Betsy Bates

RANCHO MIRAGE, CALIF. – Obstructive sleep apnea in children is associated with profound deficits in IQ, verbal comprehension, perceptual reasoning, and working memory, according to preliminary results of a case-control study at the Pediatric Sleep Disorders Center of Johns Hopkins University, Baltimore.

Ann C. Halbower, M.D., medical director of the center, reported that extensive cognitive deficits and cerebral metabolite alterations were powerfully evident in children from inner city Baltimore who suffered from moderate to severe obstructive sleep apnea (OSA).

Thus far, 17 children aged 7–16 years with OSA and 10 matched controls have completed sleep studies, neuropsychological tests, and magnetic resonance spectroscopy. The average age in both groups is 10.

“Our kids with OSA were severely impacted, their IQ scores being 10 to 15 or more points below normal. We saw huge differences in memory, especially in visual spatial processing, which is a parietal lobe function that has not received a lot of press,” Dr. Halbower said at a conference on sleep in infancy and childhood sponsored by the Annenberg Center for Health Sciences.

Group differences in IQ were mostly explained by sharply defined deficits in working memory, nonverbal reasoning, and verbal comprehension among children with OSA.

Magnetic resonance spectroscopy determined that neuropsychological deficits in the children correlated with hippocampal metabolite alterations, low oxygen saturation, and body mass index (BMI).

The study is ongoing, although Dr. Halbower said she and her team are having trouble finding normal, nonsnoring obese controls who do not have sleep apnea. The average BMI among children with OSA was 29.3 and among controls, 19.1. African American children whose mothers completed about 12–14 years of education comprise the majority of the study cohort.

Subjects in the control group had significantly higher IQs than did those with OSA, but still not as high as controls enrolled in previous studies of sleep apnea. The mean full-scale IQ among controls was 101, and among children with OSA, 86. Children with a working IQ below 75, a history of seizures or depression, or use of psychotropic medications were not enrolled.

Intriguingly, some of the neuropsychological functions most impacted by sleep apnea in adults were not significantly impaired in children with OSA. These included certain executive functions such as problem solving, planning, inhibitory control, sustained attention, and response preparation.

Motor speed and cerebellar perceptual/motor timing appeared unaffected as well.

When respiratory parameters were assessed, children with OSA had a mean oxygen desaturation time at less than 95% of 70 minutes, compared with 0 for controls. To capture small, brief, intermediate hypoxic events, the oxygen saturation nadir also was studied, and was 75 for children with OSA and 93 for controls, a statistical difference with a significance of 0.0002.

The apnea/hypopnea index showed that children in the study had severe OSA, with a mean score of 29.1 compared with 0.3 for controls.

Researchers conducted two forms of magnetic resonance spectroscopy to attempt to pinpoint any cerebral metabolite changes that might be correlated with respiratory parameters and neuropsychological test results. A global brain assessment was conducted with general magnetic resonance spectroscopy imaging (MRSI) and a single voxel image was used to explore metabolites within the anterior hippocampus on the left side.

Just six children with OSA and six controls have completed these studies.

However, preliminary results identified a “very significant” decline in N-acetyl aspartate/choline (NAA/Cho) ratios and choline/creatine (Cho/Cr) ratios in the hippocampal regions of children with OSA compared with controls.

Both oxygen saturation nadir and oxygen saturation time at less than 95% correlated with brain metabolite dysfunction, IQ deficits, and BMI.

The apnea/hypopnea index correlated with brain metabolite problems, IQ problems, parietal lobe function problems, and BMI; however, the arousal and awake index failed to correlate with brain metabolite dysfunction, IQ, or BMI, “indicating that hypoxemia may be involved in the mechanism of these alterations,” said Dr. Halbower.

Of interest, high BMI correlated with IQ deficits and low neuropsychological scores, but not with brain metabolites.

The issue deserves further study, she said.

More subjects are being enrolled in the current investigation and researchers also are exploring possible reversibility of neurologic deficits with treatment of OSA.

“Obviously, the key question is, 'Can we fix this?'” Dr. Halbower said.

Future studies will include younger and older children to determine whether very young children are prone to OSA and whether there is a particular age of vulnerability to neurologic insults attributable to OSA.

RANCHO MIRAGE, CALIF. – Obstructive sleep apnea in children is associated with profound deficits in IQ, verbal comprehension, perceptual reasoning, and working memory, according to preliminary results of a case-control study at the Pediatric Sleep Disorders Center of Johns Hopkins University, Baltimore.

Ann C. Halbower, M.D., medical director of the center, reported that extensive cognitive deficits and cerebral metabolite alterations were powerfully evident in children from inner city Baltimore who suffered from moderate to severe obstructive sleep apnea (OSA).

Thus far, 17 children aged 7–16 years with OSA and 10 matched controls have completed sleep studies, neuropsychological tests, and magnetic resonance spectroscopy. The average age in both groups is 10.

“Our kids with OSA were severely impacted, their IQ scores being 10 to 15 or more points below normal. We saw huge differences in memory, especially in visual spatial processing, which is a parietal lobe function that has not received a lot of press,” Dr. Halbower said at a conference on sleep in infancy and childhood sponsored by the Annenberg Center for Health Sciences.

Group differences in IQ were mostly explained by sharply defined deficits in working memory, nonverbal reasoning, and verbal comprehension among children with OSA.

Magnetic resonance spectroscopy determined that neuropsychological deficits in the children correlated with hippocampal metabolite alterations, low oxygen saturation, and body mass index (BMI).

The study is ongoing, although Dr. Halbower said she and her team are having trouble finding normal, nonsnoring obese controls who do not have sleep apnea. The average BMI among children with OSA was 29.3 and among controls, 19.1. African American children whose mothers completed about 12–14 years of education comprise the majority of the study cohort.

Subjects in the control group had significantly higher IQs than did those with OSA, but still not as high as controls enrolled in previous studies of sleep apnea. The mean full-scale IQ among controls was 101, and among children with OSA, 86. Children with a working IQ below 75, a history of seizures or depression, or use of psychotropic medications were not enrolled.

Intriguingly, some of the neuropsychological functions most impacted by sleep apnea in adults were not significantly impaired in children with OSA. These included certain executive functions such as problem solving, planning, inhibitory control, sustained attention, and response preparation.

Motor speed and cerebellar perceptual/motor timing appeared unaffected as well.

When respiratory parameters were assessed, children with OSA had a mean oxygen desaturation time at less than 95% of 70 minutes, compared with 0 for controls. To capture small, brief, intermediate hypoxic events, the oxygen saturation nadir also was studied, and was 75 for children with OSA and 93 for controls, a statistical difference with a significance of 0.0002.

The apnea/hypopnea index showed that children in the study had severe OSA, with a mean score of 29.1 compared with 0.3 for controls.

Researchers conducted two forms of magnetic resonance spectroscopy to attempt to pinpoint any cerebral metabolite changes that might be correlated with respiratory parameters and neuropsychological test results. A global brain assessment was conducted with general magnetic resonance spectroscopy imaging (MRSI) and a single voxel image was used to explore metabolites within the anterior hippocampus on the left side.

Just six children with OSA and six controls have completed these studies.

However, preliminary results identified a “very significant” decline in N-acetyl aspartate/choline (NAA/Cho) ratios and choline/creatine (Cho/Cr) ratios in the hippocampal regions of children with OSA compared with controls.

Both oxygen saturation nadir and oxygen saturation time at less than 95% correlated with brain metabolite dysfunction, IQ deficits, and BMI.

The apnea/hypopnea index correlated with brain metabolite problems, IQ problems, parietal lobe function problems, and BMI; however, the arousal and awake index failed to correlate with brain metabolite dysfunction, IQ, or BMI, “indicating that hypoxemia may be involved in the mechanism of these alterations,” said Dr. Halbower.

Of interest, high BMI correlated with IQ deficits and low neuropsychological scores, but not with brain metabolites.

The issue deserves further study, she said.

More subjects are being enrolled in the current investigation and researchers also are exploring possible reversibility of neurologic deficits with treatment of OSA.

“Obviously, the key question is, 'Can we fix this?'” Dr. Halbower said.

Future studies will include younger and older children to determine whether very young children are prone to OSA and whether there is a particular age of vulnerability to neurologic insults attributable to OSA.

RANCHO MIRAGE, CALIF. – Obstructive sleep apnea in children is associated with profound deficits in IQ, verbal comprehension, perceptual reasoning, and working memory, according to preliminary results of a case-control study at the Pediatric Sleep Disorders Center of Johns Hopkins University, Baltimore.

Ann C. Halbower, M.D., medical director of the center, reported that extensive cognitive deficits and cerebral metabolite alterations were powerfully evident in children from inner city Baltimore who suffered from moderate to severe obstructive sleep apnea (OSA).

Thus far, 17 children aged 7–16 years with OSA and 10 matched controls have completed sleep studies, neuropsychological tests, and magnetic resonance spectroscopy. The average age in both groups is 10.

“Our kids with OSA were severely impacted, their IQ scores being 10 to 15 or more points below normal. We saw huge differences in memory, especially in visual spatial processing, which is a parietal lobe function that has not received a lot of press,” Dr. Halbower said at a conference on sleep in infancy and childhood sponsored by the Annenberg Center for Health Sciences.

Group differences in IQ were mostly explained by sharply defined deficits in working memory, nonverbal reasoning, and verbal comprehension among children with OSA.

Magnetic resonance spectroscopy determined that neuropsychological deficits in the children correlated with hippocampal metabolite alterations, low oxygen saturation, and body mass index (BMI).

The study is ongoing, although Dr. Halbower said she and her team are having trouble finding normal, nonsnoring obese controls who do not have sleep apnea. The average BMI among children with OSA was 29.3 and among controls, 19.1. African American children whose mothers completed about 12–14 years of education comprise the majority of the study cohort.

Subjects in the control group had significantly higher IQs than did those with OSA, but still not as high as controls enrolled in previous studies of sleep apnea. The mean full-scale IQ among controls was 101, and among children with OSA, 86. Children with a working IQ below 75, a history of seizures or depression, or use of psychotropic medications were not enrolled.

Intriguingly, some of the neuropsychological functions most impacted by sleep apnea in adults were not significantly impaired in children with OSA. These included certain executive functions such as problem solving, planning, inhibitory control, sustained attention, and response preparation.

Motor speed and cerebellar perceptual/motor timing appeared unaffected as well.

When respiratory parameters were assessed, children with OSA had a mean oxygen desaturation time at less than 95% of 70 minutes, compared with 0 for controls. To capture small, brief, intermediate hypoxic events, the oxygen saturation nadir also was studied, and was 75 for children with OSA and 93 for controls, a statistical difference with a significance of 0.0002.

The apnea/hypopnea index showed that children in the study had severe OSA, with a mean score of 29.1 compared with 0.3 for controls.

Researchers conducted two forms of magnetic resonance spectroscopy to attempt to pinpoint any cerebral metabolite changes that might be correlated with respiratory parameters and neuropsychological test results. A global brain assessment was conducted with general magnetic resonance spectroscopy imaging (MRSI) and a single voxel image was used to explore metabolites within the anterior hippocampus on the left side.

Just six children with OSA and six controls have completed these studies.

However, preliminary results identified a “very significant” decline in N-acetyl aspartate/choline (NAA/Cho) ratios and choline/creatine (Cho/Cr) ratios in the hippocampal regions of children with OSA compared with controls.

Both oxygen saturation nadir and oxygen saturation time at less than 95% correlated with brain metabolite dysfunction, IQ deficits, and BMI.

The apnea/hypopnea index correlated with brain metabolite problems, IQ problems, parietal lobe function problems, and BMI; however, the arousal and awake index failed to correlate with brain metabolite dysfunction, IQ, or BMI, “indicating that hypoxemia may be involved in the mechanism of these alterations,” said Dr. Halbower.

Of interest, high BMI correlated with IQ deficits and low neuropsychological scores, but not with brain metabolites.

The issue deserves further study, she said.

More subjects are being enrolled in the current investigation and researchers also are exploring possible reversibility of neurologic deficits with treatment of OSA.

“Obviously, the key question is, 'Can we fix this?'” Dr. Halbower said.

Future studies will include younger and older children to determine whether very young children are prone to OSA and whether there is a particular age of vulnerability to neurologic insults attributable to OSA.

LOS ANGELES — Mirizzi syndrome is an uncommon cause of bile duct obstruction, but one that it is vital to recognize, David L. Carr-Locke, M.D., said at the 12th International Symposium on Pancreatic and Biliary Endoscopy sponsored by the Cedars-Sinai Medical Center.

That's because the condition requires management quite different from that used for the two conditions it mimics: choledocholithiasis and neoplastic obstruction, said Dr. Carr-Locke, director of endoscopy at Brigham and Women's Hospital, Boston.

As opposed to bile duct obstruction caused by an internal stone, Mirizzi syndrome is defined as duct obstruction due to external compression from a stone or inflammation in the infundibulum of the gallbladder or a cholecystocholedochal fistula, said Dr. Carr-Locke, also of Harvard Medical School, Boston.

Symptoms of the syndrome—named after Argentinian surgeon Pablo Luis Mirizzi—bear a frustrating similarity to symptoms of simple bile duct stones and strictures. Patients may present with abdominal pain, obstructive jaundice, and cholangitis.

“You can't see a patient in your office and say, 'ah, yes, this is Mirizzi syndrome,'” Dr. Carr-Locke said.

Imaging remains the key to detecting Mirizzi syndrome. One clue is anatomic. A short cystic duct, a low origin of the cystic duct, or a cystic duct that runs parallel to the common hepatic duct may predispose to the syndrome, he said.

On the CT scan, an inflammatory mass around the stone may resemble cancer. Magnetic resonance cholangiopancreatography may actually demonstrate extrinsic compression.

More often, though, suspicions arise during endoscopic retrograde cholangiopancreatography, with the appearance of normal pancreatic ducts and what looks like a “rather square, piston-like stone,” at the neck of the gallbladder or “in” the bile duct, Dr. Carr-Locke said.

“When you try to remove it, it will not budge,” he said. “Contrast will not flow all the way around the stone.”

“I would emphasize repeatedly, if the stone doesn't move, there has to be a reason for it,” he added.

In its simplest form, Mirizzi involves extrinsic compression caused by a stone or inflammation originating in the infundibulum of the gallbladder, or, more rarely, in a long cystic duct remnant after cholecystectomy or a mucocele of the cystic duct after liver transplantation. This is known as type I Mirizzi syndrome.

Various classification systems attempt to categorize more complex forms of the syndrome, specifically, stones entwined in cholecystocholedochal fistulas arising from necrosis that can develop along the adjacent walls between the bile duct and gallbladder. Such stones can be lodged partly within the bile duct and partly within the cystic duct or gallbladder.

One system Dr. Carr-Locke considers helpful comes from Chile and categorizes type II Mirizzi syndrome as a cholecystobiliary fistula that involves less than a third of the bile duct circumference at the time of surgery. Type III Mirizzi syndrome involves two-thirds of the bile duct, and type IV indicates complete bile duct destruction (Br. J. Surg. 1989;76:1139–43).

“For many of these patients, the treatment is surgical,” Dr. Carr-Locke said.

It can be quite helpful if an endoscopist can describe the degree of bile duct destruction along the lines of the Chilean classification system because an expert biliary surgeon may need to be recruited for reconstruction of a badly damaged duct.

In any case, the interventional endoscopist's role in treating Mirizzi syndrome is to relieve the obstruction by stenting or draining to stabilize the patient.

Occasionally, it may be possible to fragment the offending stone using direct laser or electrohydraulic lithotripsy in patients awaiting surgery or those who are poor surgery candidates, he noted.

LOS ANGELES — Mirizzi syndrome is an uncommon cause of bile duct obstruction, but one that it is vital to recognize, David L. Carr-Locke, M.D., said at the 12th International Symposium on Pancreatic and Biliary Endoscopy sponsored by the Cedars-Sinai Medical Center.

That's because the condition requires management quite different from that used for the two conditions it mimics: choledocholithiasis and neoplastic obstruction, said Dr. Carr-Locke, director of endoscopy at Brigham and Women's Hospital, Boston.

As opposed to bile duct obstruction caused by an internal stone, Mirizzi syndrome is defined as duct obstruction due to external compression from a stone or inflammation in the infundibulum of the gallbladder or a cholecystocholedochal fistula, said Dr. Carr-Locke, also of Harvard Medical School, Boston.

Symptoms of the syndrome—named after Argentinian surgeon Pablo Luis Mirizzi—bear a frustrating similarity to symptoms of simple bile duct stones and strictures. Patients may present with abdominal pain, obstructive jaundice, and cholangitis.

“You can't see a patient in your office and say, 'ah, yes, this is Mirizzi syndrome,'” Dr. Carr-Locke said.

Imaging remains the key to detecting Mirizzi syndrome. One clue is anatomic. A short cystic duct, a low origin of the cystic duct, or a cystic duct that runs parallel to the common hepatic duct may predispose to the syndrome, he said.

On the CT scan, an inflammatory mass around the stone may resemble cancer. Magnetic resonance cholangiopancreatography may actually demonstrate extrinsic compression.

More often, though, suspicions arise during endoscopic retrograde cholangiopancreatography, with the appearance of normal pancreatic ducts and what looks like a “rather square, piston-like stone,” at the neck of the gallbladder or “in” the bile duct, Dr. Carr-Locke said.

“When you try to remove it, it will not budge,” he said. “Contrast will not flow all the way around the stone.”

“I would emphasize repeatedly, if the stone doesn't move, there has to be a reason for it,” he added.

In its simplest form, Mirizzi involves extrinsic compression caused by a stone or inflammation originating in the infundibulum of the gallbladder, or, more rarely, in a long cystic duct remnant after cholecystectomy or a mucocele of the cystic duct after liver transplantation. This is known as type I Mirizzi syndrome.

Various classification systems attempt to categorize more complex forms of the syndrome, specifically, stones entwined in cholecystocholedochal fistulas arising from necrosis that can develop along the adjacent walls between the bile duct and gallbladder. Such stones can be lodged partly within the bile duct and partly within the cystic duct or gallbladder.

One system Dr. Carr-Locke considers helpful comes from Chile and categorizes type II Mirizzi syndrome as a cholecystobiliary fistula that involves less than a third of the bile duct circumference at the time of surgery. Type III Mirizzi syndrome involves two-thirds of the bile duct, and type IV indicates complete bile duct destruction (Br. J. Surg. 1989;76:1139–43).

“For many of these patients, the treatment is surgical,” Dr. Carr-Locke said.

It can be quite helpful if an endoscopist can describe the degree of bile duct destruction along the lines of the Chilean classification system because an expert biliary surgeon may need to be recruited for reconstruction of a badly damaged duct.

In any case, the interventional endoscopist's role in treating Mirizzi syndrome is to relieve the obstruction by stenting or draining to stabilize the patient.

Occasionally, it may be possible to fragment the offending stone using direct laser or electrohydraulic lithotripsy in patients awaiting surgery or those who are poor surgery candidates, he noted.

LOS ANGELES — Mirizzi syndrome is an uncommon cause of bile duct obstruction, but one that it is vital to recognize, David L. Carr-Locke, M.D., said at the 12th International Symposium on Pancreatic and Biliary Endoscopy sponsored by the Cedars-Sinai Medical Center.

That's because the condition requires management quite different from that used for the two conditions it mimics: choledocholithiasis and neoplastic obstruction, said Dr. Carr-Locke, director of endoscopy at Brigham and Women's Hospital, Boston.

As opposed to bile duct obstruction caused by an internal stone, Mirizzi syndrome is defined as duct obstruction due to external compression from a stone or inflammation in the infundibulum of the gallbladder or a cholecystocholedochal fistula, said Dr. Carr-Locke, also of Harvard Medical School, Boston.

Symptoms of the syndrome—named after Argentinian surgeon Pablo Luis Mirizzi—bear a frustrating similarity to symptoms of simple bile duct stones and strictures. Patients may present with abdominal pain, obstructive jaundice, and cholangitis.

“You can't see a patient in your office and say, 'ah, yes, this is Mirizzi syndrome,'” Dr. Carr-Locke said.

Imaging remains the key to detecting Mirizzi syndrome. One clue is anatomic. A short cystic duct, a low origin of the cystic duct, or a cystic duct that runs parallel to the common hepatic duct may predispose to the syndrome, he said.

On the CT scan, an inflammatory mass around the stone may resemble cancer. Magnetic resonance cholangiopancreatography may actually demonstrate extrinsic compression.

More often, though, suspicions arise during endoscopic retrograde cholangiopancreatography, with the appearance of normal pancreatic ducts and what looks like a “rather square, piston-like stone,” at the neck of the gallbladder or “in” the bile duct, Dr. Carr-Locke said.

“When you try to remove it, it will not budge,” he said. “Contrast will not flow all the way around the stone.”

“I would emphasize repeatedly, if the stone doesn't move, there has to be a reason for it,” he added.

In its simplest form, Mirizzi involves extrinsic compression caused by a stone or inflammation originating in the infundibulum of the gallbladder, or, more rarely, in a long cystic duct remnant after cholecystectomy or a mucocele of the cystic duct after liver transplantation. This is known as type I Mirizzi syndrome.

Various classification systems attempt to categorize more complex forms of the syndrome, specifically, stones entwined in cholecystocholedochal fistulas arising from necrosis that can develop along the adjacent walls between the bile duct and gallbladder. Such stones can be lodged partly within the bile duct and partly within the cystic duct or gallbladder.

One system Dr. Carr-Locke considers helpful comes from Chile and categorizes type II Mirizzi syndrome as a cholecystobiliary fistula that involves less than a third of the bile duct circumference at the time of surgery. Type III Mirizzi syndrome involves two-thirds of the bile duct, and type IV indicates complete bile duct destruction (Br. J. Surg. 1989;76:1139–43).

“For many of these patients, the treatment is surgical,” Dr. Carr-Locke said.

It can be quite helpful if an endoscopist can describe the degree of bile duct destruction along the lines of the Chilean classification system because an expert biliary surgeon may need to be recruited for reconstruction of a badly damaged duct.

In any case, the interventional endoscopist's role in treating Mirizzi syndrome is to relieve the obstruction by stenting or draining to stabilize the patient.

Occasionally, it may be possible to fragment the offending stone using direct laser or electrohydraulic lithotripsy in patients awaiting surgery or those who are poor surgery candidates, he noted.

A potent live zoster vaccine halved the incidence of herpes zoster and reduced its disease burden and complications even more dramatically in a large study of adults aged 60 years and older, said M.N. Oxman, M.D., of the University of California, San Diego, and associates in the Shingles Prevention Study Group.

The investigators reported that an experimental vaccine about 14 times more potent than the Varivax varicella vaccine reduced the burden of illness from herpes zoster by 61.1% and reduced the incidence of postherpetic neuralgia by 66.5% in the older adults studied.

About 1 million cases of herpes zoster occur in the United States annually, causing profound pain and substantial morbidity, especially among patients who go on to develop postherpetic neuralgia, a complication that may last for years.

Older adults, a fast-growing population in the United States, are the population most susceptible to the disease, which is believed to be associated with an age-related decline in cell-mediated immunity to latent varicella-zoster virus (N. Engl. J. Med. 2005;352:2271–80).

A total of 957 confirmed cases of herpes zoster occurred in the 38,546 adults enrolled in the study at 22 Veterans Administration medical center sites: 315 in subjects who received the live-attenuated Oka/Merck VZV virus vaccine and 642 among those who received placebo.

Postherpetic neuralgia was diagnosed in 27 recipients of the vaccine and 80 placebo recipients in the study.

Subjects who received the vaccine and did become ill with herpes zoster over a median surveillance period of just over 3 years had less severe symptoms and had them for a shorter period of time than did those who received placebo.

Adverse reactions to the vaccine were mostly mild, and included erythema, pain and tenderness, and swelling at the injection site. No subjects were hospitalized for any event thought to be related to the vaccine.

In an accompanying editorial, Donald H. Gilden, M.D., called on the Food and Drug Administration to license the vaccine and study patients carefully, rather than subjecting it to a decade of further research in another large, confirmatory trial.

“The results are impressive,” wrote Dr. Gilden, professor and chairman of neurology and professor of microbiology at the University of Colorado Health Sciences Center, Denver, in an editorial (N. Engl. J. Med. 2005;352:2344–8).

“In fact, the high incidence of zoster found in the placebo group in the Shingles Prevention Study points to an urgent need for effective therapy.

“Although oral antiviral therapy shortens the duration of zoster and analgesic medications provide some relief of pain, 'an ounce of prevention'” struck Dr. Gilden as a prudent step, using a vaccine that “appears to be safe and effective clinically.”

A potent live zoster vaccine halved the incidence of herpes zoster and reduced its disease burden and complications even more dramatically in a large study of adults aged 60 years and older, said M.N. Oxman, M.D., of the University of California, San Diego, and associates in the Shingles Prevention Study Group.

The investigators reported that an experimental vaccine about 14 times more potent than the Varivax varicella vaccine reduced the burden of illness from herpes zoster by 61.1% and reduced the incidence of postherpetic neuralgia by 66.5% in the older adults studied.

About 1 million cases of herpes zoster occur in the United States annually, causing profound pain and substantial morbidity, especially among patients who go on to develop postherpetic neuralgia, a complication that may last for years.

Older adults, a fast-growing population in the United States, are the population most susceptible to the disease, which is believed to be associated with an age-related decline in cell-mediated immunity to latent varicella-zoster virus (N. Engl. J. Med. 2005;352:2271–80).

A total of 957 confirmed cases of herpes zoster occurred in the 38,546 adults enrolled in the study at 22 Veterans Administration medical center sites: 315 in subjects who received the live-attenuated Oka/Merck VZV virus vaccine and 642 among those who received placebo.

Postherpetic neuralgia was diagnosed in 27 recipients of the vaccine and 80 placebo recipients in the study.

Subjects who received the vaccine and did become ill with herpes zoster over a median surveillance period of just over 3 years had less severe symptoms and had them for a shorter period of time than did those who received placebo.

Adverse reactions to the vaccine were mostly mild, and included erythema, pain and tenderness, and swelling at the injection site. No subjects were hospitalized for any event thought to be related to the vaccine.

In an accompanying editorial, Donald H. Gilden, M.D., called on the Food and Drug Administration to license the vaccine and study patients carefully, rather than subjecting it to a decade of further research in another large, confirmatory trial.

“The results are impressive,” wrote Dr. Gilden, professor and chairman of neurology and professor of microbiology at the University of Colorado Health Sciences Center, Denver, in an editorial (N. Engl. J. Med. 2005;352:2344–8).

“In fact, the high incidence of zoster found in the placebo group in the Shingles Prevention Study points to an urgent need for effective therapy.

“Although oral antiviral therapy shortens the duration of zoster and analgesic medications provide some relief of pain, 'an ounce of prevention'” struck Dr. Gilden as a prudent step, using a vaccine that “appears to be safe and effective clinically.”

A potent live zoster vaccine halved the incidence of herpes zoster and reduced its disease burden and complications even more dramatically in a large study of adults aged 60 years and older, said M.N. Oxman, M.D., of the University of California, San Diego, and associates in the Shingles Prevention Study Group.

The investigators reported that an experimental vaccine about 14 times more potent than the Varivax varicella vaccine reduced the burden of illness from herpes zoster by 61.1% and reduced the incidence of postherpetic neuralgia by 66.5% in the older adults studied.

About 1 million cases of herpes zoster occur in the United States annually, causing profound pain and substantial morbidity, especially among patients who go on to develop postherpetic neuralgia, a complication that may last for years.

Older adults, a fast-growing population in the United States, are the population most susceptible to the disease, which is believed to be associated with an age-related decline in cell-mediated immunity to latent varicella-zoster virus (N. Engl. J. Med. 2005;352:2271–80).

A total of 957 confirmed cases of herpes zoster occurred in the 38,546 adults enrolled in the study at 22 Veterans Administration medical center sites: 315 in subjects who received the live-attenuated Oka/Merck VZV virus vaccine and 642 among those who received placebo.

Postherpetic neuralgia was diagnosed in 27 recipients of the vaccine and 80 placebo recipients in the study.

Subjects who received the vaccine and did become ill with herpes zoster over a median surveillance period of just over 3 years had less severe symptoms and had them for a shorter period of time than did those who received placebo.

Adverse reactions to the vaccine were mostly mild, and included erythema, pain and tenderness, and swelling at the injection site. No subjects were hospitalized for any event thought to be related to the vaccine.

In an accompanying editorial, Donald H. Gilden, M.D., called on the Food and Drug Administration to license the vaccine and study patients carefully, rather than subjecting it to a decade of further research in another large, confirmatory trial.

“The results are impressive,” wrote Dr. Gilden, professor and chairman of neurology and professor of microbiology at the University of Colorado Health Sciences Center, Denver, in an editorial (N. Engl. J. Med. 2005;352:2344–8).

“In fact, the high incidence of zoster found in the placebo group in the Shingles Prevention Study points to an urgent need for effective therapy.

“Although oral antiviral therapy shortens the duration of zoster and analgesic medications provide some relief of pain, 'an ounce of prevention'” struck Dr. Gilden as a prudent step, using a vaccine that “appears to be safe and effective clinically.”

LOS ANGELES — One in five stethoscopes used by hospital physicians was contaminated with Staphylococcus aureus, including one that harbored methicillin-resistant S. aureus, according to a study presented at the annual meeting of the Society for Healthcare Epidemiology of America.

Cultures taken from stethoscopes also grew Enterococcus species and Enterobacter aerogenes.

Skin flora, including diphtheroids, α-hemolytic streptococci, and coagulase-negative staphylococci, were the most common microorganisms found on 84 randomly tested stethoscopes from house staff, medical students, and attending physicians at Grady Memorial and Emory Crawford Long Hospitals, Atlanta.

The median number of colony-forming units isolated from stethoscopes was 35, with a range of 0–247. The stethoscopes were tested by investigators from Emory University, Atlanta.

“We don't mean to claim stethoscopes are the scourge of civilization, or that they are anywhere near as important in transmitting disease as hand carriage,” James P. Steinberg, M.D., an associate chief of medicine and hospital epidemiologist, said in an interview. “But they can be colonized.”

In a related survey of stethoscope users, 10 said they cleaned their stethoscopes between patients. Another 35 cleaned them daily, 30 did so weekly, 7 cleaned them monthly, and 2 never cleaned them.

When 24 of the stethoscopes were wiped with an alcohol pad as part of the study, the median number of colony-forming units plummeted to 0, with a range of 0–59.

However, because there is no “smoking gun” linking contaminated stethoscopes with disease, Dr. Steinberg said it seems excessive to recommend that all health professionals clean their stethoscopes with alcohol wipes before and after every patient contact.

Use of alcohol hand rubs, on the other hand, is already routinely recommended before and after patient contacts, so Dr. Steinberg and associates set out to determine whether a quick rub of the stethoscope might suffice.

Indeed it did.

Among 60 stethoscopes with a median of 33.5 colony-forming units at baseline (range, 1–247), the median colony-forming units dropped to 4 (range, 0–60) after the stethoscopes were swiped with an alcohol hand rub.

“Combining stethoscope 'rubbing' with routine hand hygiene provides a practical and effective method of stethoscope disinfection that could be incorporated into routine bedside practice,” Dr. Steinberg's poster presentation concluded.

LOS ANGELES — One in five stethoscopes used by hospital physicians was contaminated with Staphylococcus aureus, including one that harbored methicillin-resistant S. aureus, according to a study presented at the annual meeting of the Society for Healthcare Epidemiology of America.

Cultures taken from stethoscopes also grew Enterococcus species and Enterobacter aerogenes.

Skin flora, including diphtheroids, α-hemolytic streptococci, and coagulase-negative staphylococci, were the most common microorganisms found on 84 randomly tested stethoscopes from house staff, medical students, and attending physicians at Grady Memorial and Emory Crawford Long Hospitals, Atlanta.

The median number of colony-forming units isolated from stethoscopes was 35, with a range of 0–247. The stethoscopes were tested by investigators from Emory University, Atlanta.

“We don't mean to claim stethoscopes are the scourge of civilization, or that they are anywhere near as important in transmitting disease as hand carriage,” James P. Steinberg, M.D., an associate chief of medicine and hospital epidemiologist, said in an interview. “But they can be colonized.”

In a related survey of stethoscope users, 10 said they cleaned their stethoscopes between patients. Another 35 cleaned them daily, 30 did so weekly, 7 cleaned them monthly, and 2 never cleaned them.

When 24 of the stethoscopes were wiped with an alcohol pad as part of the study, the median number of colony-forming units plummeted to 0, with a range of 0–59.

However, because there is no “smoking gun” linking contaminated stethoscopes with disease, Dr. Steinberg said it seems excessive to recommend that all health professionals clean their stethoscopes with alcohol wipes before and after every patient contact.

Use of alcohol hand rubs, on the other hand, is already routinely recommended before and after patient contacts, so Dr. Steinberg and associates set out to determine whether a quick rub of the stethoscope might suffice.

Indeed it did.

Among 60 stethoscopes with a median of 33.5 colony-forming units at baseline (range, 1–247), the median colony-forming units dropped to 4 (range, 0–60) after the stethoscopes were swiped with an alcohol hand rub.

“Combining stethoscope 'rubbing' with routine hand hygiene provides a practical and effective method of stethoscope disinfection that could be incorporated into routine bedside practice,” Dr. Steinberg's poster presentation concluded.

LOS ANGELES — One in five stethoscopes used by hospital physicians was contaminated with Staphylococcus aureus, including one that harbored methicillin-resistant S. aureus, according to a study presented at the annual meeting of the Society for Healthcare Epidemiology of America.

Cultures taken from stethoscopes also grew Enterococcus species and Enterobacter aerogenes.

Skin flora, including diphtheroids, α-hemolytic streptococci, and coagulase-negative staphylococci, were the most common microorganisms found on 84 randomly tested stethoscopes from house staff, medical students, and attending physicians at Grady Memorial and Emory Crawford Long Hospitals, Atlanta.

The median number of colony-forming units isolated from stethoscopes was 35, with a range of 0–247. The stethoscopes were tested by investigators from Emory University, Atlanta.

“We don't mean to claim stethoscopes are the scourge of civilization, or that they are anywhere near as important in transmitting disease as hand carriage,” James P. Steinberg, M.D., an associate chief of medicine and hospital epidemiologist, said in an interview. “But they can be colonized.”

In a related survey of stethoscope users, 10 said they cleaned their stethoscopes between patients. Another 35 cleaned them daily, 30 did so weekly, 7 cleaned them monthly, and 2 never cleaned them.

When 24 of the stethoscopes were wiped with an alcohol pad as part of the study, the median number of colony-forming units plummeted to 0, with a range of 0–59.

However, because there is no “smoking gun” linking contaminated stethoscopes with disease, Dr. Steinberg said it seems excessive to recommend that all health professionals clean their stethoscopes with alcohol wipes before and after every patient contact.

Use of alcohol hand rubs, on the other hand, is already routinely recommended before and after patient contacts, so Dr. Steinberg and associates set out to determine whether a quick rub of the stethoscope might suffice.

Indeed it did.

Among 60 stethoscopes with a median of 33.5 colony-forming units at baseline (range, 1–247), the median colony-forming units dropped to 4 (range, 0–60) after the stethoscopes were swiped with an alcohol hand rub.

“Combining stethoscope 'rubbing' with routine hand hygiene provides a practical and effective method of stethoscope disinfection that could be incorporated into routine bedside practice,” Dr. Steinberg's poster presentation concluded.

PALM DESERT, CALF. — Obstetricians, emergency physicians, and anesthesiologists may suffer significant knowledge gaps when it comes to resuscitation of women in labor, suggest survey results presented in poster form at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

Faculty and residents in all three groups of specialists at Stanford (Calif.) University responded to an 11-question anonymous survey covering four critical knowledge areas concerning resuscitation after catastrophic events in labor that lead to cardiorespiratory arrest:

▸ Awareness of the need for left uterine displacement.

▸ Recall of specific standard advanced cardiac life support (ACLS) algorithms.

▸ Knowledge of pertinent maternal physiology.

▸ Awareness of the recommendation to perform C-section in women at more than 20 weeks' gestation after 5 minutes of unsuccessful resuscitation for cardiac arrest.

Among 74 respondents, anesthesiologists answered the most questions correctly (average 76%). They were also better informed than other specialists about relevant maternal physiology.

Emergency physicians scored highest on questions regarding ACLS algorithms, averaging 93% correct responses.

All three groups earned similar scores on questions relating to left uterine displacement during resuscitation and the 5-minute cesarean rule. However, the rate of correct responses to those questions was low, at 60%–75%, said Leslie C. Andes, M.D., of the Stanford department of anesthesiology, and her associates.

They recommended that residents in all three specialties be required to complete ACLS certification, with an emphasis on the special resuscitation needs of women in labor. Labor and delivery suites are not the only places in a hospital where pregnant women may need to be resuscitated, the investigators noted in the poster.

PALM DESERT, CALF. — Obstetricians, emergency physicians, and anesthesiologists may suffer significant knowledge gaps when it comes to resuscitation of women in labor, suggest survey results presented in poster form at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

Faculty and residents in all three groups of specialists at Stanford (Calif.) University responded to an 11-question anonymous survey covering four critical knowledge areas concerning resuscitation after catastrophic events in labor that lead to cardiorespiratory arrest:

▸ Awareness of the need for left uterine displacement.

▸ Recall of specific standard advanced cardiac life support (ACLS) algorithms.

▸ Knowledge of pertinent maternal physiology.

▸ Awareness of the recommendation to perform C-section in women at more than 20 weeks' gestation after 5 minutes of unsuccessful resuscitation for cardiac arrest.

Among 74 respondents, anesthesiologists answered the most questions correctly (average 76%). They were also better informed than other specialists about relevant maternal physiology.

Emergency physicians scored highest on questions regarding ACLS algorithms, averaging 93% correct responses.

All three groups earned similar scores on questions relating to left uterine displacement during resuscitation and the 5-minute cesarean rule. However, the rate of correct responses to those questions was low, at 60%–75%, said Leslie C. Andes, M.D., of the Stanford department of anesthesiology, and her associates.

They recommended that residents in all three specialties be required to complete ACLS certification, with an emphasis on the special resuscitation needs of women in labor. Labor and delivery suites are not the only places in a hospital where pregnant women may need to be resuscitated, the investigators noted in the poster.

PALM DESERT, CALF. — Obstetricians, emergency physicians, and anesthesiologists may suffer significant knowledge gaps when it comes to resuscitation of women in labor, suggest survey results presented in poster form at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

Faculty and residents in all three groups of specialists at Stanford (Calif.) University responded to an 11-question anonymous survey covering four critical knowledge areas concerning resuscitation after catastrophic events in labor that lead to cardiorespiratory arrest:

▸ Awareness of the need for left uterine displacement.

▸ Recall of specific standard advanced cardiac life support (ACLS) algorithms.

▸ Knowledge of pertinent maternal physiology.

▸ Awareness of the recommendation to perform C-section in women at more than 20 weeks' gestation after 5 minutes of unsuccessful resuscitation for cardiac arrest.

Among 74 respondents, anesthesiologists answered the most questions correctly (average 76%). They were also better informed than other specialists about relevant maternal physiology.

Emergency physicians scored highest on questions regarding ACLS algorithms, averaging 93% correct responses.

All three groups earned similar scores on questions relating to left uterine displacement during resuscitation and the 5-minute cesarean rule. However, the rate of correct responses to those questions was low, at 60%–75%, said Leslie C. Andes, M.D., of the Stanford department of anesthesiology, and her associates.

They recommended that residents in all three specialties be required to complete ACLS certification, with an emphasis on the special resuscitation needs of women in labor. Labor and delivery suites are not the only places in a hospital where pregnant women may need to be resuscitated, the investigators noted in the poster.

LOS ANGELES — Computer keyboards and keyboard covers harbored vancomycin-resistant Enterococcus faecium and methicillin-resistant Staphylococcus aureus for more than 24 hours, during which time the bacteria easily spread to bare, and in some cases, gloved hands, a Northwestern University study has found.

The findings strongly suggest the need for health care providers to wash their hands after using computers, particularly in hospital settings and around immunocompromised patients, said Gary A. Noskin, M.D., an infectious disease specialist at Northwestern University and director of health care epidemiology and quality at Northwestern Memorial Hospital in Chicago.

Electronic patient records have ushered more computers into examining and patient rooms, heightening the importance of their role as a “viable reservoir for pathogenic bacteria,” in the words of the study presented in poster form at the annual meeting of the Society for Healthcare Epidemiology of America.

Investigators inoculated a number of standard computer keyboards and Dell computer keyboard covers with isolates of vancomycin-resistant E. faecium (VRE), methicillin-resistant S. aureus (MRSA), and Pseudomonas aeruginosa (PSAE).

Samples obtained at various time intervals determined that both VRE and MRSA survived for 24 hours, while PSAE was less hardy, growing for 5 minutes on computer keyboard covers and 1 hour on computer keyboards.

Bacteria transmission to volunteers' hands increased with the number of times they touched the computer keyboards.

For example, MRSA resulted in recovery of bacteria on hands 92% of the time with 5 touches, versus 42% of the time after 1 touch of the computer keyboard.

Rates for VRE were 50% and 22% after 5 touches and 1 touch, and with PSAE, 18% and 9%, respectively.

Bare hands were more likely than were gloved hands to acquire VRE and MRSA, 67% versus 7%, and 80% versus 67%, respectively.

Investigators then conducted an experiment to see whether two quaternary ammonium-based germicides commonly used in health care settings could eliminate bacterial contamination on keyboards and keyboard covers.

Virex II 256 (Johnson Wax Professional, Sturtevant, Wisc.), when used as directed with a 10-minute dwell time, successfully disinfected both keyboards and keyboard covers.

Sani-Wipes (PDI, Upper Saddle River, N.J.), when used as directed and allowed a 5-minute dwell time, disinfected computer keyboards but failed to eliminate VRE and PSAE on computer keyboard covers.

Dr. Noskin and his associates recommended hand washing after contact with computers.

It is unknown how keyboards and keyboard covers should be disinfected, since there are “just no data” on how frequent germicide use might impact their durability, circuitry, and electronics, he said in a telephone interview following the meeting.

“On a practical level, keyboards and other environmental surfaces are never going to be sterile, so it's just very important for health care workers to wash their hands so the contamination is less relevant,” he said.

No industry funding was used for the study.

LOS ANGELES — Computer keyboards and keyboard covers harbored vancomycin-resistant Enterococcus faecium and methicillin-resistant Staphylococcus aureus for more than 24 hours, during which time the bacteria easily spread to bare, and in some cases, gloved hands, a Northwestern University study has found.

The findings strongly suggest the need for health care providers to wash their hands after using computers, particularly in hospital settings and around immunocompromised patients, said Gary A. Noskin, M.D., an infectious disease specialist at Northwestern University and director of health care epidemiology and quality at Northwestern Memorial Hospital in Chicago.

Electronic patient records have ushered more computers into examining and patient rooms, heightening the importance of their role as a “viable reservoir for pathogenic bacteria,” in the words of the study presented in poster form at the annual meeting of the Society for Healthcare Epidemiology of America.

Investigators inoculated a number of standard computer keyboards and Dell computer keyboard covers with isolates of vancomycin-resistant E. faecium (VRE), methicillin-resistant S. aureus (MRSA), and Pseudomonas aeruginosa (PSAE).

Samples obtained at various time intervals determined that both VRE and MRSA survived for 24 hours, while PSAE was less hardy, growing for 5 minutes on computer keyboard covers and 1 hour on computer keyboards.

Bacteria transmission to volunteers' hands increased with the number of times they touched the computer keyboards.

For example, MRSA resulted in recovery of bacteria on hands 92% of the time with 5 touches, versus 42% of the time after 1 touch of the computer keyboard.

Rates for VRE were 50% and 22% after 5 touches and 1 touch, and with PSAE, 18% and 9%, respectively.

Bare hands were more likely than were gloved hands to acquire VRE and MRSA, 67% versus 7%, and 80% versus 67%, respectively.

Investigators then conducted an experiment to see whether two quaternary ammonium-based germicides commonly used in health care settings could eliminate bacterial contamination on keyboards and keyboard covers.

Virex II 256 (Johnson Wax Professional, Sturtevant, Wisc.), when used as directed with a 10-minute dwell time, successfully disinfected both keyboards and keyboard covers.

Sani-Wipes (PDI, Upper Saddle River, N.J.), when used as directed and allowed a 5-minute dwell time, disinfected computer keyboards but failed to eliminate VRE and PSAE on computer keyboard covers.

Dr. Noskin and his associates recommended hand washing after contact with computers.

It is unknown how keyboards and keyboard covers should be disinfected, since there are “just no data” on how frequent germicide use might impact their durability, circuitry, and electronics, he said in a telephone interview following the meeting.

“On a practical level, keyboards and other environmental surfaces are never going to be sterile, so it's just very important for health care workers to wash their hands so the contamination is less relevant,” he said.

No industry funding was used for the study.

LOS ANGELES — Computer keyboards and keyboard covers harbored vancomycin-resistant Enterococcus faecium and methicillin-resistant Staphylococcus aureus for more than 24 hours, during which time the bacteria easily spread to bare, and in some cases, gloved hands, a Northwestern University study has found.

The findings strongly suggest the need for health care providers to wash their hands after using computers, particularly in hospital settings and around immunocompromised patients, said Gary A. Noskin, M.D., an infectious disease specialist at Northwestern University and director of health care epidemiology and quality at Northwestern Memorial Hospital in Chicago.

Electronic patient records have ushered more computers into examining and patient rooms, heightening the importance of their role as a “viable reservoir for pathogenic bacteria,” in the words of the study presented in poster form at the annual meeting of the Society for Healthcare Epidemiology of America.

Investigators inoculated a number of standard computer keyboards and Dell computer keyboard covers with isolates of vancomycin-resistant E. faecium (VRE), methicillin-resistant S. aureus (MRSA), and Pseudomonas aeruginosa (PSAE).

Samples obtained at various time intervals determined that both VRE and MRSA survived for 24 hours, while PSAE was less hardy, growing for 5 minutes on computer keyboard covers and 1 hour on computer keyboards.

Bacteria transmission to volunteers' hands increased with the number of times they touched the computer keyboards.

For example, MRSA resulted in recovery of bacteria on hands 92% of the time with 5 touches, versus 42% of the time after 1 touch of the computer keyboard.

Rates for VRE were 50% and 22% after 5 touches and 1 touch, and with PSAE, 18% and 9%, respectively.

Bare hands were more likely than were gloved hands to acquire VRE and MRSA, 67% versus 7%, and 80% versus 67%, respectively.

Investigators then conducted an experiment to see whether two quaternary ammonium-based germicides commonly used in health care settings could eliminate bacterial contamination on keyboards and keyboard covers.

Virex II 256 (Johnson Wax Professional, Sturtevant, Wisc.), when used as directed with a 10-minute dwell time, successfully disinfected both keyboards and keyboard covers.

Sani-Wipes (PDI, Upper Saddle River, N.J.), when used as directed and allowed a 5-minute dwell time, disinfected computer keyboards but failed to eliminate VRE and PSAE on computer keyboard covers.

Dr. Noskin and his associates recommended hand washing after contact with computers.

It is unknown how keyboards and keyboard covers should be disinfected, since there are “just no data” on how frequent germicide use might impact their durability, circuitry, and electronics, he said in a telephone interview following the meeting.

“On a practical level, keyboards and other environmental surfaces are never going to be sterile, so it's just very important for health care workers to wash their hands so the contamination is less relevant,” he said.

No industry funding was used for the study.

Depression strikes one in five patients hospitalized for myocardial infarction, with severe consequences, including a threefold increased risk of cardiac mortality and significantly elevated mortality from all causes, a comprehensive evidence review has concluded.

The review, conducted by the federal Agency for Healthcare Research and Quality at the behest of the American Academy of Family Physicians, is destined to become the framework for evidence-based clinical practice guidelines, according to the AAFP.

Highlights of the review coordinated by the Johns Hopkins Evidence-Based Practice Center in Baltimore include:

▸ Evidence from 25 trials pointing to a prevalence of depression in one in five patients hospitalized for an MI.

▸ Data from three studies that depression during the initial MI hospitalization persists from 1–4 months in 60%–70% of patients.

▸ “Strikingly consistent” evidence that post-MI depression puts patients at an increased risk for death by cardiac causes (a threefold increased risk) and other causes.

▸ Conclusions from three studies showing that depressed post-MI patients are less likely than are others to take their prescribed medications or to comply with lifestyle modification.

▸ Findings that suggest psychosocial intervention and selective serotonin reuptake inhibitors (SSRIs) improve depression in post-MI patients, but not necessarily other outcomes.

The lengthy analysis pointed out a number of important gaps in scientific knowledge about depression and MI, such as the best way to measure depression in hospitalized MI patients and the true impact of interventions.

For example, SSRIs were found to improve some surrogate markers of cardiac risk, “but no studies of sufficient power address the question of whether this treatment improves survival,” the analysis said.

The Johns Hopkins team, led by David E. Bush, M.D., and Roy C. Ziegelstein, M.D., included clinicians and researchers from cardiology, psychiatry, general internal medicine, and cardiac rehabilitation, as well as representatives from the AAFP, the nursing community, and private and government payers.

Six key questions were compiled, several with important subcategories. A literature review was conducted electronically and by hand of 16 specific journals and the electronic databases Medline, Cochrane Central Register of Controlled Trials, the Cochrane Database of Methodology Reviews, the Cumulative Index to Nursing and Allied Health Literature, the Psychological Abstracts, and Embase.

The intensive review unveiled the magnitude of evidence pointing to depression as an important impedance to a full recovery and a return to productive life in many MI patients.

Its conclusions suggest a pivotal role for family physicians, who may be in the best position to oversee “the whole patient” as he or she embarks on the long course of recovery, Lee A. Green, M.D., the AAFP representative to the review panel and a member of the family medicine faculty at the University of Michigan in Ann Arbor, said in a telephone interview.

Patients can survive heart attacks and their hearts can be fine, but they can be disabled by their depression, he said.

The severity of an MI may overshadow less evident aspects of health that should be identified early and managed with the best tools available.

Although the literature review shows that more research is needed to illuminate the best approaches to post-MI depression, it provides ample evidence of the worth of such research.

In the immediate future, the stark findings about the importance of depression following MI may lead to more communication among specialists, including family physicians, cardiologists, and psychiatrists, said Dr. Green.

Depression strikes one in five patients hospitalized for myocardial infarction, with severe consequences, including a threefold increased risk of cardiac mortality and significantly elevated mortality from all causes, a comprehensive evidence review has concluded.

The review, conducted by the federal Agency for Healthcare Research and Quality at the behest of the American Academy of Family Physicians, is destined to become the framework for evidence-based clinical practice guidelines, according to the AAFP.

Highlights of the review coordinated by the Johns Hopkins Evidence-Based Practice Center in Baltimore include:

▸ Evidence from 25 trials pointing to a prevalence of depression in one in five patients hospitalized for an MI.

▸ Data from three studies that depression during the initial MI hospitalization persists from 1–4 months in 60%–70% of patients.

▸ “Strikingly consistent” evidence that post-MI depression puts patients at an increased risk for death by cardiac causes (a threefold increased risk) and other causes.

▸ Conclusions from three studies showing that depressed post-MI patients are less likely than are others to take their prescribed medications or to comply with lifestyle modification.

▸ Findings that suggest psychosocial intervention and selective serotonin reuptake inhibitors (SSRIs) improve depression in post-MI patients, but not necessarily other outcomes.

The lengthy analysis pointed out a number of important gaps in scientific knowledge about depression and MI, such as the best way to measure depression in hospitalized MI patients and the true impact of interventions.

For example, SSRIs were found to improve some surrogate markers of cardiac risk, “but no studies of sufficient power address the question of whether this treatment improves survival,” the analysis said.

The Johns Hopkins team, led by David E. Bush, M.D., and Roy C. Ziegelstein, M.D., included clinicians and researchers from cardiology, psychiatry, general internal medicine, and cardiac rehabilitation, as well as representatives from the AAFP, the nursing community, and private and government payers.

Six key questions were compiled, several with important subcategories. A literature review was conducted electronically and by hand of 16 specific journals and the electronic databases Medline, Cochrane Central Register of Controlled Trials, the Cochrane Database of Methodology Reviews, the Cumulative Index to Nursing and Allied Health Literature, the Psychological Abstracts, and Embase.

The intensive review unveiled the magnitude of evidence pointing to depression as an important impedance to a full recovery and a return to productive life in many MI patients.

Its conclusions suggest a pivotal role for family physicians, who may be in the best position to oversee “the whole patient” as he or she embarks on the long course of recovery, Lee A. Green, M.D., the AAFP representative to the review panel and a member of the family medicine faculty at the University of Michigan in Ann Arbor, said in a telephone interview.

Patients can survive heart attacks and their hearts can be fine, but they can be disabled by their depression, he said.

The severity of an MI may overshadow less evident aspects of health that should be identified early and managed with the best tools available.

Although the literature review shows that more research is needed to illuminate the best approaches to post-MI depression, it provides ample evidence of the worth of such research.

In the immediate future, the stark findings about the importance of depression following MI may lead to more communication among specialists, including family physicians, cardiologists, and psychiatrists, said Dr. Green.

Depression strikes one in five patients hospitalized for myocardial infarction, with severe consequences, including a threefold increased risk of cardiac mortality and significantly elevated mortality from all causes, a comprehensive evidence review has concluded.

The review, conducted by the federal Agency for Healthcare Research and Quality at the behest of the American Academy of Family Physicians, is destined to become the framework for evidence-based clinical practice guidelines, according to the AAFP.

Highlights of the review coordinated by the Johns Hopkins Evidence-Based Practice Center in Baltimore include:

▸ Evidence from 25 trials pointing to a prevalence of depression in one in five patients hospitalized for an MI.

▸ Data from three studies that depression during the initial MI hospitalization persists from 1–4 months in 60%–70% of patients.

▸ “Strikingly consistent” evidence that post-MI depression puts patients at an increased risk for death by cardiac causes (a threefold increased risk) and other causes.

▸ Conclusions from three studies showing that depressed post-MI patients are less likely than are others to take their prescribed medications or to comply with lifestyle modification.

▸ Findings that suggest psychosocial intervention and selective serotonin reuptake inhibitors (SSRIs) improve depression in post-MI patients, but not necessarily other outcomes.

The lengthy analysis pointed out a number of important gaps in scientific knowledge about depression and MI, such as the best way to measure depression in hospitalized MI patients and the true impact of interventions.

For example, SSRIs were found to improve some surrogate markers of cardiac risk, “but no studies of sufficient power address the question of whether this treatment improves survival,” the analysis said.

The Johns Hopkins team, led by David E. Bush, M.D., and Roy C. Ziegelstein, M.D., included clinicians and researchers from cardiology, psychiatry, general internal medicine, and cardiac rehabilitation, as well as representatives from the AAFP, the nursing community, and private and government payers.

Six key questions were compiled, several with important subcategories. A literature review was conducted electronically and by hand of 16 specific journals and the electronic databases Medline, Cochrane Central Register of Controlled Trials, the Cochrane Database of Methodology Reviews, the Cumulative Index to Nursing and Allied Health Literature, the Psychological Abstracts, and Embase.

The intensive review unveiled the magnitude of evidence pointing to depression as an important impedance to a full recovery and a return to productive life in many MI patients.

Its conclusions suggest a pivotal role for family physicians, who may be in the best position to oversee “the whole patient” as he or she embarks on the long course of recovery, Lee A. Green, M.D., the AAFP representative to the review panel and a member of the family medicine faculty at the University of Michigan in Ann Arbor, said in a telephone interview.

Patients can survive heart attacks and their hearts can be fine, but they can be disabled by their depression, he said.

The severity of an MI may overshadow less evident aspects of health that should be identified early and managed with the best tools available.

Although the literature review shows that more research is needed to illuminate the best approaches to post-MI depression, it provides ample evidence of the worth of such research.

In the immediate future, the stark findings about the importance of depression following MI may lead to more communication among specialists, including family physicians, cardiologists, and psychiatrists, said Dr. Green.

PALM SPRINGS, CALIF. – Just 45% of prescriptions for the opiate OxyContin (oxycodone HCl controlled release) are taken as directed by patients being treated for nonmalignant pain, according to a study of urine samples from approximately 5% of the nation's outpatient pain clinics.

Fully 40% of the drug was recycled among other patients being treated for pain in 264 clinics whose combined caseloads exceeded 33,000 patients, Michael Kell, M.D., of the Labyrinth Institute of Smyrna, Ga., reported at the annual meeting of the American Academy of Pain Medicine.

Another 15% of OxyContin prescriptions were diverted to the black market, said Dr. Kell, who was chosen to present his poster in an oral format at the meeting. Dr. Kell, a toxicologist, collected his data using software technology that interprets highly specific urinalysis results that control for urine concentration and acidity and patient body mass index (BMI).

The urine from 55% of approximately 11,000 patients prescribed OxyContin either contained more of the drug, or less, than what would be expected based on the amount prescribed to them. To allow for time of day and other variations, Dr. Kell considered a patient compliant if the level of OxyContin in his or her urine was within three standard deviations of the mean. Interestingly, about 15% of patients prescribed OxyContin had none of the drug in their urine.

At the same time, many patients being treated with alternative pain drugs in the clinics had OxyContin in their urine, suggesting that “most of the diversion was patient to patient,” Dr. Kell said.

“There is an incredible amount of diversion on the street [as well]. We tend to be in denial,” he added.

Funding for Dr. Kell's study was provided by UD Testing Inc., a Marco Island, Fla., company that uses Dr. Kell's software to monitor patient compliance with prescription medicine.

Another study presented at the meeting described very preliminary results from a novel oxycodone drug formulation called Remoxy. The formulation delivers a long-acting dose of the opiate in a gel cap designed to be impervious to efforts to extract the full dose to achieve a “spike” effect by crushing, freezing, heating, or dissolving it in various substances.

Current formulations of the drug can be manipulated in this way, adding to abuse and diversion.

Plasma concentrations were markedly lower in 20 subjects who took Remoxy after it had been tampered with, compared with concentrations among people who had taken crushed controlled-release formulations of oxycodone.

PALM SPRINGS, CALIF. – Just 45% of prescriptions for the opiate OxyContin (oxycodone HCl controlled release) are taken as directed by patients being treated for nonmalignant pain, according to a study of urine samples from approximately 5% of the nation's outpatient pain clinics.

Fully 40% of the drug was recycled among other patients being treated for pain in 264 clinics whose combined caseloads exceeded 33,000 patients, Michael Kell, M.D., of the Labyrinth Institute of Smyrna, Ga., reported at the annual meeting of the American Academy of Pain Medicine.

Another 15% of OxyContin prescriptions were diverted to the black market, said Dr. Kell, who was chosen to present his poster in an oral format at the meeting. Dr. Kell, a toxicologist, collected his data using software technology that interprets highly specific urinalysis results that control for urine concentration and acidity and patient body mass index (BMI).

The urine from 55% of approximately 11,000 patients prescribed OxyContin either contained more of the drug, or less, than what would be expected based on the amount prescribed to them. To allow for time of day and other variations, Dr. Kell considered a patient compliant if the level of OxyContin in his or her urine was within three standard deviations of the mean. Interestingly, about 15% of patients prescribed OxyContin had none of the drug in their urine.

At the same time, many patients being treated with alternative pain drugs in the clinics had OxyContin in their urine, suggesting that “most of the diversion was patient to patient,” Dr. Kell said.

“There is an incredible amount of diversion on the street [as well]. We tend to be in denial,” he added.

Funding for Dr. Kell's study was provided by UD Testing Inc., a Marco Island, Fla., company that uses Dr. Kell's software to monitor patient compliance with prescription medicine.

Another study presented at the meeting described very preliminary results from a novel oxycodone drug formulation called Remoxy. The formulation delivers a long-acting dose of the opiate in a gel cap designed to be impervious to efforts to extract the full dose to achieve a “spike” effect by crushing, freezing, heating, or dissolving it in various substances.

Current formulations of the drug can be manipulated in this way, adding to abuse and diversion.

Plasma concentrations were markedly lower in 20 subjects who took Remoxy after it had been tampered with, compared with concentrations among people who had taken crushed controlled-release formulations of oxycodone.

PALM SPRINGS, CALIF. – Just 45% of prescriptions for the opiate OxyContin (oxycodone HCl controlled release) are taken as directed by patients being treated for nonmalignant pain, according to a study of urine samples from approximately 5% of the nation's outpatient pain clinics.

Fully 40% of the drug was recycled among other patients being treated for pain in 264 clinics whose combined caseloads exceeded 33,000 patients, Michael Kell, M.D., of the Labyrinth Institute of Smyrna, Ga., reported at the annual meeting of the American Academy of Pain Medicine.

Another 15% of OxyContin prescriptions were diverted to the black market, said Dr. Kell, who was chosen to present his poster in an oral format at the meeting. Dr. Kell, a toxicologist, collected his data using software technology that interprets highly specific urinalysis results that control for urine concentration and acidity and patient body mass index (BMI).

The urine from 55% of approximately 11,000 patients prescribed OxyContin either contained more of the drug, or less, than what would be expected based on the amount prescribed to them. To allow for time of day and other variations, Dr. Kell considered a patient compliant if the level of OxyContin in his or her urine was within three standard deviations of the mean. Interestingly, about 15% of patients prescribed OxyContin had none of the drug in their urine.

At the same time, many patients being treated with alternative pain drugs in the clinics had OxyContin in their urine, suggesting that “most of the diversion was patient to patient,” Dr. Kell said.

“There is an incredible amount of diversion on the street [as well]. We tend to be in denial,” he added.

Funding for Dr. Kell's study was provided by UD Testing Inc., a Marco Island, Fla., company that uses Dr. Kell's software to monitor patient compliance with prescription medicine.

Another study presented at the meeting described very preliminary results from a novel oxycodone drug formulation called Remoxy. The formulation delivers a long-acting dose of the opiate in a gel cap designed to be impervious to efforts to extract the full dose to achieve a “spike” effect by crushing, freezing, heating, or dissolving it in various substances.

Current formulations of the drug can be manipulated in this way, adding to abuse and diversion.

Plasma concentrations were markedly lower in 20 subjects who took Remoxy after it had been tampered with, compared with concentrations among people who had taken crushed controlled-release formulations of oxycodone.

PALM DESERT, CALIF. — The degree to which women expected postoperative pain was highly correlated with actual postcesarean section pain scores, James C. Eisenach, M.D., reported at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

He and his associates prospectively studied 31 healthy women scheduled for elective C-section. They conducted psychological and pain studies from 1 to 10 days before surgery and then monitored pain scores and analgesia use after surgery.

Preoperative testing included ratings of unpleasantness and pain during a 5-second application of heat stimuli to the forearm and lower back; administration of a state anxiety and trait anxiety questionnaire; and questions about how much pain the women expected to experience postoperatively and whether they expected to require pain medication.

State anxiety reflects one's self-assessment tension associated with a specific experience, while trait anxiety reflects one's assessment of how much he or she is generally prone to anxiety.

“What we see is what everyone sees. That is, there is a tremendous variability in pain scores at rest and with movement 24 hours after C-section,” said Dr. Eisenach, professor of anesthesiology and vice chair of research at Wake Forest University, Winston-Salem, N.C.

Pain scores indeed varied widely even though all patients received spinal anesthesia, nurse-administered intravenous opioids in the recovery room, and patient-controlled intravenous analgesia once they left the recovery room.

The subjects rated overall postoperative pain from 0.5 to 9.5 on a 10-point visual analog scale. Average pain at rest scores ranged from 0 to 7 and pain with movement from 0.2 to 9.2; morphine use in the first 10 postoperative hours ranged from 0 to 81 mg. Positive associations varied depending on the type of pain assessed.

Regression analysis identified three variables associated with postoperative pain at rest: trait anxiety, expected postoperative pain, and the sensory level at the time the incision was made.

Movement pain was associated with results of suprathreshold pain testing on the forearm (but not the lower back), state anxiety, expected pain, and the duration of surgery.

Analgesic drug use was associated with pain threshold in the forearm test, trait anxiety, expected pain, and the duration of surgery. Only expected pain was associated with all postoperative pain measures.

Dr. Eisenach theorized that duration of surgery was related to the degree of adhesions that were present from previous C-sections, since all of the procedures were performed by experienced obstetricians from a private obstetric practice in Winston-Salem.

A number of intriguing findings emerged, beyond associations with specific measures of pain.

As part of the work-up before the surgery, women were asked to listen to tones of different decibels, and these test results were compared with their scores on a visual analog pain scale during the application of a heated stimulus on the forearm and lower back. There was a high degree of correlation, Dr. Eisenach said.

He also found that women at term do not have the same type of responses to pain stimuli as men or nonpregnant women. Term women have an initially intense response to increasing temperatures, but then a marked decline in the degree of response even as temperatures rise—a phenomenon known as offset analgesia.

In the study, pain thresholds of women at term did not vary widely, but the majority could not tolerate this at all, he said. “There is clearly something very different about the ability to recruit endogenous analgesic systems” at term, he said.

The investigators were unable to find correlations between subjects' pain thresholds at different anatomic sites (the lower back versus the forearm) and postoperative pain.

PALM DESERT, CALIF. — The degree to which women expected postoperative pain was highly correlated with actual postcesarean section pain scores, James C. Eisenach, M.D., reported at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

He and his associates prospectively studied 31 healthy women scheduled for elective C-section. They conducted psychological and pain studies from 1 to 10 days before surgery and then monitored pain scores and analgesia use after surgery.

Preoperative testing included ratings of unpleasantness and pain during a 5-second application of heat stimuli to the forearm and lower back; administration of a state anxiety and trait anxiety questionnaire; and questions about how much pain the women expected to experience postoperatively and whether they expected to require pain medication.

State anxiety reflects one's self-assessment tension associated with a specific experience, while trait anxiety reflects one's assessment of how much he or she is generally prone to anxiety.

“What we see is what everyone sees. That is, there is a tremendous variability in pain scores at rest and with movement 24 hours after C-section,” said Dr. Eisenach, professor of anesthesiology and vice chair of research at Wake Forest University, Winston-Salem, N.C.

Pain scores indeed varied widely even though all patients received spinal anesthesia, nurse-administered intravenous opioids in the recovery room, and patient-controlled intravenous analgesia once they left the recovery room.

The subjects rated overall postoperative pain from 0.5 to 9.5 on a 10-point visual analog scale. Average pain at rest scores ranged from 0 to 7 and pain with movement from 0.2 to 9.2; morphine use in the first 10 postoperative hours ranged from 0 to 81 mg. Positive associations varied depending on the type of pain assessed.

Regression analysis identified three variables associated with postoperative pain at rest: trait anxiety, expected postoperative pain, and the sensory level at the time the incision was made.

Movement pain was associated with results of suprathreshold pain testing on the forearm (but not the lower back), state anxiety, expected pain, and the duration of surgery.

Analgesic drug use was associated with pain threshold in the forearm test, trait anxiety, expected pain, and the duration of surgery. Only expected pain was associated with all postoperative pain measures.

Dr. Eisenach theorized that duration of surgery was related to the degree of adhesions that were present from previous C-sections, since all of the procedures were performed by experienced obstetricians from a private obstetric practice in Winston-Salem.

A number of intriguing findings emerged, beyond associations with specific measures of pain.

As part of the work-up before the surgery, women were asked to listen to tones of different decibels, and these test results were compared with their scores on a visual analog pain scale during the application of a heated stimulus on the forearm and lower back. There was a high degree of correlation, Dr. Eisenach said.

He also found that women at term do not have the same type of responses to pain stimuli as men or nonpregnant women. Term women have an initially intense response to increasing temperatures, but then a marked decline in the degree of response even as temperatures rise—a phenomenon known as offset analgesia.

In the study, pain thresholds of women at term did not vary widely, but the majority could not tolerate this at all, he said. “There is clearly something very different about the ability to recruit endogenous analgesic systems” at term, he said.

The investigators were unable to find correlations between subjects' pain thresholds at different anatomic sites (the lower back versus the forearm) and postoperative pain.

PALM DESERT, CALIF. — The degree to which women expected postoperative pain was highly correlated with actual postcesarean section pain scores, James C. Eisenach, M.D., reported at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

He and his associates prospectively studied 31 healthy women scheduled for elective C-section. They conducted psychological and pain studies from 1 to 10 days before surgery and then monitored pain scores and analgesia use after surgery.

Preoperative testing included ratings of unpleasantness and pain during a 5-second application of heat stimuli to the forearm and lower back; administration of a state anxiety and trait anxiety questionnaire; and questions about how much pain the women expected to experience postoperatively and whether they expected to require pain medication.

State anxiety reflects one's self-assessment tension associated with a specific experience, while trait anxiety reflects one's assessment of how much he or she is generally prone to anxiety.

“What we see is what everyone sees. That is, there is a tremendous variability in pain scores at rest and with movement 24 hours after C-section,” said Dr. Eisenach, professor of anesthesiology and vice chair of research at Wake Forest University, Winston-Salem, N.C.

Pain scores indeed varied widely even though all patients received spinal anesthesia, nurse-administered intravenous opioids in the recovery room, and patient-controlled intravenous analgesia once they left the recovery room.

The subjects rated overall postoperative pain from 0.5 to 9.5 on a 10-point visual analog scale. Average pain at rest scores ranged from 0 to 7 and pain with movement from 0.2 to 9.2; morphine use in the first 10 postoperative hours ranged from 0 to 81 mg. Positive associations varied depending on the type of pain assessed.

Regression analysis identified three variables associated with postoperative pain at rest: trait anxiety, expected postoperative pain, and the sensory level at the time the incision was made.

Movement pain was associated with results of suprathreshold pain testing on the forearm (but not the lower back), state anxiety, expected pain, and the duration of surgery.

Analgesic drug use was associated with pain threshold in the forearm test, trait anxiety, expected pain, and the duration of surgery. Only expected pain was associated with all postoperative pain measures.

Dr. Eisenach theorized that duration of surgery was related to the degree of adhesions that were present from previous C-sections, since all of the procedures were performed by experienced obstetricians from a private obstetric practice in Winston-Salem.

A number of intriguing findings emerged, beyond associations with specific measures of pain.

As part of the work-up before the surgery, women were asked to listen to tones of different decibels, and these test results were compared with their scores on a visual analog pain scale during the application of a heated stimulus on the forearm and lower back. There was a high degree of correlation, Dr. Eisenach said.

He also found that women at term do not have the same type of responses to pain stimuli as men or nonpregnant women. Term women have an initially intense response to increasing temperatures, but then a marked decline in the degree of response even as temperatures rise—a phenomenon known as offset analgesia.

In the study, pain thresholds of women at term did not vary widely, but the majority could not tolerate this at all, he said. “There is clearly something very different about the ability to recruit endogenous analgesic systems” at term, he said.

The investigators were unable to find correlations between subjects' pain thresholds at different anatomic sites (the lower back versus the forearm) and postoperative pain.

PALM DESERT, CALIF. — More than one in seven healthy parturients report residual pain 6 months after undergoing an elective cesarean section, a Belgian research group reported at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

Three characteristics distinguished patients suffering chronic postoperative pain from those who reported no pain at 6 months: higher pain scores 24 hours after surgery; a greater likelihood of reporting wound hyperalgesia at 24 and 48 hours; and a previous history of a genitourinary infection.

Patricia M. Lavand'homme, M.D., said her 100-subject study is one of the first to address the issue, despite the rising rate of elective C-sections and the importance of identifying risk factors that may point to preventive strategies.

“I think we really, really need to have more studies,” she remarked.

One previous study included all C-sections, including emergency procedures, and found that 12% of patients still suffered residual pain and discomfort after an average of 10 months, and among these patients, 6% had daily pain. General anesthesia appeared to induce more residual pain and discomfort than did spinal anesthesia (Acta Anaesthesiol. Scand. 2004;48:111–6).

She and her associates at the Université Catholique de Louvain in Brussels prospectively followed 100 healthy women who had undergone elective C-section.

At 6 months, 15 reported chronic pain around the scar. In four women, the pain was intense enough to require analgesics, including codeine and NSAIDs, at least three times a week. The pain was associated with a visceral component in two of the subjects with chronic pain.

No significant differences were found in women with or without chronic pain in terms of previous C-sections or other abdominal surgeries, age, number of pregnancies, endometriosis, or obstetric procedures.

Eight of 15 patients who had chronic pain reported previous genitourinary infections, compared with just 14 of 85 patients with no pain at 6 months. This difference was statistically significant.

At 24 hours, patients who would go on to experience chronic pain rated their pain at rest as a 30 and with movement as a 72 on a 100-point visual analog scale. Patients whose pain resolved before 6 months averaged visual pain scores of 17 at rest and 46 with movement. These differences between groups were also significant.

Chronic pain patients also experienced postoperative wound hyperalgesia at far higher rates than other patients (10 of 15 patients at 24 hours, compared with 20 of 85 in the no chronic pain group, and 8 of 15 patients at 48 hours, compared with 12 of 85 patients).

In response to a question from an audience member, Dr. Lavand'homme said the type of C-section incision used might play a role in rates of residual pain. All patients in the study received a Pfannenstiel incision with peritoneal layer closure. This incision is more comparable with the incision for an inguinal hernia repair—a surgery linked to high rates of residual pain—than is a vertical incision, she said.

However, much more study is needed to determine what specific factors contribute to chronic post-C-section pain and discomfort, Dr. Lavand'homme stressed.

PALM DESERT, CALIF. — More than one in seven healthy parturients report residual pain 6 months after undergoing an elective cesarean section, a Belgian research group reported at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

Three characteristics distinguished patients suffering chronic postoperative pain from those who reported no pain at 6 months: higher pain scores 24 hours after surgery; a greater likelihood of reporting wound hyperalgesia at 24 and 48 hours; and a previous history of a genitourinary infection.

Patricia M. Lavand'homme, M.D., said her 100-subject study is one of the first to address the issue, despite the rising rate of elective C-sections and the importance of identifying risk factors that may point to preventive strategies.

“I think we really, really need to have more studies,” she remarked.

One previous study included all C-sections, including emergency procedures, and found that 12% of patients still suffered residual pain and discomfort after an average of 10 months, and among these patients, 6% had daily pain. General anesthesia appeared to induce more residual pain and discomfort than did spinal anesthesia (Acta Anaesthesiol. Scand. 2004;48:111–6).

She and her associates at the Université Catholique de Louvain in Brussels prospectively followed 100 healthy women who had undergone elective C-section.

At 6 months, 15 reported chronic pain around the scar. In four women, the pain was intense enough to require analgesics, including codeine and NSAIDs, at least three times a week. The pain was associated with a visceral component in two of the subjects with chronic pain.

No significant differences were found in women with or without chronic pain in terms of previous C-sections or other abdominal surgeries, age, number of pregnancies, endometriosis, or obstetric procedures.

Eight of 15 patients who had chronic pain reported previous genitourinary infections, compared with just 14 of 85 patients with no pain at 6 months. This difference was statistically significant.

At 24 hours, patients who would go on to experience chronic pain rated their pain at rest as a 30 and with movement as a 72 on a 100-point visual analog scale. Patients whose pain resolved before 6 months averaged visual pain scores of 17 at rest and 46 with movement. These differences between groups were also significant.

Chronic pain patients also experienced postoperative wound hyperalgesia at far higher rates than other patients (10 of 15 patients at 24 hours, compared with 20 of 85 in the no chronic pain group, and 8 of 15 patients at 48 hours, compared with 12 of 85 patients).

In response to a question from an audience member, Dr. Lavand'homme said the type of C-section incision used might play a role in rates of residual pain. All patients in the study received a Pfannenstiel incision with peritoneal layer closure. This incision is more comparable with the incision for an inguinal hernia repair—a surgery linked to high rates of residual pain—than is a vertical incision, she said.

However, much more study is needed to determine what specific factors contribute to chronic post-C-section pain and discomfort, Dr. Lavand'homme stressed.

PALM DESERT, CALIF. — More than one in seven healthy parturients report residual pain 6 months after undergoing an elective cesarean section, a Belgian research group reported at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

Three characteristics distinguished patients suffering chronic postoperative pain from those who reported no pain at 6 months: higher pain scores 24 hours after surgery; a greater likelihood of reporting wound hyperalgesia at 24 and 48 hours; and a previous history of a genitourinary infection.

Patricia M. Lavand'homme, M.D., said her 100-subject study is one of the first to address the issue, despite the rising rate of elective C-sections and the importance of identifying risk factors that may point to preventive strategies.

“I think we really, really need to have more studies,” she remarked.

One previous study included all C-sections, including emergency procedures, and found that 12% of patients still suffered residual pain and discomfort after an average of 10 months, and among these patients, 6% had daily pain. General anesthesia appeared to induce more residual pain and discomfort than did spinal anesthesia (Acta Anaesthesiol. Scand. 2004;48:111–6).

She and her associates at the Université Catholique de Louvain in Brussels prospectively followed 100 healthy women who had undergone elective C-section.

At 6 months, 15 reported chronic pain around the scar. In four women, the pain was intense enough to require analgesics, including codeine and NSAIDs, at least three times a week. The pain was associated with a visceral component in two of the subjects with chronic pain.

No significant differences were found in women with or without chronic pain in terms of previous C-sections or other abdominal surgeries, age, number of pregnancies, endometriosis, or obstetric procedures.

Eight of 15 patients who had chronic pain reported previous genitourinary infections, compared with just 14 of 85 patients with no pain at 6 months. This difference was statistically significant.

At 24 hours, patients who would go on to experience chronic pain rated their pain at rest as a 30 and with movement as a 72 on a 100-point visual analog scale. Patients whose pain resolved before 6 months averaged visual pain scores of 17 at rest and 46 with movement. These differences between groups were also significant.

Chronic pain patients also experienced postoperative wound hyperalgesia at far higher rates than other patients (10 of 15 patients at 24 hours, compared with 20 of 85 in the no chronic pain group, and 8 of 15 patients at 48 hours, compared with 12 of 85 patients).

In response to a question from an audience member, Dr. Lavand'homme said the type of C-section incision used might play a role in rates of residual pain. All patients in the study received a Pfannenstiel incision with peritoneal layer closure. This incision is more comparable with the incision for an inguinal hernia repair—a surgery linked to high rates of residual pain—than is a vertical incision, she said.

However, much more study is needed to determine what specific factors contribute to chronic post-C-section pain and discomfort, Dr. Lavand'homme stressed.