Society.

The complex study design featured a control group of 34 children who received a conventional 40 mcg/kg per day dose of growth hormone. The other two groups received targeted, adjustable doses of growth hormone based on their IGF-1 levels at 3-month checkups.

One group (70 children) received growth hormone in amounts necessary to achieve normal IGF-1 levels. The other group (68 children) received enough growth hormone to drive their IGF-1 levels two standard deviations above the norm.

The three groups achieved mean IGF-1 levels of +0.4, +0.4, and +2.0 standard deviation scores in the first 9 months of the study, and doses of 41 mcg/kg per day, 33 mcg/kg per day, and 110 mcg/kg per day were required to sustain these levels.

The big difference in height was seen in children whose growth hormone dose was aimed at raising their IGF-1 levels to two standard deviations above the norm. In this group, children with growth hormone deficiency grew 45% more, and children with idiopathic short stature grew 58% more than children in the other groups.

Dr. Cohen serves as a consultant or receives research support from several companies that manufacture human growth hormone, including Novo Nordisk.

SAN DIEGO — Short children grew taller when their growth hormone doses were adjusted to their insulinlike growth factor 1 levels rather than to their weight, according to randomized study results.

“IGF-1 levels do matter,” said Dr. Pinchas Cohen, professor and director of research and training in the division of endocrinology at the University of California, Los Angeles.

In all, 172 children diagnosed with growth hormone deficiency or idiopathic short stature were enrolled in the 2-year trial sponsored by Novo Nordisk Inc., and the Lucile Packard Foundation for Children's Health.

The children were aged 3–15 years and significantly below normal height for their age, with a mean standard deviation score of −2.63. They also had low levels of IGF-1, the core mediator of growth hormone action on linear growth, Dr. Cohen reported at the annual meeting of the Endocrine Society.

The complex study design featured a control group of 34 children who received a conventional 40 mcg/kg per day dose of growth hormone. The other two groups received targeted, adjustable doses of growth hormone based on their IGF-1 levels at 3-month checkups.

One group (70 children) received growth hormone in amounts necessary to achieve normal IGF-1 levels. The other group (68 children) received enough growth hormone to drive their IGF-1 levels two standard deviations above the norm.

The three groups achieved mean IGF-1 levels of +0.4, +0.4, and +2.0 standard deviation scores in the first 9 months of the study, and doses of 41 mcg/kg per day, 33 mcg/kg per day, and 110 mcg/kg per day were required to sustain these levels.

The big difference in height was seen in children whose growth hormone dose was aimed at raising their IGF-1 levels to two standard deviations above the norm. In this group, children with growth hormone deficiency grew 45% more, and children with idiopathic short stature grew 58% more than children in the other groups.

Dr. Cohen serves as a consultant or receives research support from several companies that manufacture human growth hormone, including Novo Nordisk.

SAN DIEGO — Far fewer patients receive the full spectrum of recommended secondary prevention interventions after suffering a neurovascular event than do patients who have suffered a cardiac event, a national database study concluded.

Dr. Eric T. Cheng, of the University of California, Los Angeles, and his associates examined data from the 2002 Medical Expenditure Panel Survey, a government-sponsored survey that sampled 15,000 representative U.S. households.

They then compared the care received by 943 people who reported a cardiac event such as myocardial infarction or angina with the care received by 523 people who had suffered a neurovascular event such as a stroke or a transient ischemic attack.

The results of the study were presented in poster form at the annual meeting of the American Neurological Association.

Both cardiac and stroke patients reported having their blood pressure and cholesterol levels measured often (97% and 96%, respectively).

These patients also were highly likely to receive advice to quit smoking (95% and 93%, respectively).

However, cardiac patients were much more likely than were neurovascular event patients to receive antithrombotic medication (83% vs. 77%), advice to exercise more (66% vs. 52%), or instruction to limit high-fat and high-cholesterol foods in their diet (70% vs. 54%).

Dr. Cheng and his associates at UCLA and the VA Greater Los Angeles Health Care System suggested that successful programs that have been used to enhance secondary preventive care after heart attacks should be replicated in the stroke population.

The Department of Veterans Affairs supported the study.

SAN DIEGO — Far fewer patients receive the full spectrum of recommended secondary prevention interventions after suffering a neurovascular event than do patients who have suffered a cardiac event, a national database study concluded.

Dr. Eric T. Cheng, of the University of California, Los Angeles, and his associates examined data from the 2002 Medical Expenditure Panel Survey, a government-sponsored survey that sampled 15,000 representative U.S. households.

They then compared the care received by 943 people who reported a cardiac event such as myocardial infarction or angina with the care received by 523 people who had suffered a neurovascular event such as a stroke or a transient ischemic attack.

The results of the study were presented in poster form at the annual meeting of the American Neurological Association.

Both cardiac and stroke patients reported having their blood pressure and cholesterol levels measured often (97% and 96%, respectively).

These patients also were highly likely to receive advice to quit smoking (95% and 93%, respectively).

However, cardiac patients were much more likely than were neurovascular event patients to receive antithrombotic medication (83% vs. 77%), advice to exercise more (66% vs. 52%), or instruction to limit high-fat and high-cholesterol foods in their diet (70% vs. 54%).

Dr. Cheng and his associates at UCLA and the VA Greater Los Angeles Health Care System suggested that successful programs that have been used to enhance secondary preventive care after heart attacks should be replicated in the stroke population.

The Department of Veterans Affairs supported the study.

SAN DIEGO — Far fewer patients receive the full spectrum of recommended secondary prevention interventions after suffering a neurovascular event than do patients who have suffered a cardiac event, a national database study concluded.

Dr. Eric T. Cheng, of the University of California, Los Angeles, and his associates examined data from the 2002 Medical Expenditure Panel Survey, a government-sponsored survey that sampled 15,000 representative U.S. households.

They then compared the care received by 943 people who reported a cardiac event such as myocardial infarction or angina with the care received by 523 people who had suffered a neurovascular event such as a stroke or a transient ischemic attack.

The results of the study were presented in poster form at the annual meeting of the American Neurological Association.

Both cardiac and stroke patients reported having their blood pressure and cholesterol levels measured often (97% and 96%, respectively).

These patients also were highly likely to receive advice to quit smoking (95% and 93%, respectively).

However, cardiac patients were much more likely than were neurovascular event patients to receive antithrombotic medication (83% vs. 77%), advice to exercise more (66% vs. 52%), or instruction to limit high-fat and high-cholesterol foods in their diet (70% vs. 54%).

Dr. Cheng and his associates at UCLA and the VA Greater Los Angeles Health Care System suggested that successful programs that have been used to enhance secondary preventive care after heart attacks should be replicated in the stroke population.

The Department of Veterans Affairs supported the study.

SAN DIEGO — A small but intriguing study has found that treating obstructive sleep apnea in patients with polycystic ovary syndrome lowered their cortisol levels not only at night, but during the daytime as well.

Obstructive sleep apnea symptoms also greatly improved in five nondiabetic PCOS patients who received continuous positive airway pressure (CPAP) for 8 weeks as part of a study presented at the annual meeting of the Endocrine Society.

Previous research has determined that the risk of obstructive sleep apnea is 30-fold to 40-fold higher in women with PCOS compared with weight-matched controls. It has been theorized that there may be a link between obstructive sleep apnea and the metabolic and hormonal abnormalities associated with the disease.

“These findings strongly suggest that obstructive sleep apnea is likely to contribute to elevated cortisol levels in women with PCOS and could play a role in the risk for adverse metabolic alterations in this patient population,” concluded researchers Eve Van Cauter, Ph.D., and Dr. Esra Tasali, of the department of medicine at the University of Chicago, who presented a poster at the meeting.

Subjects in the study were in their early to mid-30s and had a mean body mass index (kg/m2) of 51. Three of the five had impaired glucose tolerance. CPAP treatments were administered for 8 weeks at the patients' homes, with compliance confirmed by built-in monitors.

Following therapy, mean 24-hour cortisol levels fell from 10.2 mcg/dL to 7.7 mcg/dL. Daytime cortisol levels fell from 10.3 mcg/dL to 7.9 mcg/dL, whereas nighttime cortisol dropped from 10.1 mcg/dL to 7.5 mcg/dL. These decreases were all statistically significant.

The cortisol nadir declined by 40%.

“Interestingly, this decrease in the nadir was associated with the severity of patients' sleep apnea,” Dr. Tasali, a pulmonologist and sleep researcher at the university, said in an interview at the meeting.

CPAP may emerge as a treatment modality in some patients, not only to alleviate symptoms of obstructive sleep apnea, but also to independently target hormonally and metabolically driven symptoms, said Dr. Van Cauter, a professor of medicine at the university.

SAN DIEGO — A small but intriguing study has found that treating obstructive sleep apnea in patients with polycystic ovary syndrome lowered their cortisol levels not only at night, but during the daytime as well.

Obstructive sleep apnea symptoms also greatly improved in five nondiabetic PCOS patients who received continuous positive airway pressure (CPAP) for 8 weeks as part of a study presented at the annual meeting of the Endocrine Society.

Previous research has determined that the risk of obstructive sleep apnea is 30-fold to 40-fold higher in women with PCOS compared with weight-matched controls. It has been theorized that there may be a link between obstructive sleep apnea and the metabolic and hormonal abnormalities associated with the disease.

“These findings strongly suggest that obstructive sleep apnea is likely to contribute to elevated cortisol levels in women with PCOS and could play a role in the risk for adverse metabolic alterations in this patient population,” concluded researchers Eve Van Cauter, Ph.D., and Dr. Esra Tasali, of the department of medicine at the University of Chicago, who presented a poster at the meeting.

Subjects in the study were in their early to mid-30s and had a mean body mass index (kg/m2) of 51. Three of the five had impaired glucose tolerance. CPAP treatments were administered for 8 weeks at the patients' homes, with compliance confirmed by built-in monitors.

Following therapy, mean 24-hour cortisol levels fell from 10.2 mcg/dL to 7.7 mcg/dL. Daytime cortisol levels fell from 10.3 mcg/dL to 7.9 mcg/dL, whereas nighttime cortisol dropped from 10.1 mcg/dL to 7.5 mcg/dL. These decreases were all statistically significant.

The cortisol nadir declined by 40%.

“Interestingly, this decrease in the nadir was associated with the severity of patients' sleep apnea,” Dr. Tasali, a pulmonologist and sleep researcher at the university, said in an interview at the meeting.

CPAP may emerge as a treatment modality in some patients, not only to alleviate symptoms of obstructive sleep apnea, but also to independently target hormonally and metabolically driven symptoms, said Dr. Van Cauter, a professor of medicine at the university.

SAN DIEGO — A small but intriguing study has found that treating obstructive sleep apnea in patients with polycystic ovary syndrome lowered their cortisol levels not only at night, but during the daytime as well.

Obstructive sleep apnea symptoms also greatly improved in five nondiabetic PCOS patients who received continuous positive airway pressure (CPAP) for 8 weeks as part of a study presented at the annual meeting of the Endocrine Society.

Previous research has determined that the risk of obstructive sleep apnea is 30-fold to 40-fold higher in women with PCOS compared with weight-matched controls. It has been theorized that there may be a link between obstructive sleep apnea and the metabolic and hormonal abnormalities associated with the disease.

“These findings strongly suggest that obstructive sleep apnea is likely to contribute to elevated cortisol levels in women with PCOS and could play a role in the risk for adverse metabolic alterations in this patient population,” concluded researchers Eve Van Cauter, Ph.D., and Dr. Esra Tasali, of the department of medicine at the University of Chicago, who presented a poster at the meeting.

Subjects in the study were in their early to mid-30s and had a mean body mass index (kg/m2) of 51. Three of the five had impaired glucose tolerance. CPAP treatments were administered for 8 weeks at the patients' homes, with compliance confirmed by built-in monitors.

Following therapy, mean 24-hour cortisol levels fell from 10.2 mcg/dL to 7.7 mcg/dL. Daytime cortisol levels fell from 10.3 mcg/dL to 7.9 mcg/dL, whereas nighttime cortisol dropped from 10.1 mcg/dL to 7.5 mcg/dL. These decreases were all statistically significant.

The cortisol nadir declined by 40%.

“Interestingly, this decrease in the nadir was associated with the severity of patients' sleep apnea,” Dr. Tasali, a pulmonologist and sleep researcher at the university, said in an interview at the meeting.

CPAP may emerge as a treatment modality in some patients, not only to alleviate symptoms of obstructive sleep apnea, but also to independently target hormonally and metabolically driven symptoms, said Dr. Van Cauter, a professor of medicine at the university.