Damian McNamara

BOCA RATON, FLA. — The use of methylphenidate or mixed amphetamine salts for attention-deficit/hyperactivity disorder can increase heart rate, blood pressure, and the QT interval in children, adolescents, and adults, according to a review of placebo-controlled and open-label extension trials published since 2000.

The magnitude of the effects appears small for most patients, which points to the importance of screening for preexisting cardiovascular disease and asking about any relevant family or patient history, Dr. Raul R. Silva said.

Despite long-term use and the effectiveness of these stimulant medications at reducing the core symptoms of ADHD, concerns arose about increased potential for cardiovascular events. The American Heart Association released guidelines for cardiac monitoring of all children with ADHD before treatment (Circulation 2008;117:2407-23).

“Some of what they came out with was severe,” said Dr. Silva, vice chair of the department of child and adolescent psychiatry at New York University. “Even the American Academy of Pediatrics said it had to temper its recommendations” (Pediatrics 2008;122:451-3).

Ultimately, the two organizations released a clarification statement that recognizes the need for responsible cardiovascular monitoring while not withholding these medications to treat ADHD, Dr. Silva said (J. Dev. Behav. Pediatr. 2008;29:335.

Despite the joint clarification, confusion about the actual risks remains, Dr. Silva said.

To learn more about the risk of cardiovascular disease in patients taking these medications, Dr. Silva and his colleagues identified and reviewed five double-blind, placebo-controlled studies and six open-label studies that reported relevant cardiovascular data.

“We looked at 10 years' worth of studies in children and adults that reported heart rate, blood pressure, and EKG changes,” Dr. Silva said in an interview at his poster presentation during the meeting, which was sponsored by the National Institute of Mental Health.

Both types of studies were included because double-blind, placebo-controlled studies “are so short, there is not always a clear picture” and because “long-term studies tend to be open label,” said Dr. Silva, who also has a private practice in Cresskill, N.J.

In the double-blind studies, mean heart rate increased by 1-8.5 beats per minute after 3-6 weeks of treatment. The percentages of patients who experienced predefined, “clinically notable” heart rate events were similar among groups who received methylphenidate (MPH), mixed amphetamine salts (MAS), or placebo.

Significant increases of 1.5-4.4 bpm in mean heart rate were reported by most of the long-term, open-label extension studies.

A comparison of the short-term and long-term studies does not suggest an accumulative risk, Dr. Silva said. He added that it is unclear whether long-term increases in heart rate associated with these stimulants could increase the risk for stroke, heart attacks, or dysrhythmias.

“It may be reasonable to assume that increases in heart rate with therapeutic doses of stimulants are relatively safe in patients without predisposing or preexisting cardiac risk factors; however, further research and data are required to confirm any potential increased risk for cardiovascular events later in life,” the authors wrote.

In terms of blood pressure changes, most of the double-blind studies demonstrated no significant increases with stimulant treatment, compared with baseline. Again, the percentages of patients who experienced clinically notable increases in blood pressure were similar among groups that received MPH, MAS, or placebo.

In contrast, most of the open-label studies found significant increases in systolic blood pressure (0.6-3.5 mm Hg) and diastolic blood pressure (0.7-2.6 mm Hg), compared with baseline. Despite the disparity in significance, numerically, the changes in blood pressure in both study types were similar, suggesting no accumulative effect.

Researchers have not demonstrated a relationship between such small increases in blood pressure and increased morbidity, Dr. Silva said.

It is also unclear whether these increases translate to an increased risk for cardiovascular events in patients with preexisting hypertension.

“In essence, you end up seeing [that] there aren't that many serious changes that occur, and there are some you see in the placebo group as well,” Dr. Silva said.

Even so, he added, the rate for these heart rate and blood pressure changes “tends to be a little higher for stimulant drugs, and that is what you want to be most concerned about.”

Acute consequences in children with preexisting cardiac disease, as well as the unknown potential for long-term adverse effects in all children who are exposed to these stimulants, are two major concerns.

“Personally, I always follow up [with patients]. I take a family history, for example, of arrhythmias, and a personal history for syncope and chest pain,” said Dr. Silva.

These are among the recommendations in the 12-item screening recommendations from the American Heart Association (Circulation 2008;117:2407-23 and Circulation 2007;115:1643-55). Also, pay attention to symptoms such as palpitations, near syncope, or syncope that could indicate a cardiac condition.

Family history should include hypertrophic cardiomyopathy, long QT syndrome, Wolff-Parkinson-White syndrome, and Marfan syndrome.

Dr. Silva also recommends that all patients be screened with at least an electrocardiogram. An echocardiogram is more accurate and will show structural abnormalities, but it is not always readily available, he said.

“I think everyone should screen,” he noted.

Data on QT interval changes were inconsistent. All but one of the double-blind studies that the investigators reviewed reported no significant change in QT interval findings with stimulant treatment vs. placebo.

One study in adults reported a significant increase in the QTcB interval of 7 ms after 6 weeks of MPH treatment, compared with placebo (Biol. Psychiatry 2006;59:829-35).

Four open-label extension trials reported QT interval data. One of these found significant increases in QT intervals (using different formulas for QTcB and QTcF) after 15 weeks of MAS-XR treatment in children (Biol. Psychiatry. 2007;61:706-12).

In contrast, a study in adolescents reported a mean decrease in the QTcB of 4.6 ms after 6 months of MAS-XR treatment (CNS Spectr. 2005:10 [10 suppl. 15]:22-30). In addition, a study of adults treated with MAS-XR found significant increases in mean QTcB intervals of 7.2 ms and QTcF intervals of 2.9 ms (CNS Spectr. 2005;10 [12 Suppl. 20]:35-43).

Different formulas all correct for the QT interval differently, Dr. Silva said. In addition, it remains uncertain whether prolongation of the QTcB interval by these medications corresponds to an increase risk of sudden death.

“No deaths were reported in any of these studies with pretty large numbers,” Dr. Silva said.

Disclosures: Novartis Pharmaceuticals Corp. supported the study. Dr. Silva disclosed that he is a consultant and on the speakers bureau for Novartis.

'There aren't that many serious changes that occur, and there are some you see in the placebo group as well.'

Source DR. SILVA

BOCA RATON, FLA. — The use of methylphenidate or mixed amphetamine salts for attention-deficit/hyperactivity disorder can increase heart rate, blood pressure, and the QT interval in children, adolescents, and adults, according to a review of placebo-controlled and open-label extension trials published since 2000.

The magnitude of the effects appears small for most patients, which points to the importance of screening for preexisting cardiovascular disease and asking about any relevant family or patient history, Dr. Raul R. Silva said.

Despite long-term use and the effectiveness of these stimulant medications at reducing the core symptoms of ADHD, concerns arose about increased potential for cardiovascular events. The American Heart Association released guidelines for cardiac monitoring of all children with ADHD before treatment (Circulation 2008;117:2407-23).

“Some of what they came out with was severe,” said Dr. Silva, vice chair of the department of child and adolescent psychiatry at New York University. “Even the American Academy of Pediatrics said it had to temper its recommendations” (Pediatrics 2008;122:451-3).

Ultimately, the two organizations released a clarification statement that recognizes the need for responsible cardiovascular monitoring while not withholding these medications to treat ADHD, Dr. Silva said (J. Dev. Behav. Pediatr. 2008;29:335.

Despite the joint clarification, confusion about the actual risks remains, Dr. Silva said.

To learn more about the risk of cardiovascular disease in patients taking these medications, Dr. Silva and his colleagues identified and reviewed five double-blind, placebo-controlled studies and six open-label studies that reported relevant cardiovascular data.

“We looked at 10 years' worth of studies in children and adults that reported heart rate, blood pressure, and EKG changes,” Dr. Silva said in an interview at his poster presentation during the meeting, which was sponsored by the National Institute of Mental Health.

Both types of studies were included because double-blind, placebo-controlled studies “are so short, there is not always a clear picture” and because “long-term studies tend to be open label,” said Dr. Silva, who also has a private practice in Cresskill, N.J.

In the double-blind studies, mean heart rate increased by 1-8.5 beats per minute after 3-6 weeks of treatment. The percentages of patients who experienced predefined, “clinically notable” heart rate events were similar among groups who received methylphenidate (MPH), mixed amphetamine salts (MAS), or placebo.

Significant increases of 1.5-4.4 bpm in mean heart rate were reported by most of the long-term, open-label extension studies.

A comparison of the short-term and long-term studies does not suggest an accumulative risk, Dr. Silva said. He added that it is unclear whether long-term increases in heart rate associated with these stimulants could increase the risk for stroke, heart attacks, or dysrhythmias.

“It may be reasonable to assume that increases in heart rate with therapeutic doses of stimulants are relatively safe in patients without predisposing or preexisting cardiac risk factors; however, further research and data are required to confirm any potential increased risk for cardiovascular events later in life,” the authors wrote.

In terms of blood pressure changes, most of the double-blind studies demonstrated no significant increases with stimulant treatment, compared with baseline. Again, the percentages of patients who experienced clinically notable increases in blood pressure were similar among groups that received MPH, MAS, or placebo.

In contrast, most of the open-label studies found significant increases in systolic blood pressure (0.6-3.5 mm Hg) and diastolic blood pressure (0.7-2.6 mm Hg), compared with baseline. Despite the disparity in significance, numerically, the changes in blood pressure in both study types were similar, suggesting no accumulative effect.

Researchers have not demonstrated a relationship between such small increases in blood pressure and increased morbidity, Dr. Silva said.

It is also unclear whether these increases translate to an increased risk for cardiovascular events in patients with preexisting hypertension.

“In essence, you end up seeing [that] there aren't that many serious changes that occur, and there are some you see in the placebo group as well,” Dr. Silva said.

Even so, he added, the rate for these heart rate and blood pressure changes “tends to be a little higher for stimulant drugs, and that is what you want to be most concerned about.”

Acute consequences in children with preexisting cardiac disease, as well as the unknown potential for long-term adverse effects in all children who are exposed to these stimulants, are two major concerns.

“Personally, I always follow up [with patients]. I take a family history, for example, of arrhythmias, and a personal history for syncope and chest pain,” said Dr. Silva.

These are among the recommendations in the 12-item screening recommendations from the American Heart Association (Circulation 2008;117:2407-23 and Circulation 2007;115:1643-55). Also, pay attention to symptoms such as palpitations, near syncope, or syncope that could indicate a cardiac condition.

Family history should include hypertrophic cardiomyopathy, long QT syndrome, Wolff-Parkinson-White syndrome, and Marfan syndrome.

Dr. Silva also recommends that all patients be screened with at least an electrocardiogram. An echocardiogram is more accurate and will show structural abnormalities, but it is not always readily available, he said.

“I think everyone should screen,” he noted.

Data on QT interval changes were inconsistent. All but one of the double-blind studies that the investigators reviewed reported no significant change in QT interval findings with stimulant treatment vs. placebo.

One study in adults reported a significant increase in the QTcB interval of 7 ms after 6 weeks of MPH treatment, compared with placebo (Biol. Psychiatry 2006;59:829-35).

Four open-label extension trials reported QT interval data. One of these found significant increases in QT intervals (using different formulas for QTcB and QTcF) after 15 weeks of MAS-XR treatment in children (Biol. Psychiatry. 2007;61:706-12).

In contrast, a study in adolescents reported a mean decrease in the QTcB of 4.6 ms after 6 months of MAS-XR treatment (CNS Spectr. 2005:10 [10 suppl. 15]:22-30). In addition, a study of adults treated with MAS-XR found significant increases in mean QTcB intervals of 7.2 ms and QTcF intervals of 2.9 ms (CNS Spectr. 2005;10 [12 Suppl. 20]:35-43).

Different formulas all correct for the QT interval differently, Dr. Silva said. In addition, it remains uncertain whether prolongation of the QTcB interval by these medications corresponds to an increase risk of sudden death.

“No deaths were reported in any of these studies with pretty large numbers,” Dr. Silva said.

Disclosures: Novartis Pharmaceuticals Corp. supported the study. Dr. Silva disclosed that he is a consultant and on the speakers bureau for Novartis.

'There aren't that many serious changes that occur, and there are some you see in the placebo group as well.'

Source DR. SILVA

BOCA RATON, FLA. — The use of methylphenidate or mixed amphetamine salts for attention-deficit/hyperactivity disorder can increase heart rate, blood pressure, and the QT interval in children, adolescents, and adults, according to a review of placebo-controlled and open-label extension trials published since 2000.

The magnitude of the effects appears small for most patients, which points to the importance of screening for preexisting cardiovascular disease and asking about any relevant family or patient history, Dr. Raul R. Silva said.

Despite long-term use and the effectiveness of these stimulant medications at reducing the core symptoms of ADHD, concerns arose about increased potential for cardiovascular events. The American Heart Association released guidelines for cardiac monitoring of all children with ADHD before treatment (Circulation 2008;117:2407-23).

“Some of what they came out with was severe,” said Dr. Silva, vice chair of the department of child and adolescent psychiatry at New York University. “Even the American Academy of Pediatrics said it had to temper its recommendations” (Pediatrics 2008;122:451-3).

Ultimately, the two organizations released a clarification statement that recognizes the need for responsible cardiovascular monitoring while not withholding these medications to treat ADHD, Dr. Silva said (J. Dev. Behav. Pediatr. 2008;29:335.

Despite the joint clarification, confusion about the actual risks remains, Dr. Silva said.

To learn more about the risk of cardiovascular disease in patients taking these medications, Dr. Silva and his colleagues identified and reviewed five double-blind, placebo-controlled studies and six open-label studies that reported relevant cardiovascular data.

“We looked at 10 years' worth of studies in children and adults that reported heart rate, blood pressure, and EKG changes,” Dr. Silva said in an interview at his poster presentation during the meeting, which was sponsored by the National Institute of Mental Health.

Both types of studies were included because double-blind, placebo-controlled studies “are so short, there is not always a clear picture” and because “long-term studies tend to be open label,” said Dr. Silva, who also has a private practice in Cresskill, N.J.

In the double-blind studies, mean heart rate increased by 1-8.5 beats per minute after 3-6 weeks of treatment. The percentages of patients who experienced predefined, “clinically notable” heart rate events were similar among groups who received methylphenidate (MPH), mixed amphetamine salts (MAS), or placebo.

Significant increases of 1.5-4.4 bpm in mean heart rate were reported by most of the long-term, open-label extension studies.

A comparison of the short-term and long-term studies does not suggest an accumulative risk, Dr. Silva said. He added that it is unclear whether long-term increases in heart rate associated with these stimulants could increase the risk for stroke, heart attacks, or dysrhythmias.

“It may be reasonable to assume that increases in heart rate with therapeutic doses of stimulants are relatively safe in patients without predisposing or preexisting cardiac risk factors; however, further research and data are required to confirm any potential increased risk for cardiovascular events later in life,” the authors wrote.

In terms of blood pressure changes, most of the double-blind studies demonstrated no significant increases with stimulant treatment, compared with baseline. Again, the percentages of patients who experienced clinically notable increases in blood pressure were similar among groups that received MPH, MAS, or placebo.

In contrast, most of the open-label studies found significant increases in systolic blood pressure (0.6-3.5 mm Hg) and diastolic blood pressure (0.7-2.6 mm Hg), compared with baseline. Despite the disparity in significance, numerically, the changes in blood pressure in both study types were similar, suggesting no accumulative effect.

Researchers have not demonstrated a relationship between such small increases in blood pressure and increased morbidity, Dr. Silva said.

It is also unclear whether these increases translate to an increased risk for cardiovascular events in patients with preexisting hypertension.

“In essence, you end up seeing [that] there aren't that many serious changes that occur, and there are some you see in the placebo group as well,” Dr. Silva said.

Even so, he added, the rate for these heart rate and blood pressure changes “tends to be a little higher for stimulant drugs, and that is what you want to be most concerned about.”

Acute consequences in children with preexisting cardiac disease, as well as the unknown potential for long-term adverse effects in all children who are exposed to these stimulants, are two major concerns.

“Personally, I always follow up [with patients]. I take a family history, for example, of arrhythmias, and a personal history for syncope and chest pain,” said Dr. Silva.

These are among the recommendations in the 12-item screening recommendations from the American Heart Association (Circulation 2008;117:2407-23 and Circulation 2007;115:1643-55). Also, pay attention to symptoms such as palpitations, near syncope, or syncope that could indicate a cardiac condition.

Family history should include hypertrophic cardiomyopathy, long QT syndrome, Wolff-Parkinson-White syndrome, and Marfan syndrome.

Dr. Silva also recommends that all patients be screened with at least an electrocardiogram. An echocardiogram is more accurate and will show structural abnormalities, but it is not always readily available, he said.

“I think everyone should screen,” he noted.

Data on QT interval changes were inconsistent. All but one of the double-blind studies that the investigators reviewed reported no significant change in QT interval findings with stimulant treatment vs. placebo.

One study in adults reported a significant increase in the QTcB interval of 7 ms after 6 weeks of MPH treatment, compared with placebo (Biol. Psychiatry 2006;59:829-35).

Four open-label extension trials reported QT interval data. One of these found significant increases in QT intervals (using different formulas for QTcB and QTcF) after 15 weeks of MAS-XR treatment in children (Biol. Psychiatry. 2007;61:706-12).

In contrast, a study in adolescents reported a mean decrease in the QTcB of 4.6 ms after 6 months of MAS-XR treatment (CNS Spectr. 2005:10 [10 suppl. 15]:22-30). In addition, a study of adults treated with MAS-XR found significant increases in mean QTcB intervals of 7.2 ms and QTcF intervals of 2.9 ms (CNS Spectr. 2005;10 [12 Suppl. 20]:35-43).

Different formulas all correct for the QT interval differently, Dr. Silva said. In addition, it remains uncertain whether prolongation of the QTcB interval by these medications corresponds to an increase risk of sudden death.

“No deaths were reported in any of these studies with pretty large numbers,” Dr. Silva said.

Disclosures: Novartis Pharmaceuticals Corp. supported the study. Dr. Silva disclosed that he is a consultant and on the speakers bureau for Novartis.

'There aren't that many serious changes that occur, and there are some you see in the placebo group as well.'

Source DR. SILVA

DESTIN, FLA. — Despite a paucity of conclusive data in the literature—including only one prospective, randomized, controlled trial—most patients perceive an association between their diet and acne.

“The majority of our patients feel diet has some influence on their acne,” Dr. Diane Thiboutot said at the meeting. Therefore, be prepared to discuss the limited evidence about acne and such potential culprits as dairy intake and high glycemic diets.

More than half of students surveyed in two studies believed there was an association. A total of 62% of 347 high school students in Greece believed diet was a cause of their acne (J. Eur. Acad. Dermatol. Venereol. 2007;21:806-10). Another survey featured more specific questions and revealed, for example, that 53% of 539 Nigerian students aged 11–19 believed eating too much butter or margarine contributed to their acne (Int. J. Dermatol. 2009;48:498-505). Eating too much fatty food was cited by 38%.

“We don't know if these things are true or not, but the perception persists,” said Dr. Thiboutot, professor of dermatology at Pennsylvania State University, Hershey.

“There has really only been one prospective, randomized, controlled trial,” she said. The trial included 43 adolescent and adult men in Australia, aged 15–25 years with a mean of 30 inflammatory acne lesions (J. Am. Acad. Dermatol. 2007;57:247-56). One group, randomized to 12 weeks of a low-glycemic-load diet, experienced a significant decrease in total lesions—approximately 50%—compared with a 25% decrease for those randomized to a control diet.

“However, patients on the low glycemic diet lost more weight, so it is hard to differentiate the effect of diet versus weight loss,” Dr. Thiboutot said.

In an observational study, investigators found no acne in certain populations with a low glycemic diet, specifically the Kitavan Islanders of Papua New Guinea and the Aché Indians of Paraguay (Arch. Dermatol. 2002;138:1584-90).

“I reviewed this paper and wrote an editorial,” Dr. Thiboutot said. “I had some reservations about it, but it was also very interesting.” One of the criticisms of this study was the gene-versus-environment argument, she added. “What if they would not have developed acne anyway [regardless of diet]?”

Other researchers have looked at a genetic basis for acne. For example, the risk of adult acne was almost fourfold greater in first-degree relatives of those with adult acne, compared with those without, in another observational study (Br. J. Dermatol. 1999;141:297-300).

“The genetic component may come in with very severe acne,” Dr. Thiboutot said. “How many of you see a teenager with severe acne and you turn and look at the parent, and you see evidence of scarring?” Ask about family history of acne, and if it is positive, more aggressive treatment may be warranted, she said.

Epidemiologic evidence of an association between diet and acne includes two studies about dairy intake. The first assessed intake and acne in girls (J. Am. Acad. Dermatol. 2005;52:207-14). The prevalence of acne correlated with total milk intake (multivariate prevalence ratio, 1.2) and intake of skim milk (1.4), which Dr. Thiboutot described as “not overwhelming.”

She said, “It could be recall bias. How accurately do people remember their milk intake as teenagers?”

Three years later, the investigators published a prospective study of milk intake and acne in 4,273 teenage boys (J. Am. Acad. Dermatol. 2008;58:787-93). Participants self-reported milk consumption and acne assessment. Multivariate prevalence ratios showed weak associations with total milk intake (1.2), whole or 2% milk consumption (1.1), 1% milk (1.2), or skim milk (1.2), Dr. Thiboutot said. They found no association between acne and any other dairy product.

“Clearly, prospective, randomized, controlled trials are needed to further address these questions,” Dr. Thiboutot concluded.

Disclosures: Dr. Thiboutot disclosed financial ties to Allergan, Arcutis Pharmaceuticals, Galderma, Intendis, Medicis, Obagi Medical, and Stiefel Laboratories.

Studies show only a weak association between milk intake and acne.

Source ©Maciej Mamro/Fotolia.com

“Clearly, prospective, randomized, controlled trials are needed to further address these questions,” Dr. Diane Thiboutot concluded.

Source Damian McNamara/Elsevier Medical News Group

DESTIN, FLA. — Despite a paucity of conclusive data in the literature—including only one prospective, randomized, controlled trial—most patients perceive an association between their diet and acne.

“The majority of our patients feel diet has some influence on their acne,” Dr. Diane Thiboutot said at the meeting. Therefore, be prepared to discuss the limited evidence about acne and such potential culprits as dairy intake and high glycemic diets.

More than half of students surveyed in two studies believed there was an association. A total of 62% of 347 high school students in Greece believed diet was a cause of their acne (J. Eur. Acad. Dermatol. Venereol. 2007;21:806-10). Another survey featured more specific questions and revealed, for example, that 53% of 539 Nigerian students aged 11–19 believed eating too much butter or margarine contributed to their acne (Int. J. Dermatol. 2009;48:498-505). Eating too much fatty food was cited by 38%.

“We don't know if these things are true or not, but the perception persists,” said Dr. Thiboutot, professor of dermatology at Pennsylvania State University, Hershey.

“There has really only been one prospective, randomized, controlled trial,” she said. The trial included 43 adolescent and adult men in Australia, aged 15–25 years with a mean of 30 inflammatory acne lesions (J. Am. Acad. Dermatol. 2007;57:247-56). One group, randomized to 12 weeks of a low-glycemic-load diet, experienced a significant decrease in total lesions—approximately 50%—compared with a 25% decrease for those randomized to a control diet.

“However, patients on the low glycemic diet lost more weight, so it is hard to differentiate the effect of diet versus weight loss,” Dr. Thiboutot said.

In an observational study, investigators found no acne in certain populations with a low glycemic diet, specifically the Kitavan Islanders of Papua New Guinea and the Aché Indians of Paraguay (Arch. Dermatol. 2002;138:1584-90).

“I reviewed this paper and wrote an editorial,” Dr. Thiboutot said. “I had some reservations about it, but it was also very interesting.” One of the criticisms of this study was the gene-versus-environment argument, she added. “What if they would not have developed acne anyway [regardless of diet]?”

Other researchers have looked at a genetic basis for acne. For example, the risk of adult acne was almost fourfold greater in first-degree relatives of those with adult acne, compared with those without, in another observational study (Br. J. Dermatol. 1999;141:297-300).

“The genetic component may come in with very severe acne,” Dr. Thiboutot said. “How many of you see a teenager with severe acne and you turn and look at the parent, and you see evidence of scarring?” Ask about family history of acne, and if it is positive, more aggressive treatment may be warranted, she said.

Epidemiologic evidence of an association between diet and acne includes two studies about dairy intake. The first assessed intake and acne in girls (J. Am. Acad. Dermatol. 2005;52:207-14). The prevalence of acne correlated with total milk intake (multivariate prevalence ratio, 1.2) and intake of skim milk (1.4), which Dr. Thiboutot described as “not overwhelming.”

She said, “It could be recall bias. How accurately do people remember their milk intake as teenagers?”

Three years later, the investigators published a prospective study of milk intake and acne in 4,273 teenage boys (J. Am. Acad. Dermatol. 2008;58:787-93). Participants self-reported milk consumption and acne assessment. Multivariate prevalence ratios showed weak associations with total milk intake (1.2), whole or 2% milk consumption (1.1), 1% milk (1.2), or skim milk (1.2), Dr. Thiboutot said. They found no association between acne and any other dairy product.

“Clearly, prospective, randomized, controlled trials are needed to further address these questions,” Dr. Thiboutot concluded.

Disclosures: Dr. Thiboutot disclosed financial ties to Allergan, Arcutis Pharmaceuticals, Galderma, Intendis, Medicis, Obagi Medical, and Stiefel Laboratories.

Studies show only a weak association between milk intake and acne.

Source ©Maciej Mamro/Fotolia.com

“Clearly, prospective, randomized, controlled trials are needed to further address these questions,” Dr. Diane Thiboutot concluded.

Source Damian McNamara/Elsevier Medical News Group

DESTIN, FLA. — Despite a paucity of conclusive data in the literature—including only one prospective, randomized, controlled trial—most patients perceive an association between their diet and acne.

“The majority of our patients feel diet has some influence on their acne,” Dr. Diane Thiboutot said at the meeting. Therefore, be prepared to discuss the limited evidence about acne and such potential culprits as dairy intake and high glycemic diets.

More than half of students surveyed in two studies believed there was an association. A total of 62% of 347 high school students in Greece believed diet was a cause of their acne (J. Eur. Acad. Dermatol. Venereol. 2007;21:806-10). Another survey featured more specific questions and revealed, for example, that 53% of 539 Nigerian students aged 11–19 believed eating too much butter or margarine contributed to their acne (Int. J. Dermatol. 2009;48:498-505). Eating too much fatty food was cited by 38%.

“We don't know if these things are true or not, but the perception persists,” said Dr. Thiboutot, professor of dermatology at Pennsylvania State University, Hershey.

“There has really only been one prospective, randomized, controlled trial,” she said. The trial included 43 adolescent and adult men in Australia, aged 15–25 years with a mean of 30 inflammatory acne lesions (J. Am. Acad. Dermatol. 2007;57:247-56). One group, randomized to 12 weeks of a low-glycemic-load diet, experienced a significant decrease in total lesions—approximately 50%—compared with a 25% decrease for those randomized to a control diet.

“However, patients on the low glycemic diet lost more weight, so it is hard to differentiate the effect of diet versus weight loss,” Dr. Thiboutot said.

In an observational study, investigators found no acne in certain populations with a low glycemic diet, specifically the Kitavan Islanders of Papua New Guinea and the Aché Indians of Paraguay (Arch. Dermatol. 2002;138:1584-90).

“I reviewed this paper and wrote an editorial,” Dr. Thiboutot said. “I had some reservations about it, but it was also very interesting.” One of the criticisms of this study was the gene-versus-environment argument, she added. “What if they would not have developed acne anyway [regardless of diet]?”

Other researchers have looked at a genetic basis for acne. For example, the risk of adult acne was almost fourfold greater in first-degree relatives of those with adult acne, compared with those without, in another observational study (Br. J. Dermatol. 1999;141:297-300).

“The genetic component may come in with very severe acne,” Dr. Thiboutot said. “How many of you see a teenager with severe acne and you turn and look at the parent, and you see evidence of scarring?” Ask about family history of acne, and if it is positive, more aggressive treatment may be warranted, she said.

Epidemiologic evidence of an association between diet and acne includes two studies about dairy intake. The first assessed intake and acne in girls (J. Am. Acad. Dermatol. 2005;52:207-14). The prevalence of acne correlated with total milk intake (multivariate prevalence ratio, 1.2) and intake of skim milk (1.4), which Dr. Thiboutot described as “not overwhelming.”

She said, “It could be recall bias. How accurately do people remember their milk intake as teenagers?”

Three years later, the investigators published a prospective study of milk intake and acne in 4,273 teenage boys (J. Am. Acad. Dermatol. 2008;58:787-93). Participants self-reported milk consumption and acne assessment. Multivariate prevalence ratios showed weak associations with total milk intake (1.2), whole or 2% milk consumption (1.1), 1% milk (1.2), or skim milk (1.2), Dr. Thiboutot said. They found no association between acne and any other dairy product.

“Clearly, prospective, randomized, controlled trials are needed to further address these questions,” Dr. Thiboutot concluded.

Disclosures: Dr. Thiboutot disclosed financial ties to Allergan, Arcutis Pharmaceuticals, Galderma, Intendis, Medicis, Obagi Medical, and Stiefel Laboratories.

Studies show only a weak association between milk intake and acne.

Source ©Maciej Mamro/Fotolia.com

“Clearly, prospective, randomized, controlled trials are needed to further address these questions,” Dr. Diane Thiboutot concluded.

Source Damian McNamara/Elsevier Medical News Group

Major Finding: Asking patients to recite the days of the week backward correlated better with a standard dementia screen (3.88 on a scale of 0-5) than did a standard spelling (2.24) or counting task (0.90).

Data Source: Prospective study of 222 seniors with varying levels of literacy and education completion.

Disclosures: None was reported.

ORLANDO – Modification of the Mini-Mental State Examination detects dementia with fewer false positives, according to a prospective study of older patients with varying degrees of literacy.

The Mini-Mental State Exam “is highly dependent on patient education,” Dr. Razia Hafiz said at the meeting. For example, clinicians who administer the Mini-Mental State Exam (MMSE) to screen for dementia typically ask people to spell W-O-R-L-D backward, or to start at 100 and count backward in units of seven (100, 93, 86, and so on).

“We are from Eastern North Carolina, where we have a lot of illiterate and low-literacy people. We were falsely classifying a lot of people as dementia,” said Dr. Hafiz, a geriatrics fellow in the department of family medicine at East Carolina University in Greenville, N.C.

Dr. Hafiz and her colleagues modified the MMSE and instead asked 222 participants to recite the days of the week backward. The initiative was successful, she said. “We had fewer false positives.”

They enrolled 28 illiterate patients (13%), 46 semiliterate patients (20%), and 148 literate patients (67%) at an academic outpatient geriatric center, a family medicine center, and a hospital. All participants in the open study had complaints of memory loss or a diagnosis of dementia at baseline.

Each participant also completed the Mini-Cog instrument as a control. The Mini-Cog test indicates dementia if a participant cannot recall any of three items, is interpreted as normal if the individual can recall all three, and relies on the accuracy of a clock drawing when the participant recalls only one or two items. A majority, 71%, met the Mini-Cog criteria for dementia.

Patients with dementia scored higher on the modified MMSE than the traditional MMSE, regardless of literacy level, education, sex, or race. Mean scores were 19.39 on the MMSE and 20.88 on the modified MMSE. On a scale of 0-5 regarding correlation with the Mini-Cog, this group scored a mean of 0.90 on the serial 7 test, 2.24 on the spelling task, and 3.88 on the weekdays exercise.

In addition, participants without dementia all correctly recited the days of the week backward (a score of 5.00) and scored higher on this exercise, compared with the counting (3.85) or serial 7 task (2.02).

Of the 111 participants with less than a high school education, both the mini-Cog and modified MMSE identified 86 with dementia. In contrast, the MMSE identified 95 with dementia, suggesting some were false positives, Dr. Hafiz said.

Using a modified MMSE score cutoff of 27 or less correlated better with the Mini-Cog than did the MMSE among participants who were illiterate, who were semiliterate, or who did not complete high school. With this cutoff, the modified MMSE had a higher sensitivity and specificity for all participants, she said.

The study included 162 women (73%) and 60 men. The mean age of the participants was 80 years. The cohort was 51% white and 49% black. Education level was evenly divided between 111 participants who graduated from high school and 111 others who did not.

Use of the Mini-Cog as a surrogate for dementia instead of a formal diagnostic assessment was a potential limitation of the study, Dr. Hafiz said.

The next step is to make sure that the modified MMSE is applicable over time to monitor the dementia disease process, she said.

Major Finding: Asking patients to recite the days of the week backward correlated better with a standard dementia screen (3.88 on a scale of 0-5) than did a standard spelling (2.24) or counting task (0.90).

Data Source: Prospective study of 222 seniors with varying levels of literacy and education completion.

Disclosures: None was reported.

ORLANDO – Modification of the Mini-Mental State Examination detects dementia with fewer false positives, according to a prospective study of older patients with varying degrees of literacy.

The Mini-Mental State Exam “is highly dependent on patient education,” Dr. Razia Hafiz said at the meeting. For example, clinicians who administer the Mini-Mental State Exam (MMSE) to screen for dementia typically ask people to spell W-O-R-L-D backward, or to start at 100 and count backward in units of seven (100, 93, 86, and so on).

“We are from Eastern North Carolina, where we have a lot of illiterate and low-literacy people. We were falsely classifying a lot of people as dementia,” said Dr. Hafiz, a geriatrics fellow in the department of family medicine at East Carolina University in Greenville, N.C.

Dr. Hafiz and her colleagues modified the MMSE and instead asked 222 participants to recite the days of the week backward. The initiative was successful, she said. “We had fewer false positives.”

They enrolled 28 illiterate patients (13%), 46 semiliterate patients (20%), and 148 literate patients (67%) at an academic outpatient geriatric center, a family medicine center, and a hospital. All participants in the open study had complaints of memory loss or a diagnosis of dementia at baseline.

Each participant also completed the Mini-Cog instrument as a control. The Mini-Cog test indicates dementia if a participant cannot recall any of three items, is interpreted as normal if the individual can recall all three, and relies on the accuracy of a clock drawing when the participant recalls only one or two items. A majority, 71%, met the Mini-Cog criteria for dementia.

Patients with dementia scored higher on the modified MMSE than the traditional MMSE, regardless of literacy level, education, sex, or race. Mean scores were 19.39 on the MMSE and 20.88 on the modified MMSE. On a scale of 0-5 regarding correlation with the Mini-Cog, this group scored a mean of 0.90 on the serial 7 test, 2.24 on the spelling task, and 3.88 on the weekdays exercise.

In addition, participants without dementia all correctly recited the days of the week backward (a score of 5.00) and scored higher on this exercise, compared with the counting (3.85) or serial 7 task (2.02).

Of the 111 participants with less than a high school education, both the mini-Cog and modified MMSE identified 86 with dementia. In contrast, the MMSE identified 95 with dementia, suggesting some were false positives, Dr. Hafiz said.

Using a modified MMSE score cutoff of 27 or less correlated better with the Mini-Cog than did the MMSE among participants who were illiterate, who were semiliterate, or who did not complete high school. With this cutoff, the modified MMSE had a higher sensitivity and specificity for all participants, she said.

The study included 162 women (73%) and 60 men. The mean age of the participants was 80 years. The cohort was 51% white and 49% black. Education level was evenly divided between 111 participants who graduated from high school and 111 others who did not.

Use of the Mini-Cog as a surrogate for dementia instead of a formal diagnostic assessment was a potential limitation of the study, Dr. Hafiz said.

The next step is to make sure that the modified MMSE is applicable over time to monitor the dementia disease process, she said.

Major Finding: Asking patients to recite the days of the week backward correlated better with a standard dementia screen (3.88 on a scale of 0-5) than did a standard spelling (2.24) or counting task (0.90).

Data Source: Prospective study of 222 seniors with varying levels of literacy and education completion.

Disclosures: None was reported.

ORLANDO – Modification of the Mini-Mental State Examination detects dementia with fewer false positives, according to a prospective study of older patients with varying degrees of literacy.

The Mini-Mental State Exam “is highly dependent on patient education,” Dr. Razia Hafiz said at the meeting. For example, clinicians who administer the Mini-Mental State Exam (MMSE) to screen for dementia typically ask people to spell W-O-R-L-D backward, or to start at 100 and count backward in units of seven (100, 93, 86, and so on).

“We are from Eastern North Carolina, where we have a lot of illiterate and low-literacy people. We were falsely classifying a lot of people as dementia,” said Dr. Hafiz, a geriatrics fellow in the department of family medicine at East Carolina University in Greenville, N.C.

Dr. Hafiz and her colleagues modified the MMSE and instead asked 222 participants to recite the days of the week backward. The initiative was successful, she said. “We had fewer false positives.”

They enrolled 28 illiterate patients (13%), 46 semiliterate patients (20%), and 148 literate patients (67%) at an academic outpatient geriatric center, a family medicine center, and a hospital. All participants in the open study had complaints of memory loss or a diagnosis of dementia at baseline.

Each participant also completed the Mini-Cog instrument as a control. The Mini-Cog test indicates dementia if a participant cannot recall any of three items, is interpreted as normal if the individual can recall all three, and relies on the accuracy of a clock drawing when the participant recalls only one or two items. A majority, 71%, met the Mini-Cog criteria for dementia.

Patients with dementia scored higher on the modified MMSE than the traditional MMSE, regardless of literacy level, education, sex, or race. Mean scores were 19.39 on the MMSE and 20.88 on the modified MMSE. On a scale of 0-5 regarding correlation with the Mini-Cog, this group scored a mean of 0.90 on the serial 7 test, 2.24 on the spelling task, and 3.88 on the weekdays exercise.

In addition, participants without dementia all correctly recited the days of the week backward (a score of 5.00) and scored higher on this exercise, compared with the counting (3.85) or serial 7 task (2.02).

Of the 111 participants with less than a high school education, both the mini-Cog and modified MMSE identified 86 with dementia. In contrast, the MMSE identified 95 with dementia, suggesting some were false positives, Dr. Hafiz said.

Using a modified MMSE score cutoff of 27 or less correlated better with the Mini-Cog than did the MMSE among participants who were illiterate, who were semiliterate, or who did not complete high school. With this cutoff, the modified MMSE had a higher sensitivity and specificity for all participants, she said.

The study included 162 women (73%) and 60 men. The mean age of the participants was 80 years. The cohort was 51% white and 49% black. Education level was evenly divided between 111 participants who graduated from high school and 111 others who did not.

Use of the Mini-Cog as a surrogate for dementia instead of a formal diagnostic assessment was a potential limitation of the study, Dr. Hafiz said.

The next step is to make sure that the modified MMSE is applicable over time to monitor the dementia disease process, she said.

ORLANDO — Primary care is a “ripe and rich environment” for youth suicide screening, and a new computer-based tool shows promise for identification of patients at risk, said Guy Diamond, Ph.D.

Dr. Diamond and his colleagues developed a Web-based behavioral health screen that adolescents and young adults can complete in about 10 minutes before seeing their doctor. The 55-item core questions also assess depression, anxiety, and trauma, as well as relevant behaviors, such as drug use and risky sexual behavior. “We put suicide into a bigger context,” he said.

The tool, which Dr. Diamond and his colleagues hope to launch in the fall, addresses everything the American Medical Association and the American Academy of Pediatrics recommend is covered during screening. Although all patients get the same questions asked in the same way, the time to take the screen varies from 9 to 14 minutes, depending on how many symptoms a patient endorses. Responses to the core items can trigger up to 41 additional questions.

The standardized format reduces provider bias, helps focus the clinical visit, and increases case identification, said Dr. Diamond, who is on the psychiatry and behavioral science faculty at Children's Hospital of Pittsburgh.

Sensitivity and specificity are 83% and 87%, respectively, for suicidal risk; 85% and 76% for depression; and 88% and 67% for anxiety, Dr. Diamond said.

When the patient has completed the screen, an automatically generated report prints out with scaled scoring and flagged critical items. On the plus side, the report also identifies individual patient strengths—such as “has a job” or “gets along well with parents.”

The screen's validity was demonstrated in a study of 1,547 primary care patients (Pediatrics 2010;125:945-52). A total of 209 (14%) of the 11- to 20-year-old respondents reported suicidal thoughts in the previous month. Girls, younger youths, substance users, depressed youths, youths who carried weapons, and those who had been in fights were at higher risk. Social workers were able to triage 205 (98%) of those identified, the majority on the same day. Most (152 patients or 74%) were recommended for a mental health evaluation.

Most other primary care screening tools inquire about symptoms that are current or from the previous 2 weeks, even though many physician visits are annual. “Kids who said no to 'current' but yes to 'past' are [still] very high risk,” Dr. Diamond said. “They have just as many risk factors as kids who say they are currently at risk.”

Dr. Diamond said primary care physicians are more likely, in general, to screen for suicide risk if it is part of a comprehensive screen. “When I ask a room of docs how many have seen suicide in their practice, four or five raise their hands. When I ask about depression, everyone raises their hands.”

Although most screening instruments are still paper-and-pencil format, a computerized instrument offers several advantages, Dr. Diamond said. Automated scoring is one example, and greater flexibility to tailor the screen with practice-specific items is another. “If a practice doesn't want to ask about child abuse, we can take it out. If another practice wants to add an STD [sexually transmitted disease] question, we can do that.”

The screen does not fully integrate with electronic medical record systems, Dr. Diamond said in response to a meeting attendee question. For now, the paper report is scanned as a pdf file and entered in the patient's EMR. He added that many doctors were initially nervous about using the tool, but that “many have now integrated it.”

Disclosures: Dr. Diamond will have a financial interest in the screening instrument when it is launched in the fall. At that time, physicians will be able to license the tool, he said.

ORLANDO — Primary care is a “ripe and rich environment” for youth suicide screening, and a new computer-based tool shows promise for identification of patients at risk, said Guy Diamond, Ph.D.

Dr. Diamond and his colleagues developed a Web-based behavioral health screen that adolescents and young adults can complete in about 10 minutes before seeing their doctor. The 55-item core questions also assess depression, anxiety, and trauma, as well as relevant behaviors, such as drug use and risky sexual behavior. “We put suicide into a bigger context,” he said.

The tool, which Dr. Diamond and his colleagues hope to launch in the fall, addresses everything the American Medical Association and the American Academy of Pediatrics recommend is covered during screening. Although all patients get the same questions asked in the same way, the time to take the screen varies from 9 to 14 minutes, depending on how many symptoms a patient endorses. Responses to the core items can trigger up to 41 additional questions.

The standardized format reduces provider bias, helps focus the clinical visit, and increases case identification, said Dr. Diamond, who is on the psychiatry and behavioral science faculty at Children's Hospital of Pittsburgh.

Sensitivity and specificity are 83% and 87%, respectively, for suicidal risk; 85% and 76% for depression; and 88% and 67% for anxiety, Dr. Diamond said.

When the patient has completed the screen, an automatically generated report prints out with scaled scoring and flagged critical items. On the plus side, the report also identifies individual patient strengths—such as “has a job” or “gets along well with parents.”

The screen's validity was demonstrated in a study of 1,547 primary care patients (Pediatrics 2010;125:945-52). A total of 209 (14%) of the 11- to 20-year-old respondents reported suicidal thoughts in the previous month. Girls, younger youths, substance users, depressed youths, youths who carried weapons, and those who had been in fights were at higher risk. Social workers were able to triage 205 (98%) of those identified, the majority on the same day. Most (152 patients or 74%) were recommended for a mental health evaluation.

Most other primary care screening tools inquire about symptoms that are current or from the previous 2 weeks, even though many physician visits are annual. “Kids who said no to 'current' but yes to 'past' are [still] very high risk,” Dr. Diamond said. “They have just as many risk factors as kids who say they are currently at risk.”

Dr. Diamond said primary care physicians are more likely, in general, to screen for suicide risk if it is part of a comprehensive screen. “When I ask a room of docs how many have seen suicide in their practice, four or five raise their hands. When I ask about depression, everyone raises their hands.”

Although most screening instruments are still paper-and-pencil format, a computerized instrument offers several advantages, Dr. Diamond said. Automated scoring is one example, and greater flexibility to tailor the screen with practice-specific items is another. “If a practice doesn't want to ask about child abuse, we can take it out. If another practice wants to add an STD [sexually transmitted disease] question, we can do that.”

The screen does not fully integrate with electronic medical record systems, Dr. Diamond said in response to a meeting attendee question. For now, the paper report is scanned as a pdf file and entered in the patient's EMR. He added that many doctors were initially nervous about using the tool, but that “many have now integrated it.”

Disclosures: Dr. Diamond will have a financial interest in the screening instrument when it is launched in the fall. At that time, physicians will be able to license the tool, he said.

ORLANDO — Primary care is a “ripe and rich environment” for youth suicide screening, and a new computer-based tool shows promise for identification of patients at risk, said Guy Diamond, Ph.D.

Dr. Diamond and his colleagues developed a Web-based behavioral health screen that adolescents and young adults can complete in about 10 minutes before seeing their doctor. The 55-item core questions also assess depression, anxiety, and trauma, as well as relevant behaviors, such as drug use and risky sexual behavior. “We put suicide into a bigger context,” he said.

The tool, which Dr. Diamond and his colleagues hope to launch in the fall, addresses everything the American Medical Association and the American Academy of Pediatrics recommend is covered during screening. Although all patients get the same questions asked in the same way, the time to take the screen varies from 9 to 14 minutes, depending on how many symptoms a patient endorses. Responses to the core items can trigger up to 41 additional questions.

The standardized format reduces provider bias, helps focus the clinical visit, and increases case identification, said Dr. Diamond, who is on the psychiatry and behavioral science faculty at Children's Hospital of Pittsburgh.

Sensitivity and specificity are 83% and 87%, respectively, for suicidal risk; 85% and 76% for depression; and 88% and 67% for anxiety, Dr. Diamond said.

When the patient has completed the screen, an automatically generated report prints out with scaled scoring and flagged critical items. On the plus side, the report also identifies individual patient strengths—such as “has a job” or “gets along well with parents.”

The screen's validity was demonstrated in a study of 1,547 primary care patients (Pediatrics 2010;125:945-52). A total of 209 (14%) of the 11- to 20-year-old respondents reported suicidal thoughts in the previous month. Girls, younger youths, substance users, depressed youths, youths who carried weapons, and those who had been in fights were at higher risk. Social workers were able to triage 205 (98%) of those identified, the majority on the same day. Most (152 patients or 74%) were recommended for a mental health evaluation.

Most other primary care screening tools inquire about symptoms that are current or from the previous 2 weeks, even though many physician visits are annual. “Kids who said no to 'current' but yes to 'past' are [still] very high risk,” Dr. Diamond said. “They have just as many risk factors as kids who say they are currently at risk.”

Dr. Diamond said primary care physicians are more likely, in general, to screen for suicide risk if it is part of a comprehensive screen. “When I ask a room of docs how many have seen suicide in their practice, four or five raise their hands. When I ask about depression, everyone raises their hands.”

Although most screening instruments are still paper-and-pencil format, a computerized instrument offers several advantages, Dr. Diamond said. Automated scoring is one example, and greater flexibility to tailor the screen with practice-specific items is another. “If a practice doesn't want to ask about child abuse, we can take it out. If another practice wants to add an STD [sexually transmitted disease] question, we can do that.”

The screen does not fully integrate with electronic medical record systems, Dr. Diamond said in response to a meeting attendee question. For now, the paper report is scanned as a pdf file and entered in the patient's EMR. He added that many doctors were initially nervous about using the tool, but that “many have now integrated it.”

Disclosures: Dr. Diamond will have a financial interest in the screening instrument when it is launched in the fall. At that time, physicians will be able to license the tool, he said.

ORLANDO — Physicians will see more elderly people with HIV, because of both more new infections among the population and prolonged survival of people with HIV, according to a physician epidemiologist.

Physicians should be screening their senior patients for HIV risk. Ask about sexual activity and counsel them about prevention of sexually transmitted diseases, Dr. Kelly A. Gebo advised.

Older people, in general, have a lack of awareness about HIV risk factors, said Dr. Gebo, associate professor and director of undergraduate research studies at John Hopkins Bloomberg School of Public Health in Baltimore. A lack of HIV prevention targeted at seniors is partly to blame, she said.

As a result, seniors with HIV infection often are diagnosed late in the disease. “The average CD4 count is about 250 in our practice at time of diagnosis. We'd like to diagnose them earlier,” she said.

Many older people are newly single and believe that HIV affects only younger people—two additional challenges to HIV prevention in this population. Erectile dysfunction drugs that increase senior sexual activity may play a role, and some older women stop using condoms once the risk of pregnancy passes with menopause, Dr. Gebo noted.

“I ask everyone from 12 to 112 about alcohol, sexual history, and drug use,” she said, while acknowledging that some physicians aren't as comfortable as she asking seniors about these delicate issues.

In a subsequent presentation, Dr. Kevin P. High suggested how doctors could phrase a recommendation for HIV testing: “I don't believe this is likely, but I would not be doing my job in 2010 if I did not test you for HIV. It's a very treatable illness, and we ought to test.” He added, “I've never had anyone say no.”

Almost 18% of HIV diagnoses in 2007 were made in people older than 50 years, according to the Centers for Disease Control and Prevention. This proportion is expected to grow, Dr. Gebo added.

Compared with younger people, elderly people with HIV get less immunologic boost from some treatments and have shorter survivals. In addition, seniors with HIV can experience an acceleration of the effects of normal aging, including greater bone loss, muscle mass decreases, and memory loss, Dr. Gebo said.

Inflammation could be at the root of seniors' HIV vulnerability. “We all know inflammation is bad in cardiovascular disease,” said Dr. High, professor of infectious diseases at Wake Forest University, Winston-Salem, N.C. Inflammation “is more present in HIV than in age-matched, HIV-negative adults. We think that is the reason for the disease acceleration in older patients with HIV,” he added.

On the plus side, older people are generally more compliant than younger people with their medication regimens. Adherence to prescriptions is particularly important to combat HIV infection because of an elevated risk for viral resistance, Dr. Gebo said.

Another plus, she added, is that older patients tend to experience better virologic suppression following treatment. In response to an audience question, she said that the improved suppression reported in this population was independent of their better medication compliance.

“Unfortunately, it is not all good news for these older patients,” Dr. Gebo said. Evidence suggests that the decrease in immune system strength that comes with normal aging can diminish the efficacy of antiretroviral agents.

Frailty is another factor working against older people with HIV, Dr. High pointed out. The risk for frailty is increased ninefold by HIV infection, he said. For example, only 1%-2% of 55-year-old HIV-negative men will meet the definition for frailty (J. Acquir. Immune Defic. Syndr. 2009;50:299-306). In contrast, 14% of men of the same age with an 8-year-old HIV diagnosis will meet the definition.

Disclosures: Dr. Gebo and Dr. High reported no financial conflicts of interest.

ORLANDO — Physicians will see more elderly people with HIV, because of both more new infections among the population and prolonged survival of people with HIV, according to a physician epidemiologist.

Physicians should be screening their senior patients for HIV risk. Ask about sexual activity and counsel them about prevention of sexually transmitted diseases, Dr. Kelly A. Gebo advised.

Older people, in general, have a lack of awareness about HIV risk factors, said Dr. Gebo, associate professor and director of undergraduate research studies at John Hopkins Bloomberg School of Public Health in Baltimore. A lack of HIV prevention targeted at seniors is partly to blame, she said.

As a result, seniors with HIV infection often are diagnosed late in the disease. “The average CD4 count is about 250 in our practice at time of diagnosis. We'd like to diagnose them earlier,” she said.

Many older people are newly single and believe that HIV affects only younger people—two additional challenges to HIV prevention in this population. Erectile dysfunction drugs that increase senior sexual activity may play a role, and some older women stop using condoms once the risk of pregnancy passes with menopause, Dr. Gebo noted.

“I ask everyone from 12 to 112 about alcohol, sexual history, and drug use,” she said, while acknowledging that some physicians aren't as comfortable as she asking seniors about these delicate issues.

In a subsequent presentation, Dr. Kevin P. High suggested how doctors could phrase a recommendation for HIV testing: “I don't believe this is likely, but I would not be doing my job in 2010 if I did not test you for HIV. It's a very treatable illness, and we ought to test.” He added, “I've never had anyone say no.”

Almost 18% of HIV diagnoses in 2007 were made in people older than 50 years, according to the Centers for Disease Control and Prevention. This proportion is expected to grow, Dr. Gebo added.

Compared with younger people, elderly people with HIV get less immunologic boost from some treatments and have shorter survivals. In addition, seniors with HIV can experience an acceleration of the effects of normal aging, including greater bone loss, muscle mass decreases, and memory loss, Dr. Gebo said.

Inflammation could be at the root of seniors' HIV vulnerability. “We all know inflammation is bad in cardiovascular disease,” said Dr. High, professor of infectious diseases at Wake Forest University, Winston-Salem, N.C. Inflammation “is more present in HIV than in age-matched, HIV-negative adults. We think that is the reason for the disease acceleration in older patients with HIV,” he added.

On the plus side, older people are generally more compliant than younger people with their medication regimens. Adherence to prescriptions is particularly important to combat HIV infection because of an elevated risk for viral resistance, Dr. Gebo said.

Another plus, she added, is that older patients tend to experience better virologic suppression following treatment. In response to an audience question, she said that the improved suppression reported in this population was independent of their better medication compliance.

“Unfortunately, it is not all good news for these older patients,” Dr. Gebo said. Evidence suggests that the decrease in immune system strength that comes with normal aging can diminish the efficacy of antiretroviral agents.

Frailty is another factor working against older people with HIV, Dr. High pointed out. The risk for frailty is increased ninefold by HIV infection, he said. For example, only 1%-2% of 55-year-old HIV-negative men will meet the definition for frailty (J. Acquir. Immune Defic. Syndr. 2009;50:299-306). In contrast, 14% of men of the same age with an 8-year-old HIV diagnosis will meet the definition.

Disclosures: Dr. Gebo and Dr. High reported no financial conflicts of interest.

ORLANDO — Physicians will see more elderly people with HIV, because of both more new infections among the population and prolonged survival of people with HIV, according to a physician epidemiologist.

Physicians should be screening their senior patients for HIV risk. Ask about sexual activity and counsel them about prevention of sexually transmitted diseases, Dr. Kelly A. Gebo advised.

Older people, in general, have a lack of awareness about HIV risk factors, said Dr. Gebo, associate professor and director of undergraduate research studies at John Hopkins Bloomberg School of Public Health in Baltimore. A lack of HIV prevention targeted at seniors is partly to blame, she said.

As a result, seniors with HIV infection often are diagnosed late in the disease. “The average CD4 count is about 250 in our practice at time of diagnosis. We'd like to diagnose them earlier,” she said.

Many older people are newly single and believe that HIV affects only younger people—two additional challenges to HIV prevention in this population. Erectile dysfunction drugs that increase senior sexual activity may play a role, and some older women stop using condoms once the risk of pregnancy passes with menopause, Dr. Gebo noted.

“I ask everyone from 12 to 112 about alcohol, sexual history, and drug use,” she said, while acknowledging that some physicians aren't as comfortable as she asking seniors about these delicate issues.

In a subsequent presentation, Dr. Kevin P. High suggested how doctors could phrase a recommendation for HIV testing: “I don't believe this is likely, but I would not be doing my job in 2010 if I did not test you for HIV. It's a very treatable illness, and we ought to test.” He added, “I've never had anyone say no.”

Almost 18% of HIV diagnoses in 2007 were made in people older than 50 years, according to the Centers for Disease Control and Prevention. This proportion is expected to grow, Dr. Gebo added.

Compared with younger people, elderly people with HIV get less immunologic boost from some treatments and have shorter survivals. In addition, seniors with HIV can experience an acceleration of the effects of normal aging, including greater bone loss, muscle mass decreases, and memory loss, Dr. Gebo said.

Inflammation could be at the root of seniors' HIV vulnerability. “We all know inflammation is bad in cardiovascular disease,” said Dr. High, professor of infectious diseases at Wake Forest University, Winston-Salem, N.C. Inflammation “is more present in HIV than in age-matched, HIV-negative adults. We think that is the reason for the disease acceleration in older patients with HIV,” he added.

On the plus side, older people are generally more compliant than younger people with their medication regimens. Adherence to prescriptions is particularly important to combat HIV infection because of an elevated risk for viral resistance, Dr. Gebo said.

Another plus, she added, is that older patients tend to experience better virologic suppression following treatment. In response to an audience question, she said that the improved suppression reported in this population was independent of their better medication compliance.

“Unfortunately, it is not all good news for these older patients,” Dr. Gebo said. Evidence suggests that the decrease in immune system strength that comes with normal aging can diminish the efficacy of antiretroviral agents.

Frailty is another factor working against older people with HIV, Dr. High pointed out. The risk for frailty is increased ninefold by HIV infection, he said. For example, only 1%-2% of 55-year-old HIV-negative men will meet the definition for frailty (J. Acquir. Immune Defic. Syndr. 2009;50:299-306). In contrast, 14% of men of the same age with an 8-year-old HIV diagnosis will meet the definition.

Disclosures: Dr. Gebo and Dr. High reported no financial conflicts of interest.

Major Finding: Among 16 focus groups made up of 103 residents and staff, 18% of the groups and 38% of participants reported witnessing sexually aggressive behavior in a nursing home setting.

Data Source: Analysis of focus group answers to questions at single, large, not-for-profit skilled nursing facility.

Disclosures: Tony Rosen, a medical student and researcher, had no relevant disclosures.

ORLANDO – Sexually aggressive behavior might be common between nursing home residents, according to a focus group study.

Most sexual aggression against older adults occurs in long-term care facilities rather than in community settings, according to previous case series. “Very little direct research exists [regarding] what we've begun to call RRSA or resident-to-resident sexual aggression,” said Tony Rosen, who conducted the research within the division of geriatrics and gerontology of Cornell University, New York.

Fellow residents are the most common perpetrators of sexually aggressive behavior, not nursing home staff, as sometimes reported in the media, Mr. Rosen said at the annual meeting of the American Geriatrics Society.

Among 103 participants in 16 focus groups including nursing home employees and some residents, 38% of participants in 18% of the focus groups reported having witnessed sexually aggressive behavior.

Inappropriate touching was the most commonly reported behavior in the study, mentioned in 38% of focus groups by 7% of participants. Residents attempting to get into the bed of another (13% of groups and 18% of participants) and verbal sexual abuse (13% of groups and 5% of participants) were the next most frequent incidents reported.

A behavior cited in the focus groups that surprised the researchers was inappropriate caregiving, mentioned in 6% of groups and by 3% of participants. “Inappropriate caregiving is residents trying to give intimate nursing care to other residents, a phenomenon we did not expect,” Mr. Rosen said.

The focus groups included 7 cognitively intact residents and 96 clinical and nonclinical employees from all three shifts at a single, large, not-for-profit long-term care facility. The descriptions of witnessed sexually aggressive behavior came from a larger focus group study evaluating overall resident-to-resident verbal and physical aggression.

“Prevention and management [of these behaviors] are more challenging due to legitimate and increasingly recognized need for sexual expression by nursing home residents,” said Mr. Rosen, a medical student at Cornell.

Mr. Rosen and his colleagues defined RRSA as “negative sexual interactions between long-term care residents, that in a community setting would likely be construed as unwelcome and have high potential to cause physical or psychological distress in the recipient.” Consequences for residents include sexually transmitted diseases, agitation, and posttraumatic stress disorder, he said.

Focus group facilitators used semistructured, open-ended interview questions. Average focus group time was 45 minutes.

The researchers also elicited reasons or triggers for RRSA. For example, a resident mistaking another for his or her spouse was reported by 13% of groups and 8% of participants. Cognitive impairment and wandering each were cited as reasons in 13% of groups and by 5% of participants.

“This is a very challenging issue,” Mr. Rosen said. “And sexual aggression can be a very charged topic.” He recommended that these behaviors be studied and understood in the context of brain disease and agitation-related behaviors.

Resident rooms were the setting for the sexually aggressive behavior mentioned by 13% of groups and 2% of participants. Similarly, nursing home dining rooms were mentioned by 13% of groups and 1% of participants. Somewhat surprisingly, Mr. Rosen said, 6% of groups and 3% of participants also said they saw sexual aggression in main lounges or television viewing areas.

Mr. Rosen made no relevant financial disclosures.

Management of these behaviors is complicated because residents have a need for sexual expression.

Source MR. ROSEN

Major Finding: Among 16 focus groups made up of 103 residents and staff, 18% of the groups and 38% of participants reported witnessing sexually aggressive behavior in a nursing home setting.

Data Source: Analysis of focus group answers to questions at single, large, not-for-profit skilled nursing facility.

Disclosures: Tony Rosen, a medical student and researcher, had no relevant disclosures.

ORLANDO – Sexually aggressive behavior might be common between nursing home residents, according to a focus group study.

Most sexual aggression against older adults occurs in long-term care facilities rather than in community settings, according to previous case series. “Very little direct research exists [regarding] what we've begun to call RRSA or resident-to-resident sexual aggression,” said Tony Rosen, who conducted the research within the division of geriatrics and gerontology of Cornell University, New York.

Fellow residents are the most common perpetrators of sexually aggressive behavior, not nursing home staff, as sometimes reported in the media, Mr. Rosen said at the annual meeting of the American Geriatrics Society.

Among 103 participants in 16 focus groups including nursing home employees and some residents, 38% of participants in 18% of the focus groups reported having witnessed sexually aggressive behavior.

Inappropriate touching was the most commonly reported behavior in the study, mentioned in 38% of focus groups by 7% of participants. Residents attempting to get into the bed of another (13% of groups and 18% of participants) and verbal sexual abuse (13% of groups and 5% of participants) were the next most frequent incidents reported.

A behavior cited in the focus groups that surprised the researchers was inappropriate caregiving, mentioned in 6% of groups and by 3% of participants. “Inappropriate caregiving is residents trying to give intimate nursing care to other residents, a phenomenon we did not expect,” Mr. Rosen said.

The focus groups included 7 cognitively intact residents and 96 clinical and nonclinical employees from all three shifts at a single, large, not-for-profit long-term care facility. The descriptions of witnessed sexually aggressive behavior came from a larger focus group study evaluating overall resident-to-resident verbal and physical aggression.

“Prevention and management [of these behaviors] are more challenging due to legitimate and increasingly recognized need for sexual expression by nursing home residents,” said Mr. Rosen, a medical student at Cornell.

Mr. Rosen and his colleagues defined RRSA as “negative sexual interactions between long-term care residents, that in a community setting would likely be construed as unwelcome and have high potential to cause physical or psychological distress in the recipient.” Consequences for residents include sexually transmitted diseases, agitation, and posttraumatic stress disorder, he said.

Focus group facilitators used semistructured, open-ended interview questions. Average focus group time was 45 minutes.

The researchers also elicited reasons or triggers for RRSA. For example, a resident mistaking another for his or her spouse was reported by 13% of groups and 8% of participants. Cognitive impairment and wandering each were cited as reasons in 13% of groups and by 5% of participants.

“This is a very challenging issue,” Mr. Rosen said. “And sexual aggression can be a very charged topic.” He recommended that these behaviors be studied and understood in the context of brain disease and agitation-related behaviors.

Resident rooms were the setting for the sexually aggressive behavior mentioned by 13% of groups and 2% of participants. Similarly, nursing home dining rooms were mentioned by 13% of groups and 1% of participants. Somewhat surprisingly, Mr. Rosen said, 6% of groups and 3% of participants also said they saw sexual aggression in main lounges or television viewing areas.

Mr. Rosen made no relevant financial disclosures.

Management of these behaviors is complicated because residents have a need for sexual expression.

Source MR. ROSEN

Major Finding: Among 16 focus groups made up of 103 residents and staff, 18% of the groups and 38% of participants reported witnessing sexually aggressive behavior in a nursing home setting.

Data Source: Analysis of focus group answers to questions at single, large, not-for-profit skilled nursing facility.

Disclosures: Tony Rosen, a medical student and researcher, had no relevant disclosures.

ORLANDO – Sexually aggressive behavior might be common between nursing home residents, according to a focus group study.

Most sexual aggression against older adults occurs in long-term care facilities rather than in community settings, according to previous case series. “Very little direct research exists [regarding] what we've begun to call RRSA or resident-to-resident sexual aggression,” said Tony Rosen, who conducted the research within the division of geriatrics and gerontology of Cornell University, New York.

Fellow residents are the most common perpetrators of sexually aggressive behavior, not nursing home staff, as sometimes reported in the media, Mr. Rosen said at the annual meeting of the American Geriatrics Society.

Among 103 participants in 16 focus groups including nursing home employees and some residents, 38% of participants in 18% of the focus groups reported having witnessed sexually aggressive behavior.

Inappropriate touching was the most commonly reported behavior in the study, mentioned in 38% of focus groups by 7% of participants. Residents attempting to get into the bed of another (13% of groups and 18% of participants) and verbal sexual abuse (13% of groups and 5% of participants) were the next most frequent incidents reported.

A behavior cited in the focus groups that surprised the researchers was inappropriate caregiving, mentioned in 6% of groups and by 3% of participants. “Inappropriate caregiving is residents trying to give intimate nursing care to other residents, a phenomenon we did not expect,” Mr. Rosen said.

The focus groups included 7 cognitively intact residents and 96 clinical and nonclinical employees from all three shifts at a single, large, not-for-profit long-term care facility. The descriptions of witnessed sexually aggressive behavior came from a larger focus group study evaluating overall resident-to-resident verbal and physical aggression.

“Prevention and management [of these behaviors] are more challenging due to legitimate and increasingly recognized need for sexual expression by nursing home residents,” said Mr. Rosen, a medical student at Cornell.

Mr. Rosen and his colleagues defined RRSA as “negative sexual interactions between long-term care residents, that in a community setting would likely be construed as unwelcome and have high potential to cause physical or psychological distress in the recipient.” Consequences for residents include sexually transmitted diseases, agitation, and posttraumatic stress disorder, he said.

Focus group facilitators used semistructured, open-ended interview questions. Average focus group time was 45 minutes.

The researchers also elicited reasons or triggers for RRSA. For example, a resident mistaking another for his or her spouse was reported by 13% of groups and 8% of participants. Cognitive impairment and wandering each were cited as reasons in 13% of groups and by 5% of participants.

“This is a very challenging issue,” Mr. Rosen said. “And sexual aggression can be a very charged topic.” He recommended that these behaviors be studied and understood in the context of brain disease and agitation-related behaviors.

Resident rooms were the setting for the sexually aggressive behavior mentioned by 13% of groups and 2% of participants. Similarly, nursing home dining rooms were mentioned by 13% of groups and 1% of participants. Somewhat surprisingly, Mr. Rosen said, 6% of groups and 3% of participants also said they saw sexual aggression in main lounges or television viewing areas.

Mr. Rosen made no relevant financial disclosures.

Management of these behaviors is complicated because residents have a need for sexual expression.

Source MR. ROSEN

Major Finding: For infants undergoing corrective surgery for hypertrophic pyloric stenosis, freestanding children's hospitals had the lowest unadjusted complication rate, at 1.2% vs. 1.6% at children's units located within general hospitals and 2.2% at general hospitals.

Data Source: Kids' Inpatient Database of 10,969 pyloromyotomies that were performed during 2000, 2003, and 2006.

Disclosures: Dr. Raval had no relevant financial disclosures.

SAN ANTONIO — Infants with hypertrophic pyloric stenosis experience a shorter length of hospital stay and fewer complications if they undergo surgery at a freestanding children's hospital rather than a general hospital with or without a children's unit, according to a retrospective study of nearly 11,000 cases.

Dr. Mehul Raval and his associates compared length of stay, charges, and morbidity associated with pyloromyotomy at the three hospital types. They identified 10,969 infants using the Agency for Healthcare Research and Quality Kids' Inpatient Database for 2000, 2003, and 2006. Patients were less than 1 year old at surgery.

Overall mean length of hospital stay was 2.62 days. Least squares means adjusted length of stay was 2.41 days for freestanding children's hospitals, 2.75 days for the children's units, and 2.82 days for general hospitals.

“We decided a length of stay of 4 or more days would be considered a prolonged length of stay,” said Dr. Raval, a clinical scholar in residence in the division of research and optimal patient care at the American College of Surgeons and a general surgery resident at Northwestern University in Chicago.

Prolonged stays were seen in 16% of cases and were more likely following surgery at a general hospital (odds ratio, 1.7) than at a children's hospital after adjusting for patient and hospital factors.

Least squares means adjusted pyloromyotomy charges were $11,160 at children's hospitals, $12,284 at children's units, and $10,197 at general hospitals.

Charges rose over the 3 years of the study. Adjusted mean charges were $7,733 in 2000, and increased to $11,335 in 2003 and to $14,572 in 2006. These differences were statistically significant.

Of the 786 hospitals in the database, 30 (4%) were freestanding children's hospitals, “but they accounted for nearly 25% of our procedures,” Dr. Raval said. There were also 94 children's units at general hospitals, where 35% of pyloromyotomies were done, as well as 662 general hospitals that accounted for the remaining 40% of surgeries.

“We see overall complications are lower at children's hospitals and at children's units,” Dr. Raval said. The overall complication rate was 1.8%. Freestanding children's hospitals had the lowest unadjusted complication rate, 1.2%, compared with 1.6% at children's units and 2.2% at general hospitals.

The difference could be a volume effect, he added. Children's hospitals averaged 30 pyloromyotomies per hospital per year in the study, compared with 13 at children's units and 2 at the general hospitals.

The administrative study data do not address some factors, such as extent of surgeon training or type of pyloromyotomy (laparoscopic vs. open), a potential limitation of the study. In addition, charges and costs are not identical, Dr. Raval said.

Major Finding: For infants undergoing corrective surgery for hypertrophic pyloric stenosis, freestanding children's hospitals had the lowest unadjusted complication rate, at 1.2% vs. 1.6% at children's units located within general hospitals and 2.2% at general hospitals.

Data Source: Kids' Inpatient Database of 10,969 pyloromyotomies that were performed during 2000, 2003, and 2006.

Disclosures: Dr. Raval had no relevant financial disclosures.

SAN ANTONIO — Infants with hypertrophic pyloric stenosis experience a shorter length of hospital stay and fewer complications if they undergo surgery at a freestanding children's hospital rather than a general hospital with or without a children's unit, according to a retrospective study of nearly 11,000 cases.

Dr. Mehul Raval and his associates compared length of stay, charges, and morbidity associated with pyloromyotomy at the three hospital types. They identified 10,969 infants using the Agency for Healthcare Research and Quality Kids' Inpatient Database for 2000, 2003, and 2006. Patients were less than 1 year old at surgery.

Overall mean length of hospital stay was 2.62 days. Least squares means adjusted length of stay was 2.41 days for freestanding children's hospitals, 2.75 days for the children's units, and 2.82 days for general hospitals.

“We decided a length of stay of 4 or more days would be considered a prolonged length of stay,” said Dr. Raval, a clinical scholar in residence in the division of research and optimal patient care at the American College of Surgeons and a general surgery resident at Northwestern University in Chicago.

Prolonged stays were seen in 16% of cases and were more likely following surgery at a general hospital (odds ratio, 1.7) than at a children's hospital after adjusting for patient and hospital factors.

Least squares means adjusted pyloromyotomy charges were $11,160 at children's hospitals, $12,284 at children's units, and $10,197 at general hospitals.

Charges rose over the 3 years of the study. Adjusted mean charges were $7,733 in 2000, and increased to $11,335 in 2003 and to $14,572 in 2006. These differences were statistically significant.

Of the 786 hospitals in the database, 30 (4%) were freestanding children's hospitals, “but they accounted for nearly 25% of our procedures,” Dr. Raval said. There were also 94 children's units at general hospitals, where 35% of pyloromyotomies were done, as well as 662 general hospitals that accounted for the remaining 40% of surgeries.

“We see overall complications are lower at children's hospitals and at children's units,” Dr. Raval said. The overall complication rate was 1.8%. Freestanding children's hospitals had the lowest unadjusted complication rate, 1.2%, compared with 1.6% at children's units and 2.2% at general hospitals.

The difference could be a volume effect, he added. Children's hospitals averaged 30 pyloromyotomies per hospital per year in the study, compared with 13 at children's units and 2 at the general hospitals.

The administrative study data do not address some factors, such as extent of surgeon training or type of pyloromyotomy (laparoscopic vs. open), a potential limitation of the study. In addition, charges and costs are not identical, Dr. Raval said.

Major Finding: For infants undergoing corrective surgery for hypertrophic pyloric stenosis, freestanding children's hospitals had the lowest unadjusted complication rate, at 1.2% vs. 1.6% at children's units located within general hospitals and 2.2% at general hospitals.

Data Source: Kids' Inpatient Database of 10,969 pyloromyotomies that were performed during 2000, 2003, and 2006.

Disclosures: Dr. Raval had no relevant financial disclosures.

SAN ANTONIO — Infants with hypertrophic pyloric stenosis experience a shorter length of hospital stay and fewer complications if they undergo surgery at a freestanding children's hospital rather than a general hospital with or without a children's unit, according to a retrospective study of nearly 11,000 cases.

Dr. Mehul Raval and his associates compared length of stay, charges, and morbidity associated with pyloromyotomy at the three hospital types. They identified 10,969 infants using the Agency for Healthcare Research and Quality Kids' Inpatient Database for 2000, 2003, and 2006. Patients were less than 1 year old at surgery.

Overall mean length of hospital stay was 2.62 days. Least squares means adjusted length of stay was 2.41 days for freestanding children's hospitals, 2.75 days for the children's units, and 2.82 days for general hospitals.

“We decided a length of stay of 4 or more days would be considered a prolonged length of stay,” said Dr. Raval, a clinical scholar in residence in the division of research and optimal patient care at the American College of Surgeons and a general surgery resident at Northwestern University in Chicago.

Prolonged stays were seen in 16% of cases and were more likely following surgery at a general hospital (odds ratio, 1.7) than at a children's hospital after adjusting for patient and hospital factors.

Least squares means adjusted pyloromyotomy charges were $11,160 at children's hospitals, $12,284 at children's units, and $10,197 at general hospitals.

Charges rose over the 3 years of the study. Adjusted mean charges were $7,733 in 2000, and increased to $11,335 in 2003 and to $14,572 in 2006. These differences were statistically significant.

Of the 786 hospitals in the database, 30 (4%) were freestanding children's hospitals, “but they accounted for nearly 25% of our procedures,” Dr. Raval said. There were also 94 children's units at general hospitals, where 35% of pyloromyotomies were done, as well as 662 general hospitals that accounted for the remaining 40% of surgeries.

“We see overall complications are lower at children's hospitals and at children's units,” Dr. Raval said. The overall complication rate was 1.8%. Freestanding children's hospitals had the lowest unadjusted complication rate, 1.2%, compared with 1.6% at children's units and 2.2% at general hospitals.

The difference could be a volume effect, he added. Children's hospitals averaged 30 pyloromyotomies per hospital per year in the study, compared with 13 at children's units and 2 at the general hospitals.

The administrative study data do not address some factors, such as extent of surgeon training or type of pyloromyotomy (laparoscopic vs. open), a potential limitation of the study. In addition, charges and costs are not identical, Dr. Raval said.

Major Finding: In 996 patients on mechanical ventilation longer than expected, standardized mortality ratios were 0.74 for the ICU and 0.77 for the hospital.

Data Source: Single-center review of 5,345 patients ventilated on their first day in the ICU during the period 2004-2009.

Disclosures: None were reported.

MIAMI BEACH — Patients who exceeded their expected time on mechanical ventilation by 2 or more days fared no worse than did those who were weaned within predicted times, based on discharge rates and follow-up at 30, 60, and 90 days.

Of 5,345 patients who were mechanically ventilated on their first ICU day, nearly 19% (996) were outliers. Yet survival was better than expected in this group, with standardized mortality ratios of 0.74 for the ICU and 0.77 for the hospital. In other terms, 65 of the 996 patients in the outlier group were “unexpected survivors,” Kelly Becker, R.N., said at the annual congress of the Society of Critical Care Medicine.

Survival to, 30, 60, and 90 days was assessed for a subset of 99 patients ventilated in 2008. Of those patients, 75% survived for at least 90 days post discharge.

“We did not have the outcomes we expected at all—we were surprised,” Ms. Becker said in an interview at a poster she copresented with Sue Hanna. Both presenters are affiliated with Borgess Medical Center, a 424-bed research and teaching hospital in Kalamazoo, Mich.

“Length of stay and length of time on a ventilator does not always measure how well you are taking care of a patient who is critically ill,” she remarked.

Patients in the study were on mechanical ventilation between November 2004 and July 2009. The median APACHE score was 78 (range, 74-104). Nearly half (48%) were aged 65 years or older.

In aggregate, the patients who exceeded their expected mechanical ventilation time by at least 2 days (the APACHE IV definition of ventilator outlier) had 9,163 more total days of mechanical ventilation than predicted. Similarly, this group spent 10,956 more days than expected in the ICU and 9,750 additional days in the hospital.

The study is ongoing, with more patients being recruited, Ms. Becker said.

Major Finding: In 996 patients on mechanical ventilation longer than expected, standardized mortality ratios were 0.74 for the ICU and 0.77 for the hospital.

Data Source: Single-center review of 5,345 patients ventilated on their first day in the ICU during the period 2004-2009.

Disclosures: None were reported.

MIAMI BEACH — Patients who exceeded their expected time on mechanical ventilation by 2 or more days fared no worse than did those who were weaned within predicted times, based on discharge rates and follow-up at 30, 60, and 90 days.

Of 5,345 patients who were mechanically ventilated on their first ICU day, nearly 19% (996) were outliers. Yet survival was better than expected in this group, with standardized mortality ratios of 0.74 for the ICU and 0.77 for the hospital. In other terms, 65 of the 996 patients in the outlier group were “unexpected survivors,” Kelly Becker, R.N., said at the annual congress of the Society of Critical Care Medicine.

Survival to, 30, 60, and 90 days was assessed for a subset of 99 patients ventilated in 2008. Of those patients, 75% survived for at least 90 days post discharge.

“We did not have the outcomes we expected at all—we were surprised,” Ms. Becker said in an interview at a poster she copresented with Sue Hanna. Both presenters are affiliated with Borgess Medical Center, a 424-bed research and teaching hospital in Kalamazoo, Mich.

“Length of stay and length of time on a ventilator does not always measure how well you are taking care of a patient who is critically ill,” she remarked.

Patients in the study were on mechanical ventilation between November 2004 and July 2009. The median APACHE score was 78 (range, 74-104). Nearly half (48%) were aged 65 years or older.

In aggregate, the patients who exceeded their expected mechanical ventilation time by at least 2 days (the APACHE IV definition of ventilator outlier) had 9,163 more total days of mechanical ventilation than predicted. Similarly, this group spent 10,956 more days than expected in the ICU and 9,750 additional days in the hospital.

The study is ongoing, with more patients being recruited, Ms. Becker said.

Major Finding: In 996 patients on mechanical ventilation longer than expected, standardized mortality ratios were 0.74 for the ICU and 0.77 for the hospital.

Data Source: Single-center review of 5,345 patients ventilated on their first day in the ICU during the period 2004-2009.

Disclosures: None were reported.

MIAMI BEACH — Patients who exceeded their expected time on mechanical ventilation by 2 or more days fared no worse than did those who were weaned within predicted times, based on discharge rates and follow-up at 30, 60, and 90 days.

Of 5,345 patients who were mechanically ventilated on their first ICU day, nearly 19% (996) were outliers. Yet survival was better than expected in this group, with standardized mortality ratios of 0.74 for the ICU and 0.77 for the hospital. In other terms, 65 of the 996 patients in the outlier group were “unexpected survivors,” Kelly Becker, R.N., said at the annual congress of the Society of Critical Care Medicine.

Survival to, 30, 60, and 90 days was assessed for a subset of 99 patients ventilated in 2008. Of those patients, 75% survived for at least 90 days post discharge.

“We did not have the outcomes we expected at all—we were surprised,” Ms. Becker said in an interview at a poster she copresented with Sue Hanna. Both presenters are affiliated with Borgess Medical Center, a 424-bed research and teaching hospital in Kalamazoo, Mich.

“Length of stay and length of time on a ventilator does not always measure how well you are taking care of a patient who is critically ill,” she remarked.

Patients in the study were on mechanical ventilation between November 2004 and July 2009. The median APACHE score was 78 (range, 74-104). Nearly half (48%) were aged 65 years or older.

In aggregate, the patients who exceeded their expected mechanical ventilation time by at least 2 days (the APACHE IV definition of ventilator outlier) had 9,163 more total days of mechanical ventilation than predicted. Similarly, this group spent 10,956 more days than expected in the ICU and 9,750 additional days in the hospital.

The study is ongoing, with more patients being recruited, Ms. Becker said.

MIAMI BEACH — The extent of mortality due to ventilator-associated pneumonia remains uncertain, but its impact on increasing morbidity and hospital costs is clear, Dr. Robert C. Hyzy said.

“Pneumonia is bad; pneumonia kills people; so, ventilator-associated pneumonia must be bad, too, right?” Dr. Hyzy said at the annual congress. The unresolved issue is whether patients die with or die from ventilator-associated pneumonia (VAP).

There is little evidence-based medicine to make this determination. Most studies designed to assess VAP mortality are observational cohort trials.

For example, a systematic review of observational studies revealed an overall relative mortality risk of 1.27 for patients with VAP, compared with those without (Crit. Care Med. 2009;37:2709-18). “But a high degree of heterogeneity between studies limits the observation,” said Dr. Hyzy, who is an associate professor of medicine and director of the critical care medicine unit at the University of Michigan, Ann Arbor. “Ultimately, these investigators said they do not know.”

However, there are two subpopulations for which there is enough evidence to clear VAP of attributable mortality, he added.

In a subset of patients—those with acute respiratory distress syndrome (ARDS) or trauma—data were sufficiently robust to demonstrate that mechanically ventilated patients were not at increased risk of death if they developed VAP. “This makes sense—these patients are very sick to begin with,” Dr. Hyzy said.

Regarding morbidity, another study indicated that 27% of 401 patients with microbiologically proven VAP experienced recurrence of pneumonia within 28 days of onset of VAP (Crit. Care Med. 2007;35:146-54).

A 14% relapse rate and a 19% superinfection rate were other findings in that study. Dr. Hyzy noted that recurrence was more likely if patients were infected with methicillin-resistant Staphylococcus aureus (odds ratio, 2.50) or nonfermenting gram-negative bacilli (OR, 2.00).

Interestingly, recurrence did not differ significantly between patients who received 8 days vs. 15 days of antibiotic therapy.

Not surprisingly, superinfection increased length of hospital stay and costs for patients with VAP. Other researchers quantified those effects in a retrospective study of 74 patients (Semin. Respir. Crit. Care Med. 2009;30: 116-23). The researchers in that study found that median length of stay was 48 days for patients who had a superinfection, compared with 28 days for unaffected patients.

“If you stay longer, you may get superinfected, and you can get recurrence. Also, the longer you stay, the more it will cost,” Dr. Hyzy said.

Other researchers calculated that the cost attributable to VAP was $11,897.

They studied 819 mechanically ventilated patients, 127 (16%) of whom developed VAP. Total hospital costs also were significantly higher for VAP patients, $70,568, compared with non-VAP patients, $21,620 (Crit. Care Med. 2003;31:1312-7). Total costs included room, nursing, respiratory therapy, and pharmacy.

In March 2009, a health economist reported costs associated with a range of hospital-acquired infections, including approximately 52,542 VAP infections (www.cdc.gov/NCIDOD/DHQP/pdf/Scott_CostPaper.pdf

Silver-coated endotracheal tubes for mechanical ventilation of critical care patients were associated with lower rates of VAP, 4.8%, compared with traditional tubes, 7.5%, in another study (JAMA 2008;300:805-13). However, their higher cost needs to be considered, said Dr. Hyzy, a collaborator on the study.

Dr. Hyzy disclosed that he is a former consultant to Kimberly-Clark, maker of the silver-coated Microcuff Endotracheal Tube.

MIAMI BEACH — The extent of mortality due to ventilator-associated pneumonia remains uncertain, but its impact on increasing morbidity and hospital costs is clear, Dr. Robert C. Hyzy said.

“Pneumonia is bad; pneumonia kills people; so, ventilator-associated pneumonia must be bad, too, right?” Dr. Hyzy said at the annual congress. The unresolved issue is whether patients die with or die from ventilator-associated pneumonia (VAP).

There is little evidence-based medicine to make this determination. Most studies designed to assess VAP mortality are observational cohort trials.

For example, a systematic review of observational studies revealed an overall relative mortality risk of 1.27 for patients with VAP, compared with those without (Crit. Care Med. 2009;37:2709-18). “But a high degree of heterogeneity between studies limits the observation,” said Dr. Hyzy, who is an associate professor of medicine and director of the critical care medicine unit at the University of Michigan, Ann Arbor. “Ultimately, these investigators said they do not know.”

However, there are two subpopulations for which there is enough evidence to clear VAP of attributable mortality, he added.

In a subset of patients—those with acute respiratory distress syndrome (ARDS) or trauma—data were sufficiently robust to demonstrate that mechanically ventilated patients were not at increased risk of death if they developed VAP. “This makes sense—these patients are very sick to begin with,” Dr. Hyzy said.

Regarding morbidity, another study indicated that 27% of 401 patients with microbiologically proven VAP experienced recurrence of pneumonia within 28 days of onset of VAP (Crit. Care Med. 2007;35:146-54).

A 14% relapse rate and a 19% superinfection rate were other findings in that study. Dr. Hyzy noted that recurrence was more likely if patients were infected with methicillin-resistant Staphylococcus aureus (odds ratio, 2.50) or nonfermenting gram-negative bacilli (OR, 2.00).

Interestingly, recurrence did not differ significantly between patients who received 8 days vs. 15 days of antibiotic therapy.

Not surprisingly, superinfection increased length of hospital stay and costs for patients with VAP. Other researchers quantified those effects in a retrospective study of 74 patients (Semin. Respir. Crit. Care Med. 2009;30: 116-23). The researchers in that study found that median length of stay was 48 days for patients who had a superinfection, compared with 28 days for unaffected patients.

“If you stay longer, you may get superinfected, and you can get recurrence. Also, the longer you stay, the more it will cost,” Dr. Hyzy said.

Other researchers calculated that the cost attributable to VAP was $11,897.

They studied 819 mechanically ventilated patients, 127 (16%) of whom developed VAP. Total hospital costs also were significantly higher for VAP patients, $70,568, compared with non-VAP patients, $21,620 (Crit. Care Med. 2003;31:1312-7). Total costs included room, nursing, respiratory therapy, and pharmacy.

In March 2009, a health economist reported costs associated with a range of hospital-acquired infections, including approximately 52,542 VAP infections (www.cdc.gov/NCIDOD/DHQP/pdf/Scott_CostPaper.pdf

Silver-coated endotracheal tubes for mechanical ventilation of critical care patients were associated with lower rates of VAP, 4.8%, compared with traditional tubes, 7.5%, in another study (JAMA 2008;300:805-13). However, their higher cost needs to be considered, said Dr. Hyzy, a collaborator on the study.

Dr. Hyzy disclosed that he is a former consultant to Kimberly-Clark, maker of the silver-coated Microcuff Endotracheal Tube.

MIAMI BEACH — The extent of mortality due to ventilator-associated pneumonia remains uncertain, but its impact on increasing morbidity and hospital costs is clear, Dr. Robert C. Hyzy said.

“Pneumonia is bad; pneumonia kills people; so, ventilator-associated pneumonia must be bad, too, right?” Dr. Hyzy said at the annual congress. The unresolved issue is whether patients die with or die from ventilator-associated pneumonia (VAP).

There is little evidence-based medicine to make this determination. Most studies designed to assess VAP mortality are observational cohort trials.

For example, a systematic review of observational studies revealed an overall relative mortality risk of 1.27 for patients with VAP, compared with those without (Crit. Care Med. 2009;37:2709-18). “But a high degree of heterogeneity between studies limits the observation,” said Dr. Hyzy, who is an associate professor of medicine and director of the critical care medicine unit at the University of Michigan, Ann Arbor. “Ultimately, these investigators said they do not know.”

However, there are two subpopulations for which there is enough evidence to clear VAP of attributable mortality, he added.

In a subset of patients—those with acute respiratory distress syndrome (ARDS) or trauma—data were sufficiently robust to demonstrate that mechanically ventilated patients were not at increased risk of death if they developed VAP. “This makes sense—these patients are very sick to begin with,” Dr. Hyzy said.

Regarding morbidity, another study indicated that 27% of 401 patients with microbiologically proven VAP experienced recurrence of pneumonia within 28 days of onset of VAP (Crit. Care Med. 2007;35:146-54).

A 14% relapse rate and a 19% superinfection rate were other findings in that study. Dr. Hyzy noted that recurrence was more likely if patients were infected with methicillin-resistant Staphylococcus aureus (odds ratio, 2.50) or nonfermenting gram-negative bacilli (OR, 2.00).

Interestingly, recurrence did not differ significantly between patients who received 8 days vs. 15 days of antibiotic therapy.

Not surprisingly, superinfection increased length of hospital stay and costs for patients with VAP. Other researchers quantified those effects in a retrospective study of 74 patients (Semin. Respir. Crit. Care Med. 2009;30: 116-23). The researchers in that study found that median length of stay was 48 days for patients who had a superinfection, compared with 28 days for unaffected patients.

“If you stay longer, you may get superinfected, and you can get recurrence. Also, the longer you stay, the more it will cost,” Dr. Hyzy said.

Other researchers calculated that the cost attributable to VAP was $11,897.

They studied 819 mechanically ventilated patients, 127 (16%) of whom developed VAP. Total hospital costs also were significantly higher for VAP patients, $70,568, compared with non-VAP patients, $21,620 (Crit. Care Med. 2003;31:1312-7). Total costs included room, nursing, respiratory therapy, and pharmacy.

In March 2009, a health economist reported costs associated with a range of hospital-acquired infections, including approximately 52,542 VAP infections (www.cdc.gov/NCIDOD/DHQP/pdf/Scott_CostPaper.pdf

Silver-coated endotracheal tubes for mechanical ventilation of critical care patients were associated with lower rates of VAP, 4.8%, compared with traditional tubes, 7.5%, in another study (JAMA 2008;300:805-13). However, their higher cost needs to be considered, said Dr. Hyzy, a collaborator on the study.

Dr. Hyzy disclosed that he is a former consultant to Kimberly-Clark, maker of the silver-coated Microcuff Endotracheal Tube.

MIAMI — Probiotics are considered safe and are being recommended for hospitalized patients receiving antibiotics, but physicians continue to be skeptical about the benefits, according to results of a physician survey.

Dr. Robert Martindale presented the findings from a survey of physicians from six different hospitals affiliated with Oregon Health & Science University (OHSU), Portland. There was a 62% response rate (924 physicians). Responses were compared for faculty (surgery and primary care physicians) as well as residents regarding the utility of probiotics in routine clinical medicine, personal use of probiotics, and risks and benefits.

The findings indicate many doctors remain skeptical about a role for probiotics in medicine, citing a need for more data, said Dr. Martindale, medical director of the Hospital Nutrition Service at OHSU.

Younger physicians are more positive about the perceived benefits of probiotics, he said. About half (54%) of the 393 faculty physicians and 71% of 531 residents said that probiotics are useful in routine clinical practice. Further, 67% of primary care faculty and 44% of surgery faculty considered probiotics useful in routine practice, said Dr. Martindale, who is also a gastrointestinal surgeon at OSHU. Personal use of probiotics or probiotic yogurt was reported by 31% of faculty and 42% of residents.

Most respondents—76% of faculty and 83% of residents—said they think the benefits of probiotics outweigh the risks. Further, no respondent reported a complication in any patient taking probiotics, Dr. Martindale said.

And while 22% of surgery faculty and 81% of primary care faculty said they understand probiotics' basic mechanisms of action, 71% of the surgery faculty indicated they have suggested or prescribed probiotics to their patients.

“I'm a general surgeon, a trauma surgeon. What am I doing here talking about probiotics? I'm on the firing line, out there in the ICUs with all the diarrhea,” Dr. Martindale remarked.

At OHSU, the probiotic protocol for critical care patients is 1 teaspoon or 5-10 cc of probiotic yogurt mixed in 30-60 cc water, then infused into a feeding tube, he reported. “It is probably the least expensive thing we do all day in the ICU.”

Disclosures: Dr. Martindale said he had no relevant financial disclosures.

MIAMI — Probiotics are considered safe and are being recommended for hospitalized patients receiving antibiotics, but physicians continue to be skeptical about the benefits, according to results of a physician survey.

Dr. Robert Martindale presented the findings from a survey of physicians from six different hospitals affiliated with Oregon Health & Science University (OHSU), Portland. There was a 62% response rate (924 physicians). Responses were compared for faculty (surgery and primary care physicians) as well as residents regarding the utility of probiotics in routine clinical medicine, personal use of probiotics, and risks and benefits.

The findings indicate many doctors remain skeptical about a role for probiotics in medicine, citing a need for more data, said Dr. Martindale, medical director of the Hospital Nutrition Service at OHSU.

Younger physicians are more positive about the perceived benefits of probiotics, he said. About half (54%) of the 393 faculty physicians and 71% of 531 residents said that probiotics are useful in routine clinical practice. Further, 67% of primary care faculty and 44% of surgery faculty considered probiotics useful in routine practice, said Dr. Martindale, who is also a gastrointestinal surgeon at OSHU. Personal use of probiotics or probiotic yogurt was reported by 31% of faculty and 42% of residents.

Most respondents—76% of faculty and 83% of residents—said they think the benefits of probiotics outweigh the risks. Further, no respondent reported a complication in any patient taking probiotics, Dr. Martindale said.

And while 22% of surgery faculty and 81% of primary care faculty said they understand probiotics' basic mechanisms of action, 71% of the surgery faculty indicated they have suggested or prescribed probiotics to their patients.

“I'm a general surgeon, a trauma surgeon. What am I doing here talking about probiotics? I'm on the firing line, out there in the ICUs with all the diarrhea,” Dr. Martindale remarked.

At OHSU, the probiotic protocol for critical care patients is 1 teaspoon or 5-10 cc of probiotic yogurt mixed in 30-60 cc water, then infused into a feeding tube, he reported. “It is probably the least expensive thing we do all day in the ICU.”

Disclosures: Dr. Martindale said he had no relevant financial disclosures.

MIAMI — Probiotics are considered safe and are being recommended for hospitalized patients receiving antibiotics, but physicians continue to be skeptical about the benefits, according to results of a physician survey.

Dr. Robert Martindale presented the findings from a survey of physicians from six different hospitals affiliated with Oregon Health & Science University (OHSU), Portland. There was a 62% response rate (924 physicians). Responses were compared for faculty (surgery and primary care physicians) as well as residents regarding the utility of probiotics in routine clinical medicine, personal use of probiotics, and risks and benefits.

The findings indicate many doctors remain skeptical about a role for probiotics in medicine, citing a need for more data, said Dr. Martindale, medical director of the Hospital Nutrition Service at OHSU.

Younger physicians are more positive about the perceived benefits of probiotics, he said. About half (54%) of the 393 faculty physicians and 71% of 531 residents said that probiotics are useful in routine clinical practice. Further, 67% of primary care faculty and 44% of surgery faculty considered probiotics useful in routine practice, said Dr. Martindale, who is also a gastrointestinal surgeon at OSHU. Personal use of probiotics or probiotic yogurt was reported by 31% of faculty and 42% of residents.

Most respondents—76% of faculty and 83% of residents—said they think the benefits of probiotics outweigh the risks. Further, no respondent reported a complication in any patient taking probiotics, Dr. Martindale said.

And while 22% of surgery faculty and 81% of primary care faculty said they understand probiotics' basic mechanisms of action, 71% of the surgery faculty indicated they have suggested or prescribed probiotics to their patients.

“I'm a general surgeon, a trauma surgeon. What am I doing here talking about probiotics? I'm on the firing line, out there in the ICUs with all the diarrhea,” Dr. Martindale remarked.

At OHSU, the probiotic protocol for critical care patients is 1 teaspoon or 5-10 cc of probiotic yogurt mixed in 30-60 cc water, then infused into a feeding tube, he reported. “It is probably the least expensive thing we do all day in the ICU.”

Disclosures: Dr. Martindale said he had no relevant financial disclosures.